NCLEX Review - Management of Care Latest

pg. 1 NCLEX Review - Management of Care Latest Update / Actual Exam Questions and Correct Detailed Answers/ Graded A+

The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority ethical consideration that can help guide the nurse?

1) Nurses should not prejudge a client's pain using their own values 2) Cultural sensitivity is fundamental to pain management 3) The client's self-report of pain is the most important consideration 4) Clients have the right to have their pain relieved - Correct Answer - 3

Rationale:

Pain is a complex phenomenon that is perceived differently by each individual. This is why the self-report is the most reliable way to determine a client's pain. Nurses should apply ethical standards, such as respect for autonomy (the right of people to make their own decisions about healthcare), when assessing pain. The other statements are correct but they are not the most important considerations.

The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has been a two car accident with multiple casualties.What action would the nurse take first, before the victims arrive in the ED?

1) Set up multiple 1000 mL NaCl IV solutions with tubing and notify the blood bank 2) Prepare the trauma room and select supplies 3) Notify the nursing supervisor and request additional staff 4) Activate the disaster plan - Correct Answer – 3

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Rationale:

The ED charge nurse needs to assess, supervise and coordinate staff and to maintain full readiness of ED. The priority is for the ED charge nurse to notify the nursing supervisor that additional nursing staff will be needed. Preparing the trauma room will be next. The clients will need to be assessed prior to the administration of any IV solution and/or blood products. There is no need to activate a disaster plan for a two car accident.

The 83 year-old client, who lives in a retirement community, is admitted to the hospital.The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following clients?

1) A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder 2) An elderly person who was admitted three hours ago with a diagnosis of cyclothymia 3) A young adult who was admitted 24 hours ago for treatment following detoxification 4) An adolescent who was admitted the day before with a diagnosis of disruptive mood dysregulation - Correct Answer - 1

Rationale:

These findings suggest depression. The most therapeutic milieu for this client includes double occupancy with someone who has similar issues and/or whose condition is more stable. A secondary consideration is matching roommates' ages as closely as possible, because they potentially would share similar developmental challenges and needs. The most stable client is the one with persistent depressive disorder. Cyclothymia is an illness that's similar to bipolar disorder and disruptive mood dysregulation disorder is characterized by irritability and episodes of extreme, out-of-control behavior.

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 2 / 4

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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 - Correct Answer - 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 - Correct Answer - 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?

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pg. 4 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 - Correct Answer - 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 - Correct Answer - 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.

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.

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