Nursing Leadership and Management NCLEX Questions

Nursing Leadership and Management NCLEX Questions 5.0 (1 review) Students also studied Terms in this set (25) Science MedicineNursing Save Philippines Red Cross Training Quiz ...41 terms irenethecacti Preview NP1 Exam 1 Review Questions 382 terms desiree_lagunas Preview Disaster nursing- NCLEX 24 terms Milkduds_02Preview Ch.2 Nu 22 terms wat A registered nurse reviews a plan of care developed by a nursing student for a client with depression and notes a

nursing diagnosis of impaired nutrition: less than body

requirements. The registered nurse asks the student to revise the plan if which incorrect intervention is documented?

• offer small, high-calorie, high protein snacks frequently

throughout the day and evening

• offer high protein, high-calorie fluids frequently

throughout the day and evening

• remain with the client during meals
• complete the food menu for the client during the

depressed period D

• The client should be asked which foods or drinks she likes, and consultation with

a dietitian also may be done. The client is more likely to eat if the client has selected the foods and is given foods that she likes. Options A, B, and C are appropriate interventions for the client with depression with this nursing diagnosis.A registered nurse reviews a plan of care developed by a nursing student for client with paranoia and notes a nursing diagnosis of Disturbed thought process. The registered nurse asks the nursing student to revise the plan if which incorrect intervention is documented?

• sit with the client and hold the client's hand
• avoid a warm approach when working with the client
• use simple and clear language when speaking to the

client

• diffuse angry and hostile verbal attacks with a

nondefensive stand A

• When caring for a paranoid client, the nurse must avoid any physical contact and

should not touch the client. The nurse should ask the client's permission if touch is necessary because touch may be interpreted as a physical or sexual assault. The nurse would use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurse's intent and actions. A warm approach is avoided because it can be frightening to a person who needs emotional distance. A matter-of-fact consistency is nonthreatening. Any anger and hostile verbal attacks need to be diffused with a nondefensive stand. The anger that a paranoid client expresses is often displaced, and when the staff becomes defensive, anger of both the client and staff escalates. A nondefensive and nonjudgmental attitude provides an attitude in which feelings can be explored more easily.

A registered nurse is discussing the characteristics of anorexia nervosa with a nursing student. The registered nurse determines that the nursing student needs to further research this disorder if the student states that which of the following is a characteristic of anorexia nervosa?

• personal relationships tend to become more

superficial and distant

• social contacts are avoided because of the fear of

being invited to eat and being discovered

• the client is being preoccupied with food and meal

planning, especially for others

• the client will usually keep her weight near normal

D

• As anorexia nervosa develops, personal relationships tend to become more

superficial and distant. Social contacts are avoided because of the fear of being invited to eat and being discovered. The client is preoccupied with food and meal planning (especially for others), personal caloric intake throughout the day, and methods to avoid eating. Anorexic persons are likely to become very emaciated and will not maintain their near-normal body weight.An experienced emergency department nurse observes a new nurse employed in the emergency department obtain the equipment needed to draw a blood sample for a blood alcohol level on a client. The experienced emergency department nurse intervenes if the new nurse plans to use which item?

• tourniquet
• alcohol swabs
• a blood-draw needle
• a blood tube

B

• Isopropyl alcohol or any antiseptic solution containing alcohol must not be used

as a skin preparation before a blood alcohol specimen is drawn. These agents may falsely elevate the blood alcohol level and render the test invalid. Option A, C and D identify items needed to obtain the blood specimen.A nurse administers digoxin (Lanoxin) 0.25 mg instead of the prescribed order of 0.125 mg. The nurse discovers the error while charting the medication. The nurse completes an incident report and notifies the physician of the incident. The nurse takes which additional action?

• gives the client a copy of the incident report
• makes a copy of the incident report and sends it to the

physician's office

• documents the incident in the client's record
• places the incident report in the client's record

C

• The incident report is confidential and privileged information. It should not be

copied or placed in the chart or have any reference made to it in the client's record. It is the physician's responsibility to sign the incident report before it is sent to the risk-management department. A copy should not be made or sent to the physician's office. The incident report is not a substitute for a complete entry in the client's record concerning the incident. A copy of the incident report is not given to the client; however, the client should be informed of the error, and this is usually done by the client's physician.A registered nurse is supervising a new nursing graduate who is performing an irrigation on an assigned client with a buildup of cerumen in the left ear. Which of the following observations if made by the registered nurse would indicate that the nursing graduate is performing the procedure correctly?

