Ikawn over the fibrinolysin and is deficit? a) tells the client to scan the environment b) approaches the client from the unaffected side c) places the bedside articles on the affected side d) moves the commode and cahir to the affected side 6. A 6. A nursing instructor asks the nursing student to describe the definition of definition of a critical path. Which of the following statements, if made by the student, indicates a need for further understanding regarding critical paths? a) they are developed through the collaborative efforts of all members of the health care team b) they provide an effective way of monitoring care and for reducing or controlling the length of hospital stay for the client c) they are developed based on appropriate standards of care d) they are nursing care plans and use the steps of the nursing process 7. A community health nurse is 7. A nurse is working with a disaster relief following a tornado. The nurse's goal for the community is to prevent as much inury and death as possible from the uncontrollable event. !inding safe housing for survivors, providing support to families, organi"ing counseling, and securing physical care physical care when needed alle#amples alle#amples of of which type of prevention? a) primary level of prevention b) secondary level of prevention c) tertiary level of prevention d) aggregate care prevention 8. The nurse manager is planning to implement a change in the 8. The nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance to the change during the change process. The primary techni$ue that the nurse would use in implementing this change is which of the following? a) introduce the change gradually b) confront the individuals involved in the change process c) use coercion to implement the change d) manipulate the participants in the change process 9. A nurse 9. A nurse manager is providing providing an educational session session to nursing staff members about the phases of viral hepatitis. hepatitis. The nurse manager tells the staff that which clinical manifestation%s) manifestation%s) are primarily characteristic of preicteric phase? a) right upper $uadrant pain b) fatigue, anore#ia and anore#ia and nausea c) aundice c) aundice,, dark&colored urine, and clay&colored stools d) pruritus 10. A nurse is preparing a plan of care for a client who will be 10. A hospitali"ed for insertion of an internal cervical radiation implant. implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client? a) prepare a private room at the end of the hallway b) place a sign on the door that indicates that visitors are limited to (&minute visits
c) assign one primary nurse to care for the client during the hospital stay d) place a linen bag outside of the client's room for discarding linens after morning care 11. A nursing 11. A nursing student is developing a plan of care care for a client with a chest tube that is attached to a leur&*vac drainage system. drainage system. The nurse intervenes if the student writes which incorrect intervention in the plan? a) position the client in semi&fowler's position b) add water to the suction chamber as it evaporates c) tape the connection sites between the chest tube and the drainage system d) instruct the client to avoid coughing and coughing and deep breathing
12. A nurse 12. A nurse is caring for a client who has ust ust had a plaster leg leg cast applied. The nurse would plan to prevent the development of compartment syndrome is instructing the licensed practical nurseassigned nurseassigned to care for the client to+ a) elevate the limb and apply ice to the affected leg affected leg b) elevate the limb and cover the limb with bath blankets c) place the leg in a slightly dependent dependent position and apply ice to the affected leg d) keep the leg hori"ontal and apply ice to the affected leg 13. A registered 13. A registered nurse %-) is supervising a licensed licensed practical nurse %-) administering an intramuscular %/0) inection of iron to an assigned client. The - would intervene if the - is observed to perform which of the following? a) changing the needle after drawing up the dose and before inection b) preparing an air lock when drawing up the medication c) using a 1&track method for inection d) massaging the massaging the ine!tion site aft er ine!tion 1". A nursing student develops a plan of care for a client with 1". A paraplegia who has a risk for inury related to spasticity of the leg muscles. 2n reviewing the plan, the co&assigned nurse identifies which of the following as an incorrect intervention. a) use of padded restraints to immobili"e the limb b) performing range of motion to motion to the affected limbs c) removing potentially harmful obects near the spastic limbs d) use of prescribed muscle rela#ants as rela#ants as needed 1#. A registered nurse %-) is observing a licensed practical 1#. A nurse %-) preparing a client for treatment with a continuous passive motion %30) machine. Which observation by the would indicate that the - is performing an incorrect action? a) places the client's knee in a slightly e#ternally rotated position b) keeps the client's knee at the hinged oint of the machine c) assesses the client for pressure areas at the knee and the groin d) checks the degree of e#tension and fle#ion and the speed of the 30 machine per the physician's orders 16. A client who is mouth breathing is receiving o#ygen by face 16. A mask. mask. The nursing assistant asks assistant asks the registered nurse %-) why
a water bottle is attached to the o#ygen tubing near the wall o#ygen outlet. The - responds that the primary purpose of this feature is to+
b) administer mouth care c) monitor intake and output d) encourage coughing and deep breathing
a) prevent fluid loss from the lungs during mouth breathing b) give the client added fluid via the respiratory rate c) humidify the o#ygen that is bypassing the client's nose d) prevent the client from getting nosebleed
22. A nurse manager is reviewing with the nursing staff the purposes for applying wrist and ankle restraints %security devices) to a client. The nurse manager determines that further review is necessary when a nursing staff member states that an indication for the use of a restraint is to+
17. A nurse and a nursing assistant are assisting the respiratory therapist to position a client for postural drainage. The nursing assistant asks the nurse how the respiratory therapists selects the position used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which of the following areas? a) trachea b) main bronchi c) lobes d) alveoli 18. A registered nurse %-) is observing a licensed practical nurse %-) caring for a deceased client whose eyes will be donated. The - intervenes if the - performs which action? a) elevates the head of the bed b) closes the client's eyes c) places wet saline gau"e pads and ice pack on the eyes d) closes the client's eyes and places a dry sterile dressing over the eyes 19. The nurse has recently been assigned to manage a pulmonary progressive unit at a large urban hospital. The nurse's leadership style is participative, with the belief that all staff members assist in decision making and the development of the unit's goals. The nurse is implementing which leadership style? a) democratic b) laisse" faire c) auticratic d) situational 20. A physician has written an order for a vest restraint to be applied on a client from 4(+(( pm to 5+(( am because the client becomes disoriented during the night and is at risk for falls. At 44+(( pm, the charge nurse makes rounds on all of the clients with the vest restraint, which observation by the charge nurse would indicate that the nurse who cared for this client performed an unsafe action in the use of the restraint? a) a safety knot was used to secure the restraint b) the client's record indicates that the restraint will be released every 6 hours c) the restraint was applied tightly d) the call light was placed within reach of the client 21. A nursing student prepares a postoperative plan of care for a client scheduled for hypophysectomy. The registered nurse reviews the plan and informs the nursing student that the plan needs to be corrected if which of the following was noted? a) obtain daily weights
