NCLEX Review - Management of Care

NCLEX Review - Management of Care

A client is being prepped for a surgical procedure and the nurse is reviewing the informed consent with the client. The client asks, "Is there any other way to take care of this without having surgery?" The nurse

has a duty to first:

1) Reassure the client that the surgery is the best treatment option

2) Tell the client if they don't want the surgery, they don't have to have it

3) Notify the surgeon that the client has additional questions about alternatives to surgery

4) Call the surgeon and cancel the surgery until the consent form is signed 3

Rationale:

The client has a right to an explanation of the treatment and its expected results, anticipated risks and benefits, possible alternative treatment options and all questions answered before a consent form is signed. Remember, the client is not asking you for your opinion. The client is asking about alternative treatments for the condition. Notify the appropriate health care provider if the client needs additional information that you cannot answer. Once the client has all the necessary information then they can decide not to sign the informed content and cancel the surgery.A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?

1) Clinical specialty certification by an accredited organization

2) Complete and accurate documentation of assessments and interventions

3) Above-average performance reviews prepared by nurse manager

4) Sworn statement that health care provider orders were followed 2

Rationale:

The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information.Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.

The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrate the shared governance model?

1) Staff groups are appointed to discuss nursing practice and client education issues

2) Non-nurse managers supervise nursing staff in groups of units

3) Nursing departments share responsibility for client outcomes

4) An appointed board oversees any administrative decisions 3

Rationale:

Shared governance or self-governance is a method of organizational design. It promotes empowerment of nurses to give them responsibility for client care issues and outcomes with other divisions in the agency.The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.)

1) The UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday

2) The UAP applies moisture barrier cream to the client's excoriated perianal area

3) The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall

4) The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue

5) The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight- edge razor

3, 4, 5

Rationale:

The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee replacement surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail polish.

We have an expert-written solution to this problem!

An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs) and is unable to drive.

Reorder the steps in the case management process by dragging and dropping the options below.

1) Evaluation of progress towards client's goals

2) Referral to personal care attendant and transportation services

3) Assessment of biophysical and sociocultural considerations

4) Identification of nursing diagnoses

5) Reassessment of health status and ADL ability

3, 4, 2, 5, 1

Rationale:

Case management is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs.A nurse has unintentionally given an incorrect dose of medication to their client. No harm was done to the client. What is the next action, if any, required by the nurse?

1) The nurse is not required to report the mistake because the client was not harmed

2) The nurse is not responsible for the mistake because they have not been provided current education by their employer

3) The nurse will immediately be suspended and their license will be revoked

4) The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting 4

Rationale:

Although the client was not harmed as a result of the mistake, the incident still needs to be reported.Nurses are responsible for their practice and for staying current and competent by becoming lifelong learners. In this case, neither an immediate suspension nor revoking a license are warranted.A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects appropriate assertive communication?

1) "Would you please clarify what you have written so I am sure I am reading it correctly?"

2) "Please print in the future so I do not have to spend extra time attempting to read your writing."

3) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."

4) "I cannot give this medication as it is written. I have no idea of what you mean." 1

Rationale:

Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first?

1) 62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8

2) 79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10

3) 70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery

4) 67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the dressing 1

Rationale:

A surgical client using a narcotic PCA is at risk for respiratory depression, which is potentially life- threatening, and therefore the top priority. The other clients need assessment and attention, but the priority is given to the client with a respiratory rate of 8. Some bloody drainage on a dressing is expected after a drain is removed and of course the nurse would monitor this. Constipation is a side effect of narcotics but is not life-threatening. Pain control is also important but does not take priority over respiratory depression.The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)?

1) Teach the initial ostomy care to a client and family members

2) Provide stoma care for a client with a well-functioning ostomy

3) Assess the function of a newly created ileostomy