• the client is positioned with the ear to be irrigated

facing upward

• the irrigating solution is warmed to 100F
• a direct and slow steady stream of irrigation solution is

directed toward the eardrum

• the client is positioned with the affected ear up

following the irrigation B

• Irrigation solutions that are not close to the client's body temperature can be

uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward because this allows gravity to assist in the removal of the cerumen and solution. Following the irrigation, the client is to lie on the affected side for a period to finish the drainage of the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the tympanic membrane. Too much force could cause the tympanic membrane to rupture.

A nurse is performing a sterile wound irrigation on an assigned client. A nursing assistant enters the client's room and tells the nurse that a physician has telephoned and requests to speak to the nurse. The appropriate nursing action is which of the following?

• finish the wound irrigation while the physician waits on

the telephone

• cover the client and answer the telephone call
• ask the nursing assistant to obtain a telephone number

from the physician so that the call can be returned after the wound irrigation

• ask the nursing assistant to take a message

C

• Because wound irrigation is a sterile procedure and a risk for infection exists

with an open wound, it is most appropriate to ask the nursing assistant to obtain a telephone number from the physician so that the call can be returned. It is not appropriate to ask a physician to wait while a procedure is being completed. It is best to return the call. Option D is not a responsibility of the nursing assistant.A case manager is reviewing the records of the clients in the nursing unit. Which of the following documentation, if noted in a client's record, would the nurse indicate as a positive variance?

• a client in skeletal traction has a temperature of 98.6F

and the pin sites are clean and dry

• a postoperative client is performing coughing and

deep-breathing exercises every hour

• a client with congestive heart failure has clear breath

sounds

• a client with pneumonia is discharged to home 1 day

earlier than expected D

• Variances are actual deviations or detours from the critical path. Variances are

either positive or negative and avoidable or unavoidable, and may be caused by a variety of things. A positive variance occurs when the client has achieved maximum benefits and is discharged earlier than anticipated on her critical path.Option 4 is the only option that specifically identifies a positive variance. Options A, B, and C demonstrate progression on a critical path, but they are not specifically associated with the definition of a positive variance.A nurse is a member of a community task force on violence. The task force recognizes that it has insufficient data to make decisions about specific interventions.Using the nursing process, the first activity that the nurse

would suggest to the task force is to:

• call other communities similar in size to determine what

they do

• develop a general educational program related to

violence

• conduct a community survey to assess community

perceptions regarding violence

• develop a pamphlet on violence to be distributed to

the community C

• An assessment activity is always the first step in the nursing process. Option C

addresses assessment of community perceptions. Option A is a part of analysis from a variety of assessment data, but is not specific to the subject of the question. Options B and D are implementation measures.

A community health nurse has been assigned to be the leader of a task force to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the members express concern that more information is needed to determine appropriate measures for the target teenagers.The nurse would direct the group effectively by suggesting which of the following?

• preparing a survey that can be distributed to

community members to determine their understanding of the drug abuse problem

• initiating a drug abuse program in all of the schools
• seeking out the teenage drug abusers and referring

them to drug abuse centers

• preparing posters that can be distributed to the

schools A

• Option A is the only option that addresses the subject of the question and will

identify the additional information required by the task force. Options B, C, and D do not provide the additional information required in order for the task force to proceed with the necessary task of the group.

• A registered nurse is discussing treatment for a client

who is hospitalized with acute systemic lupus erythematosus (SLE) with a nursing student assigned to the client. The registered nurse realized that the nursing student needs to research information about the disease if the student states that which of the following is a clinical manifestation of SLE?

• fever
• bradycardia
• butterfly rash on the face
• muscular aches and pains

B

• Manifestations of acute SLE may include fever, musculoskeletal aches and pains,

butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, convulsions, psychosis, and coma.A nurse administers a fatal dose if a cardiac medication to a client. During the subsequent investigation, it was determined that the nurse did not check the client's vital signs before administering the medication. This failure to complete an appropriate assessment is addressed under which function on the Nurse Practice Act?

• defining the specific educational requirements for

licensure

• describing the scope of practice of licensed and

unlicensed care providers

• recommending disciplinary action for nurses who

violate the law

• identifying the process for disciplinary action if

standards of care are not met D In the situation described in the question, acceptable standards of care were not met (the nurse failed to adequately assess the client before administering a medication). Option D refers specifically to the situation described. Options A, B, and C do not relate to standards of care.