a) limit movement of a limb b) keep the client in bed at night c) prevent the violent client from inuring self and others d) prevent the client from pulling out intravenous lines and catheters 23. A hospitali"ed client with a diagnosis of anore#ia nervosa and in a state of starvation is in two&bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be inappropriate to assign to this two&bed room? a) a client with pneumonia b) a client who can perform self&care c) a client with a fractured leg that is casted d) a client who is scheduled for a diagnostic test 2". A multidisciplinary health care team is planning care for a client with hyperparathyroidism. The nurse identifies which client outcome to the health care team? a) describes how to take antacids b) restricts fluids to 4((( ml per day c) describes how to take antidiarrheal medications d) walks down the hall for 47 minutes, three times a day 2#. A clinic nurse wants to develop a diabetic teaching program. /n order to meet the client's needs, the nurse must first+ a) assess the client's functional abilities b) ensure that insurance will pay for participation in the program c) discuss the focus of the program with the multidisciplinary team d) include everyone who comes into the clinic in the teaching sessions 26. A nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed practical nurse %-) is assigned to the client. The appropriate action for the nurse to take is to+ a) reassign the - to the care of clients not receiving opioids b) notify the physician that the client needs an increase in opioid dosage c) review the client's medication administration record immediately and discuss the observations with the nursing supervisor d) confront the - with the information about the client having pain control problems and ask if the - is using the opioids personally 27. A medication nurse is supervising a newly hired licensed practical nurse %-) during the administration of oral
pyridostigmine bromide %0estinon) to a client with myasthenia gravis. Which observation by the medication nurse would indicate safe practice by the -? a) asking the client to take sips of water b) asking the client to lie down on his right side c) asking the client to look up at the ceiling for 8( seconds d) instructing the client to void before taking the medication 28. 9uring orientation, a graduate nurse learns that the nursing model of practice implemented in the facility is a primary nursing approach. When the nurse attends report on the medical unit, the nurse will verify with the staff which of the following characteristics of primary nursing? a) critical paths are used when providing client care b) the nurse manager assigns tasks to the staff members c) a registered nurse %-) leads nursing staff in providing care to a group of clients d) a single - is responsible for planning and providing individuali"ed nursing care to clients
a) any client has the right to refuse to participate in research studies b) collaboration with other disciplines is essential to the successful practice of nursing c) the cooperation of the physicians on staff must be ensured in order for the proect to succeed d) the corporate nurse e#ecutive should be consulted, because the proect will take nursing time 33. A nurse manager has identified a problem on the nursing unit and holds unit meetings for all shifts. The nurse manager presents an analysis of the problem and proposals for actions to team members and invites the team members to comment and provide input. Which style of leadership is the nurse manager specifically employing? a) situational b) laisse"&faire c) participative d) authoritarian
29. A clinical nurse manager conducts an inservice educational session for the staff nurses about case management. The clinical nurse manager determines that a review of the material needs to be done if a staff nurse stated that case management+
3". A charge nurse observes that a staff nurse is not able to meet client needs in a reasonable time frame, does not problem& solve situations, and does not prioriti"e nursing care. The charge nurse has the responsibility to+
a) manages client care by managing the client care environment b) ma#imi"es hospital revenues while providing for optimal client care c) is designed to promote appropriate use of hospital personnel and material resources d) represents a primary health prevention focus managed by a single case manager
a) supervise the staff nurse more closely so that tasks are completed b) ask other staff members to help the staff nurse get the work done c) provide support and identify the underlying cause of the staff nurse's problem d) report the staff nurse to the supervisor so that something is done to resolve the problem
30. A nurse manager is reviewing the critical paths of the clients on the nursing unit. The nurse manager collaborates with each nurse assigned to the clients and performs a variance analysis. Which of the following would indicate the need for further action and analysis? a) a client is performing his own colostomy care b) purulent drainage is noted from a postoperative wound incision c) a 4&day postoperative client has a temperature of :;.;! d) a client newly diagnosed with diabetes mellitus is preparing his own insulin for inection 31.
3#. A registered nurse is preceptor for a new nursing graduate and is observing the new nursing graduate organi"ethe client assignment and daily tasks. The registered nurse intervenes if the new nursing graduate does which of the following? a) provide time for une#pected tasks b) lists the supplies needed for a task c) prioriti"es client needs and daily tasks d) plans to document task completion at the end of the day 36. A registered nurse is a preceptor for a new nursing graduate an is describing critical paths and variance analysis to the new nursing graduate. The registered nurse instructs the new nursing graduate that a variance analysis is performed on all clients+ a) continuously b) daily during hospitali"ation c) every third day of hospitali"ation d) every other day of hospitali"ation 37. When a nurse manager makes a decisions regarding the management of the nursing unit without input from the staff, the type of leadership style that the nurse manager is demonstrating is+ a) autocratic
b) situational c) democratic d) laisse"&faire
a) enteric precautions should be instituted for the client
38. A charge nurse knows that drug and alcohol use by nurses is a reason for the increasing numbers of disciplinary cares by the
c) contact isolation should be initiated, because the diseases is highly contagious
a) the magnitude of drug diversion over time b) if falsification of clients records occurred c) the types of illegal activities related to the abuse d) the physiological impact of the illness on practice 39. A nurse manager is planning to implement a change in the method of the documentation system for the nursing unit. 0any problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is re$uired. The initial step in the process of change for the nurse manager is which of the following? a) plan strategies to implement the change b) set goals and priorities regarding the change process c) identify the inefficiency that needs improvement or correction d) identify potential solutions and strategies for the change process "0. A nurse receives a telephone call from the emergency department and is told that a child with a diagnosis of tonic& clonic sei"ures will be admitted to the pediatric unit. The nurse prepares for the admission of the child and instructs assistant to place which items at the bedside?
b) gloves and mask should be used when the in client's room
d) standard precautions are sufficient, because the disease is transmitted se#ually
=8. A nursing assistant is caring for an older male client with cystits who has an indwelling urinary catheter. The registered nurse provides directions regarding urinary catheter care and ensures that the nursing assistant+ a) loops the tubing under the client's leg b) places the tubing below the client's knee c) uses soap and water to cleanse the perineal area d) keeps the drainage bag above the level of the bladder
==. A nurse is planning care for a client with acute glomerulonephritis. The nurse instructs the nursing assistant to do which of the following in the care of the client? a) ambulate the client fre$uently b) monitor the temperature every 6 hours c) encourage a diet that is high in protein
a) a tracheostomy set and o#ygen b) suction apparatus and an airway c) an endotracheal tube and an airway d) an emergency cart and laryngoscope =4. When assessing the client with the vest restraint %security device) at the beginning of day shift, which observation by the charge nurse would indicate that the nurse who placed the vest restraint on the client failed to follow safety guidelines?
d) remove the water pitcher from the bedside
=7. A nurse watches a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating doughnut ne#t to the hemodialysis machine while talking with the client about the client's week. The first nurse should+ a) get a cup of coffee and oin in on the conversation
a) a hitch was used to secure the restraint
b) determine whether or not the client would like a cup of coffee
b) the call light was placed within reach of the client
c) admire the therapeutic relationship the second nurse has with the client
c) the restraint was applied tightly across the client's chest d) the client's record indicates that the restraint will be released every 6 hours
=6. A male client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the nursing assistant that+
d) ask the second nurse to refrain from eating and drinking in the client area =. A nurse is working in the emergency department of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. Which of the following actions by the nurse is contraindicated in the handling legal evidence? a) initiate a chain of custody log b) give clothing and wallet to the family c) cut clothing along seams, avoiding bullet holes
d) place personal belongings in a labeled, sealed paper bag
and the charge nurse provides instructions and observes the nurse using the cooling blanket. The charge nurse intervenes if the nurse+
=5. A registered nurse %-) is orienting a nursing assistant to the clinical nursing unit. The - would intervene if the nursing assistant did which of the following during a routine handwashing procedure?
a) keeps the child uncovered to assist in reducing the fever
a) kept hands lower than elbows
c) keeps the child dry while on the cooling blanket to reduce the risk of frostbite
b) places the cooling blanket on the bed and covers the blanket with a sheet
b) dried from forearm down to fingers c) washed continuously for 4( to 47 seconds d) used 8 to 7 ml of soap from the dispenser
=;. A registered nurse %-) on the night shift assists a staff member in completing an incident report for a client who was found sitting on the floor. !ollowing completion of the report, the - intervenes if the staff member prepares to+
d) checks the skin condition of the child before, during, and after the use of the cooling blanket 76. A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which situation, if identified by the student, would indicate the need for further study of the levels of prevention? a) teaching s stroke client how to use a walker b) screening for hypertension in a community group
a) notify the nursing supervisor
c) screening for hyperlipidemia in a community group
b) ask the secretary to telephone the physician
d) encouraging a woman who is more than =( years old to obtain periodic mammograms
c) document in the nurse's notes that an incident report was filed d) forward incident report to the 3ontinuous >uality /mprovement 9epartment
=:. A physician visiting a client on the nursing unit is paged and notified that the monthly physician's breakfast meeting is about to start. The physician states to the nurse + /'m in a hurr y. 3an you write an order t decrease the atenolol %Tenormin) to 67mg daily? Which of the following is the appropriate nursing action? a) write the order b) call the nursing supervisor to write the order c) inform the client of the change of medication d) ask the physician to return to the nursing unit to write the order 7(. A registered nurse suspects that a colleague is substance impaired and notes signs of alcohol into#ication in the colleague. The -urse ractice Act re$uires the registered nurse do which of the following? a) talk with the colleague
78. A charge nurse is supervising a new registered nurse %-) who is providing care to a client with end&stage heart failure. The client is withdrawn and reluctant to talk, and she shows little interest in participating in hygienic care or activities. Which statement, if made by the new - to the client, indicates that the new - re$uires further teaching regarding the use of therapeutic communication techni$ues? a) what are your feelings right now? b) why don't you feel like getting up for your bath? c) these dreams you mentioned, what are they like? d) many clients with end&stage heart failure fear death 7=. A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse would intervene if which of the following is performed by the nursing assistant during communication with the client? a) the nursing assistant is speaking in a normal tone b) the nursing assistant is speaking clearly to the client c) the nursing assistant is facing the client when speaking d) the nursing assistant is speaking directly into the impaired ear
b) call the impaired nurse organi"ation c) report the information to a nursing supervisor d) ask the colleague to go to the nurse's lounge to sleep for a while 74. A cooling blanket is prescribed for a child with a fever. A nurse caring for the child has never used this type of e$uipment,
77. A charge nurse reviews the plan of care formulated b y a new nursing graduate for a child returning from the operating room after a tonsillectomy. The charge nurse assists the ne w nursing graduate with changing the plan if which incorrect intervention is documented?
a) suction whenever necessary
nurse reviews the plan of care with the student and will instruct the student to remove which of hte following interventions?
b) offer clear, cool li$uids when awake c) monitor for bleeding from the surgical site d) eliminate milk or milk products from the diet 7. A nurse receives a telephone calls from emergency department and is told that a client in leg traction will be admitted to the nursing unit. The nurse prepares for the arrival of the client and asks the nursing assistant to obtain which item that will be essential for helping the client move in bed while in leg traction?
a) a foot board b) e#tra pillows
a) keep all the lights on in the room at night b) assist the client to ambulate in the hallway c) monitor the client closely while the client is showering d) push the lock&out button on the electric bed to keep the bed in the lowest position
(. A client with active tuberculosis %T<) is to be admitted to a medical&surgical unit. When planning a bed assignment, the nurse+
c) a bed trape"e d) an electric bed
a) plans to transfer the client to the intensive care unit b) places the client in a private, well&ventilated room
75. A registered nurse is observing a nursing student auscultate the breath sounds of a client. The registered nurse intervenes if the nursing student performs which incorrect action?
c) assigns the client to a double room because intravenous antibiotics will be administered d) assigns the client to a double room and places a strict handwashing sign outside the door
a) use the bell of the stethoscope b) asks the client to sit straight up c) places the stethoscope directly on the client's skin d) has the client breathe slowly and deeply through the mouth
NCLEX for RN - Leadership and Management: ANSWERS AND RATIONALE ! C
7;. A nurse has oriented a new employee to basic procedures for continuous electrocardiogram %*3@) monitoring. The nurse would intervene of the new employee did which of the following while initiating cardiac monitoring on a client?
a) clipped small areas of hair under the area planned for electrode placement b) stated the need to change the electrodes and inspect the skin every 6= hours c) stated the need to use hypoallergenic electrodes for clients who are sensitive d) cleansed the skin with
7:. A client has an order for sei"ure precautions, and a nursing student develops a plan of care for the client. The registered
- In team n"rsing# n"rsing personne$ are $ed %& a registered n"rse $eader in pro'iding (are to a gro"p of ($ients) Option A identi*es f"n(tiona$ n"rsing) Option + identi*es a (omponent of (ase management) Option D identi*es primar& n"rsing) ,! D
- Confrontation is an important strateg& to meet resistan(e head on) a(e-to-fa(e meetings to (onfront the iss"e at hand .i$$ a$$o. 'er%a$i/ation of fee$ings# identi*(ation of pro%$ems and iss"es# and de'e$opment of strategies to so$'e the pro%$em) Option A .i$$ not address the pro%$em) Option + ma& prod"(e additiona$ resistan(e) Option C ma& pro'ide a temporar& so$"tion to the resistan(e %"t .i$$ not address the (on(ern 0! D - The n"rse sho"$d instr"(t the n"rsing assistant to assess restraints and s1in integrit& e'er& 02 min"tes) Agen(& g"ide$ines regarding the "se of restraints sho"$d a$.a&s %e fo$$o.ed) 3! D - The .o"nd sho"$d %e ($eansed .ith a steri$e so$"tion and gent$& patted dr&) A thin $a&er of *%rino$&sin and deso4&ri%on"($ease 5E$ase! is app$ied and (o'ered .ith petro$at"m ga"/e) If a dr& po.der preparation is "sed# for %est e6e(ts# the so$"tion sho"$d %e prepared 7"st %efore "se) 8! + - 9ni$atera$ neg$e(t is an "na.areness of the para$&/ed side of the %od&# .hi(h in(reases the ($ients ris1 for in7"r&) The n"rses ro$e is to refo("s the ($ients attention to the a6e(ted side) The n"rse mo'es persona$ (are items and %e$ongings to the a6e(ted side# as .e$$ as the %edside (hair and (ommode) The n"rse tea(hes the ($ient to s(an the en'ironment to %e(ome a.are of that ha$f of the %od& and approa(hes the ($ient from the a6e(ted side to in(rease a.areness f"rther) ;! D - 9se the pro(ess of e$imination and 1no.$edge regarding the de*nition and p"rpose of (riti(a$ paths to dire(t &o" to option D) Note the strategi( .ords in the <"estion# a need for f"rther "nderstanding) These .ords indi(ate a negati'e e'ent <"er& and as1 &o" to se$e(t an option that is
in(orre(t) If &o" had di=("$t& .ith this <"estion# re'ie. (riti(a$ paths) >! C - Tertiar& pre'ention in'o$'es the red"(tion of the amo"nt and degree of disa%i$it&# in7"r&# and damage fo$$o.ing a (risis) ?rimar& pre'ention means 1eeping the (risis from o(("rring# and se(ondar& pre'ention fo("ses on red"(ing the intensit& and d"ration of a (risis d"ring the (risis itse$f) There is no 1no.n aggregate (are pre'ention $e'e$) @! A - The primar& te(hni<"e that (an "sed to hand$e resistan(e to (hange d"ring the (hange pro(ess is to introd"(e the (hange grad"a$$&) Confrontation is an important strateg& "sed to meet resistan(e .hen it o(("rs) Coer(ion is another strateg& that (an %e "sed to de(rease resistan(e to (hange %"t is not a$.a&s a s"((essf"$ te(hni<"e for managing resistan(e) Manip"$ation "s"a$$& in'o$'es a (o'ert a(tion# s"(h as $ea'ing o"t pie(es of 'ita$ information that the parti(ipants might re(ei'e negati'e$&) It is not the %est method of imp$ementing a (hange) ! + - In the prei(teri( phase# the ($ient has nonspe(i*( (omp$aints of fatig"e# anore4ia# na"sea# (o"gh# and 7oint pain) Options A# C# and D are ($ini(a$ manifestations that o(("r in the i(teri( phase) In the posti(teri( phase# 7a"ndi(e de(reases# the (o$or of "rine and stoo$ ret"rn to norma$# and the ($ients appetite impro'es) 2! A - The ($ient .ith an interna$ (er'i(a$ radiation imp$ant sho"$d %e p$a(ed in a pri'ate room at the end of the ha$$ %e(a"se this $o(ation pro'ides $ess of a (han(e of e4pos"re of radiation to others) The ($ients room sho"$d %e mar1ed .ith appropriate signs that indi(ate the presen(e of radiation) Bisitors sho"$d %e $imited to 02-min"te 'isits) N"rses assigned to this ($ient sho"$d %e rotated so that one n"rse is not (onsistent$& (aring for the ($ient and
e4posing him or herse$f to e4(ess amo"nts of radiation) A$$ $inens sho"$d %e 1ept in the ($ients room "nti$ the imp$ant is remo'ed in (ase the imp$ant has dis$odged and needs to %e $o(ated) ! D - It is important to en(o"rage the ($ient to (o"gh and deep %reathe .hen a (hest t"%e drainage s&stem is in p$a(e) This .i$$ assist in fa(i$itating appropriate $"ng re-e4pansion) Water is added to the s"(tion (ham%er as it e'aporates to maintain the f"$$ s"(tion $e'e$ pres(ri%ed) Conne(tions %et.een the (hest t"%e and the drainage s&stem are taped to pre'ent a((identa$ dis(onne(tion) The ($ient is positioned in semi-o.$ers to fa(i$itate ease in %reathing) ,! A - Compartment s&ndrome is pre'ented %& (ontro$$ing edema) This is a(hie'ed most optima$$& .ith the "se of e$e'ation and app$i(ation of i(e) Options +# C# and D are in(orre(t) 0! D - The site sho"$d not %e massaged after in7e(tion %e(a"se massaging (o"$d (a"se staining of the s1in) ?roper te(hni<"e for administering iron %& the IM ro"te in($"des (hanging the need$e after dra.ing "p the medi(ation and %efore gi'ing it) An air $o(1 and -tra(1 te(hni<"e %oth sho"$d %e "sed) The medi(ation sho"$d %e gi'en in the "pper o"ter <"adrant of the %"tto(1# not in an e4posed area s"(h as the arms or thighs) 3! A - Range-of-motion e4er(ises are %ene*(ia$ in stret(hing m"s($es# .hi(h ma& diminish spasti(it&) Remo'ing potentia$$& harmf"$ o%7e(ts is a good safet& meas"re) 9se of m"s($e re$a4ants a$so is indi(ated if the spasms (a"se dis(omfort to the ($ient or pose a ris1 to the ($ients safet&) 9se of $im% restraints .i$$ not a$$e'iate spasti(it& and (o"$d harm the ($ient) 8! A
- In the "se of a C?M ma(hine# the $eg sho"$d %e 1ept in a ne"tra$ position and not rotated either interna$$& or e4terna$$&) The 1nee sho"$d %e positioned at the hinge 7oint of the ma(hine) The n"rse sho"$d monitor for press"re areas at the 1nee and the groin and sho"$d fo$$o. the ph&si(ians orders and instit"tiona$ proto(o$ regarding e4tension and e4ion and speed of the C?M ma(hine) ;! C - The p"rpose of the .ater %ott$e is to h"midif& the o4&gen that is %&passing the nose d"ring mo"th %reathing) The h"midi*ed o4&gen ma& he$p 1eep m"(o"s mem%ranes moist %"t .i$$ not s"%stantia$$& a$ter "id %a$an(e 5options A and +!) A ($ient .ho is %reathing thro"gh the mo"th is not at ris1 for nose%$eeds) >! C - ?ost"ra$ drainage "ses spe(i*( ($ient positions that 'ar& depending on the a6e(ted $o%e5s!) The positions "s"a$$& in'o$'e ha'ing the head $o.er than the a6e(ted $"ng segment5s! to fa(i$itate drainage of se(retions) ?ost"ra$ drainage often is done in (on7"n(tion .ith (hest per("ssion for ma4im"m e6e(ti'eness) The other options are in(orre(t) @! C - When a (ornea$ donor dies# the e&es are ($osed and ga"/e pads .et .ith sa$ine are p$a(ed o'er them .ith a sma$$ i(e pa(1) Within , to 3 ho"rs# the e&es are en"($eated) The (ornea is "s"a$$& transp$anted .ith ,3 to 3@ ho"rs) The head of the %ed sho"$d a$so %e e$e'ated) ?$a(ing dr& steri$e dressings o'er the e&es ser'es no "sef"$ p"rpose) ! A - Demo(rati( $eadership is de*ned as parti(ipati'e .ith a fo("s on the %e$ief that a$$ mem%ers of the gro"p ha'e inp"t into the de(ision ma1ing pro(ess) This $eader a(ts as a reso"r(e person and fa(i$itator) Laisse/ faire $eaders ass"me a passi'e approa(h# .ith the de(ision ma1ing $eft to the gro"p) A"to(rati( $eadership dominates the gro"p# .ith
maintenan(e of strong (ontro$ o'er the gro"p) Sit"ationa$ $eadership is %ased on the ("rrent e'ents of the da&) ,2! C - Restraints sho"$d ne'er %e app$ied tight$& %e(a"se that (o"$d impair (ir("$ation) The restraint sho"$d %e app$ied se("re$& 5not tight$&! to pre'ent the ($ient from s$ipping thro"gh the restraint and endangering himse$f or herse$f) A safet& 1not sho"$d %e "sed %e(a"se it (an easi$& %e re$eased in an emergen(&) Restraints# espe(ia$$& $im% restraints# m"st %e re$eased e'er& , ho"rs 5or per agen(& po$i(&! to inspe(t the s1in for a%norma$ities) The (a$$ $ight m"st a$.a&s %e .ithin the ($ients rea(h in (ase the ($ient needs assistan(e) ,! D - Tooth%r"shing# snee/ing# (o"ghing# nose %$o.ing# and %ending are a(ti'ities that sho"$d %e a'oided postoperati'e$& in the ($ient .ho "nder.ent a h&poph&se(tom&) These a(ti'ities interfere .ith the hea$ing of the in(ision and (an disr"pt the graft) Options A# +# and C are appropriate postoperati'e inter'entions) ,,! + - Wrist and an1$e restraints are de'i(es "sed to $imit the ($ients mo'ement in sit"ations .hen it is ne(essar& to immo%i$i/e a $im%) The& are app$ied to pre'ent the ($ient from in7"ring se$f or othersF from p"$$ing o"t intra'eno"s $ines# (atheters# or t"%esF or from remo'ing dressings) Restraints a$so ma& %e "sed to 1eep (hi$dren sti$$ and from in7"ring themse$'es d"ring treatments and diagnosti( pro(ed"res) Restraints are not app$ied to 1eep a ($ient in %ed at night and sho"$d ne'er %e "sed as a form of p"nishment) ,0! A - The ($ient in a state of star'ation has a (ompromised imm"ne s&stem) Ga'ing a roommate .ith pne"monia .o"$d p$a(e the ($ient at ris1 for infe(tion) Options +# C# and D are appropriate roommates)
,3! D Mo%i$it& of the ($ient .ith h&perparath&roidism sho"$d %e en(o"raged as m"(h as possi%$e %e(a"se of the (a$(i"m im%a$an(e that o(("rs in this disorder and the predisposition to the formation of rena$ (a$("$i) $"ids sho"$d not %e restri(ted) Options A and C are not spe(i*(a$$& asso(iated .ith this disorder) ,8! A N"rse-managed ($ini(s fo("s on indi'id"a$i/ed disease pre'ention and hea$th promotion and maintenan(e) Therefore the n"rse m"st *rst assess the ($ients and their needs in order to e6e(ti'e$& p$an the program) Options +# C# and D do not address the ($ients needs) ,;! C - In this sit"ation# the n"rse has noted an "n"s"a$ o(("rren(e# %"t %efore de(iding .hat a(tion to ta1e ne4t# the n"rse needs more data than 7"st s"spi(ion) This (an %e o%tained %& re'ie.ing the ($ients re(ord) State and federa$ $a%or and opioid reg"$ations# as .e$$ as instit"tiona$ po$i(ies and pro(ed"res# m"st %e fo$$o.ed) It is therefore most appropriate that the n"rse dis("ss the sit"ation .ith the n"rsing s"per'isor %efore ta1ing f"rther a(tion) The ($ient does not need an in(rease in opioids) To reassign the L?N to ($ients not re(ei'ing opioids ignores the iss"e) A (onfrontation is not the most ad'isa%$e a(tion %e(a"se it (o"$d res"$t in an arg"mentati'e sit"ation) ,>! A - M&asthenia gra'is (an a6e(t the ($ients a%i$it& to s.a$$o.) The primar& assessment is to determine the ($ients a%i$it& to hand$e ora$ medi(ations or an& ora$ s"%stan(e) Options + and C are not appropriate) Option + (o"$d res"$t in aspiration and option C has no "sef"$ p"rpose) There is no spe(i*( reason for the ($ient to 'oid %efore ta1ing this medi(ation) ,@! D
- ?rimar& n"rsing is (on(erned .ith 1eeping the n"rse at the %edside a(ti'e$& in'o$'ed in dire(t (are .hi$e p$anning goa$-dire(ted# indi'id"a$i/ed ($ient (are) Option A identi*es a (omponent of (ase management) Option + identi*es f"n(tiona$ n"rsing) Option C identi*es team n"rsing)
- The proposed pro7e(t is resear(h and in($"des h"man s"%7e(ts) A$tho"gh options +# C# and D need to %e (onsidered# the& are a$$ se(ondar& to the o'erriding prin(ip$e of the $ega$ and ethi(a$ pra(ti(e of n"rsing that an& ($ient has the right to ref"se to parti(ipate in resear(h "sing h"man s"%7e(ts)
,! D
00! C
Case management represents an interdis(ip$inar& hea$th (are de$i'er& s&stem to promote appropriate "se of hospita$ personne$ and materia$ reso"r(es to ma4imi/e hospita$ re'en"es .hi$e pro'iding for optima$ ($ient (are) It manages ($ient (are %& managing the ($ient (are en'ironment)
- ?arti(ipati'e $eadership demonstrates an in%et.een st&$e# neither a"thoritarian nor demo(rati( st&$e) In parti(ipati'e $eadership# the manager presents an ana$&sis of pro%$ems and proposa$s for a(tions to team mem%ers# in'iting (riti<"e and (omments) The parti(ipati'e $eader then ana$&/es the (omments and ma1es the *na$ de(ision) A $aisse/-faire $eader a%di(ates $eadership and responsi%i$ities# a$$o.ing sta6 to .or1 .itho"t assistan(e# dire(tion# or s"per'ision) The a"to(rati( st&$e of $eadership is tas1 oriented and dire(ti'e) The sit"ationa$ $eadership st&$e "ti$i/es a st&$e depending on the sit"ation and e'ents)
02! C - Barian(es are a(t"a$ de'iations or deto"rs from the (riti(a$ paths) Barian(es (an %e either positi'e or negati'e# or a'oida%$e or "na'oida%$e and (an %e (a"sed %& a 'ariet& of things) ?ositi'e 'arian(e o(("rs .hen the ($ient a(hie'es ma4im"m %ene*t and is dis(harged ear$ier than anti(ipated) Negati'e 'arian(e o(("rs .hen "nto.ard e'ents pre'ent a time$& dis(harge) Barian(e ana$&sis o(("rs (ontin"a$$& in order to anti(ipate and re(ogni/e negati'e 'arian(e ear$& so that appropriate a(tion (an %e ta1en) Option + is the on$& option that identi*es the need for f"rther a(tion)
03! C Option C empo.ers the (harge n"rse to assist the sta6 n"rse .hi$e tr&ing to identif& and red"(e the %eha'iors that ma1e it di=("$t for the sta6 n"rse to f"n(tion) Options A# +# and D are p"niti'e a(tions# shift the %"rden to other .or1ers# and do not so$'e the pro%$em)
0! D
08! D
- The fami$& or a $ega$ g"ardian (an ma1e treatment de(isions for the ($ient .ho is "na%$e to do so) On(e the de(ision is made# the ph&si(ian .rites the order) Henera$$&# the fami$& ma1es de(isions in (o$$a%oration .ith ph&si(ians# other hea$th (are .or1ers# and other tr"sted ad'isors) A$tho"gh a .ritten order %& the ph&si(ian is ne(essar&# the n"rse *rst (he(1s for do("mentation of the fami$&s re<"est) 9n$ess spe(ia$ (ir("mstan(es e4ist# a (o"rt order is not ne(essar&) A$tho"gh some hea$th (are agen(ies ma& re<"ire re'ie.ing s"(h re<"ests 'ia the Ethi(s Committee# this is not the n"rses *rst a(tion)
- The n"rse sho"$d do("ment tas1 (omp$etion (ontin"o"s$& thro"gho"t the da&) Options A# +# and C identif& a(("rate (omponents of time management)
0,! A
0;! A - Barian(e ana$&sis o(("rs (ontin"a$$& as the (ase manager and other (aregi'ers monitor ($ient o"t(omes against (riti(a$ paths) The goa$ of (riti(a$ paths is to anti(ipate and re(ogni/e negati'e 'arian(e ear$& so that appropriate a(tion (an %e ta1en) A negati'e 'arian(e o(("rs .hen "nto.ard e'ents pre($"de a time$& dis(harge and the $ength of sta& is $onger than p$anned for a ($ient on a
spe(i*( (riti(a$ path) Options +# C and D are in(orre(t)
to ha'e an emergen(& (art 5.hi(h (ontains a $ar&ngos(ope! at the %edside# %"t a (art sho"$d %e a'ai$a%$e in the treatment room or on the n"rsing "nit)
0>! A
3! C
- The a"to(rati( st&$e of $eadership is tas1 oriented and dire(ti'e) The $eader "ses his or her po.er and position in an a"thoritarian manner to set and imp$ement organi/ationa$ goa$s) De(isions are made .itho"t inp"t from the sta6) Demo(rati( st&$es %est empo.er sta6 to.ard e4(e$$en(e %e(a"se this st&$e of $eadership a$$o.s n"rses to pro'ide inp"t regarding the de(ision-ma1ing pro(ess and an opport"nit& to gro. professiona$$&) The sit"ationa$ $eadership st&$e "ti$i/es a st&$e depending on the sit"ation and e'ents) The $aisse/-faire st&$e a$$o.s sta6 to .or1 .itho"t assistan(e# dire(tion# or s"per'ision)
- A 'est restraint sho"$d ne'er %e app$ied tight$& %e(a"se it (o"$d impair respirations) A hit(h 1not ma& %e "sed on the ($ient %e(a"se it (an easi$& %e re$eased in an emergen(&) The (a$$ $ight m"st a$.a&s %e .ithin the ($ients rea(h in (ase the ($ient needs assistan(e) The restraint needs to %e re$eased e'er& , ho"rs 5or per agen(& po$i(&! to pro'ide mo'ement)
0@! D - A n"rse m"st %e a%$e to f"n(tion at a $e'e$ that does not a6e(t the a%i$it& to pro'ide safe# <"a$it& (are) The highest priorit& is to determine ho. the i$$ness a6e(ts the n"rses a%i$it& to pra(ti(e) The other options .i$$ %e addressed if an in'estigation is (arried o"t) 0! C - When %eginning the (hange pro(ess# the n"rse sho"$d identif& and de*ne the pro%$em that needs impro'ement or (orre(tion) This important *rst step (an pre'ent man& f"t"re pro%$ems# %e(a"se# if the pro%$em is not (orre(t$& identi*ed# a p$an for (hange ma& %e aimed at the .rong pro%$em) This is fo$$o.ed %& goa$ setting# prioriti/ing# and identif&ing potentia$ so$"tions and strategies to imp$ement the (hange) 32! + - Toni(-($oni( sei/"res (a"se tightening of a$$ %od& m"s($es fo$$o.ed %& tremors) O%str"(ted air.a& and in(reased ora$ se(retions are the ma7or (omp$i(ations d"ring and fo$$o.ing a sei/"re) S"(tion is he$pf"$ to pre'ent (ho1ing and (&anosis) Options A and C are in(orre(t %e(a"se inserting an endotra(hea$ t"%e or a tra(heostom& is not done) It is not ne(essar&
3,!D - Ch$am&dia is a se4"a$$& transmitted disease) Caregi'ers (annot a(<"ire the disease d"ring administration of (are# and standard pre(a"tions are the on$& meas"re that needs to %e "sed)
30! C - ?roper (are of an ind.e$$ing "rinar& (atheter is espe(ia$$& important to pre'ent pro$onged infe(tion or reinfe(tion in the ($ient .ith (&stitis) The perinea$ area is ($eansed thoro"gh$& "sing mi$d soap and .ater at $east t.i(e a da& and fo$$o.ing a %o.e$ mo'ement) The drainage %ag is 1ept %e$o. the $e'e$ of the %$adder to pre'ent "rine from %eing trapped in the %$adder# and# for the same reason# the drainage t"%ing is not p$a(ed or $ooped "nder the ($ients $eg) The t"%ing m"st drain free$& at a$$ times)
33! D - A ($ient .ith a("te g$omer"$onephritis (ommon$& e4perien(es "id 'o$"me e4(ess and fatig"e) Inter'entions in($"de "id restri(tion as .e$$ as monitoring .eight and inta1e and o"tp"t) The ($ient ma& %e p$a(ed on %ed rest or at $east en(o"raged to rest# %e(a"se a dire(t (orre$ation e4ists %et.een protein"ria# hemat"ria# edema# and in(reased a(ti'it& $e'e$s) The diet is high in (a$ories %"t
$o. in protein) It is "nne(essar& to monitor the temperat"re as fre<"ent$& as e'er& , ho"rs) 38! D - A potentia$ (omp$i(ation of hemodia$&sis is the a(<"isition of dia$&sis-asso(iated hepatitis +) This is a (on(ern for ($ients 5.ho ma& (arr& the 'ir"s!# ($ient fami$ies 5at ris1 from (onta(t .ith the ($ient and .ith en'ironmenta$ s"rfa(es!# and sta6 5.ho ma& a(<"ire the 'ir"s from (onta(t .ith the ($ients %$ood!) This ris1 is minimi/ed %& the "se of standard pre(a"tions# appropriate hand.ashing and steri$i/ation pro(ed"res# and the prohi%ition of eating# drin1ing# or other hand-to-mo"th a(ti'it& in the hemodia$&sis "nit) The *rst n"rse sho"$d as1 the se(ond n"rse to stop eating and drin1ing in the ($ient area) 3;! D - +asi( r"$es for hand$ing e'iden(e in($"de $imiting the n"m%er of peop$e .ith a((ess to the e'iden(e# initiating a (hain of ("stod& $og to tra(1 hand$ing and mo'ement of e'iden(e# and (aref"$$& remo'ing of ($othing to a'oid destro&ing e'iden(e) This "s"a$$& in($"des ("tting ($othes a$ong seams# .hi$e a'oiding areas .here there are o%'io"s ho$es or tears) ?otentia$ e'iden(e is ne'er re$eased to the fami$& to ta1e home) 3>! + - ?roper hand.ashing pro(ed"re in'o$'es .etting the hands and .rists and 1eeping the hands $o.er than the forearms so that .ater o.s to.ard the *ngertips) The n"rse "ses 0 to 8 mL of soap and s(r"%s for 2 to 8 se(onds# "sing r"%%ing and (ir("$ar motions) The hands are rinsed and then dried# mo'ing from the *ngers to the forearms) The paper to.e$ is then dis(arded# and a se(ond one is "sed to t"rn o6 the fa"(et to a'oid hand (ontamination) 3@! C - N"rses are ad'ised not to do("ment the *$ing of an in(ident report in the n"rses notes for $ega$ reasons) In(ident reports inform the fa(i$it&s administration of the in(ident so that
ris1 management personne$ (an (onsider (hanges that might pre'ent simi$ar o(("rren(es in the f"t"re) In(ident reports a$so a$ert the fa(i$it&s ins"ran(e (ompan& to a potentia$ ($aim and the need for f"rther in'estigation) Options A# +# and D are a(("rate inter'entions) 3! D - N"rses are en(o"raged not to a((ept 'er%a$ orders from the ph&si(ian %e(a"se of the ris1s of error) The on$& e4(eption to this ma& %e in an emergen(& sit"ation# and then the n"rse m"st fo$$o. agen(& po$i(& and pro(ed"re) A$tho"gh the ($ient .i$$ %e informed of the (hange in the treatment p$an# this is not the appropriate a(tion at this time) The ph&si(ian needs to .rite the ne. order) It is inappropriate to as1 another indi'id"a$ other than the ph&si(ian to .rite the order) 82! C - N"rse ?ra(ti(e A(ts re<"ire reporting the s"spi(ion of impaired n"rses) The +oard of N"rsing has 7"risdi(tion o'er the pra(ti(e of n"rsing and ma& de'e$op p$ans for treatment and s"per'ision) This s"spi(ion needs to %e reported to the n"rsing s"per'isor# .ho .i$$ then report to the +oard of N"rsing) Confronting the (o$$eag"e ma& (a"se (oni(t) As1ing the (o$$eag"e to go to the n"rses $o"nge to s$eep for a.hi$e does not safeg"ard ($ients) 8! A - Whi$e on a (oo$ing %$an1et# the (hi$d sho"$d %e (o'ered $ight$& to maintain pri'a(& and red"(e shi'ering) Options +# C# and D are important inter'entions to pre'ent shi'ering# frost%ite# and s1in %rea1do.n)
8,! A - Se(ondar& pre'ention fo("ses on the ear$& diagnosis and prompt treatment of disease) Tertiar& pre'ention is represented %& reha%i$itation ser'i(es) Options +# C# and D identif& s(reening pro(ed"res) Option A identi*es a reha%i$itati'e ser'i(e)
80! + - When the n"rse as1s a .h& <"estion of the ($ient# the n"rse is re<"esting an e4p$anation for fee$ings and %eha'iors .hen the ($ient ma& not 1no. the reason) Re<"esting an e4p$anation is a nontherape"ti( (omm"ni(ation te(hni<"e) In option A# the n"rse is en(o"raging the 'er%a$i/ation of emotions or fee$ings# .hi(h is a therape"ti( (omm"ni(ation te(hni<"e) In option C# the n"rse is "sing the therape"ti( (omm"ni(ation te(hni<"e of e4p$oring# .hi(h in'o$'es as1ing the ($ient to des(ri%e something in more detai$ or to dis("ss it more f"$$&) In option D# the n"rse is "sing the therape"ti( (omm"ni(ation te(hni<"e of gi'ing information) Identif&ing the (ommon fear of death among ($ients .ith end-stage heart fai$"re ma& en(o"rage the ($ient to 'oi(e (on(erns) 83! D - When (omm"ni(ating .ith a hearingimpaired ($ient# the n"rse sho"$d spea1 in a norma$ tone to the ($ient and sho"$d not sho"t) The n"rse sho"$d ta$1 dire(t$& to the ($ient .hi$e fa(ing the ($ient# and he or she sho"$d spea1 ($ear$&) If the ($ient does not seem to "nderstand .hat is %eing said# the n"rse sho"$d e4press the statement di6erent$&) Mo'ing ($oser to the ($ient and to.ard the %etter ear ma& fa(i$itate (omm"ni(ation# %"t the n"rse needs to a'oid ta$1ing dire(t$& into the impaired ear) 88! A - After tonsi$$e(tom&# s"(tion e<"ipment sho"$d %e a'ai$a%$e# %"t s"(tioning is not performed "n$ess there is an air.a& o%str"(tion) C$ear# (oo$ $i<"ids are en(o"raged) Mi$1 and mi$1 prod"(ts are a'oided initia$$& %e(a"se the& (oat the throatF this (a"ses the (hi$d to ($ear the throat# there%& in(reasing the ris1 of %$eeding) Option C is an important inter'ention after an& t&pe of s"rger&) 8;! C
- A trape/e is essentia$ to a$$o. the ($ient to $ift straight "p .hi$e %eing mo'ed so that the amo"nt of p"$$ e4erted on the $im% in tra(tion is not a$tered) A foot %oard and e4tra pi$$o.s do not fa(i$itate mo'ing) Either an e$e(tri( %ed or a man"a$ %ed (an %e "sed for tra(tion# %"t this does not spe(i*(a$$& assist the ($ient .ith mo'ing in %ed) 8>! A - The %e$$ of the stethos(ope is not "sed to a"s("$tate %reath so"nds) The ($ient idea$$& sho"$d sit "p and %reathe s$o.$& and deep$& thro"gh the mo"th) The diaphragm of the stethos(ope# .hi(h is .armed %efore "se# is p$a(ed dire(t$& on the ($ients s1in# not o'er a go.n or ($othing)
8@! D - The s1in is ($eansed .ith soap and .ater 5not +etadine!# denat"red .ith a$(oho$# and a$$o.ed to air-dr& %efore e$e(trodes are app$ied) The other three options are (orre(t) 8! A - A <"iet# restf"$ en'ironment is pro'ided as part of sei/"re pre(a"tions) This in($"des "ndist"r%ed times for s$eep# .hi$e "sing a night$ight for safet&) The ($ient sho"$d %e a((ompanied d"ring a(ti'ities s"(h as %athing and .a$1ing# so that assistan(e is readi$& a'ai$a%$e and in7"r& is minimi/ed if a sei/"re %egins) The %ed is maintained in $o. position for safet&) ;2! + - A((ording to (ategor&-spe(i*( 5respirator&! iso$ation pre(a"tions# a ($ient .ith T+ re<"ires a pri'ate room) The room needs to %e .e$$'enti$ated and sho"$d ha'e at $east si4 e4(hanges of fresh air per ho"r and sho"$d %e 'enti$ated to the o"tside if possi%$e) Therefore# option , is the on$& (orre(t option)
