Ch 21 Nclex- managing patient care

Question 1

1. At 1200 the registered nurse (RN) says to the nursing assistive personnel (NAP), “You did a good job walking Mrs. Taylor by 0930. I saw that you recorded her pulse before and after the walk. I saw that Mrs. Taylor walked in the hallway barefoot. For safety, the next time you walk a patient, you need to make sure that the patient wears slippers or shoes. Please walk Mrs. Taylor again by 1500.” Which characteristics of positive feedback did the RN use when talking to the nursing assistant? (Select all that apply.)
2. Feedback is given immediately.
3. Feedback focuses on one issue.
4. Feedback offers concrete details.
5. Feedback identifies ways to improve.
6. Feedback focuses on changeable things.
7. Feedback is specific about what is done incorrectly only.

Answer 1

2,3,4,5

Question 2

2. As a nurse, you are assigned to four patients. Which patient do you need to see first?
3. The patient who had abdominal surgery 2 days ago who is requesting pain medication
4. A patient admitted yesterday with atrial fibrillation with decreased level of consciousness
5. A patient with a wound drain who needs teaching before discharge in the early afternoon
6. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery

Answer 2

2

Question 3

3. A nurse asks a nursing assistive personnel (NAP) to help the patient in room 418 walk to the bathroom right now. The nurse tells the NAP that the patient needs the assistance of one person and the use of a walker. The nurse also tells the NAP that the patient’s oxygen can be removed while he goes to the bathroom but to make sure that it is put back on at 2L. The nurse also instructs the NAP to make sure the side rails are up and the bed alarm is reset after the patient gets back in bed. Which of the following components of the “Five Rights of Delegation” were used by the nurse? (Select all that apply.)
4. Right task
5. Right circumstances
6. Right person
7. Right direction/communication
8. Right supervision/evaluation

Answer 3

1,2,3,4

Question 4

4. A patient asks a nurse what the patient-centered care model for the hospital means. What is the nurse’s best answer?
5. “This model ensures that all patients have private rooms when they are admitted to the hospital.”
6. “In this model you and the health care team are full partners in decisions related to your health care.”
7. “This model focuses on making the patient experience a good one by providing amenities such as restaurant-style food service.”
8. “Patients and families sign a document providing them full access to their medical charts.”

Answer 4

2

Question 5

5. While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient’s health care provider. The nurse is exercising:
6. Authority.
7. Responsibility.
8. Accountability.
9. Decision making.

Answer 5

3

Question 6

6. The staff on the nursing unit are discussing implementing interprofessional rounding. Which of the following statements correctly describe interprofessional rounding? (Select all that apply.)
7. Allows team members to share information about patients to improve care
8. Provides an opportunity for early patient discharge planning
9. Improves communication among health care team members
10. Allows each of the health care team members to identify separate patient goals
11. Allows each health care provider an opportunity to delegate a task.

Answer 6

1,2,3

Question 7

7. After a nurse receives a change-of-shift report on his assigned patients, he prioritizes the tasks that need to be completed. This is an example of a nurse displaying which practice?
8. Organizational skills
9. Use of resources
10. Time management
11. Evaluation

Answer 7

3

Question 8

8. A nurse is teaching a patient about wound care that will need to be done daily at home after the patient is discharged. This is which priority nursing need for this patient?
9. Low priority
10. High priority
11. Intermediate priority
12. Nonemergency priority

Answer 8

3

Question 9

9. A registered nurse (RN) is providing care to a patient who had abdominal surgery 2 days ago. Which task is appropriate to delegate to the nursing assistant?
10. Helping the patient ambulate in the hall
11. Changing surgical wound dressing
12. Irrigating the nasogastric tube
13. Providing brochures to the patient on health diet

Answer 9

1

Question 10

10. Which task is appropriate for a registered nurse (RN) to delegate to a nursing assistant?
11. Explaining to the patient the preoperative preparation before the surgery in the morning
12. Administering the ordered antibiotic to the patient before surgery
13. Obtaining the patient’s signature on the surgical informed consent
14. Helping the patient to the bathroom before leaving for the operating room

Answer 10

4

Question 11

11. Which of the following are components of interprofessional collaboration? (Select all that apply.)
12. Interprofessional education does not impact the collaboration among interprofessional team members.
13. Nurses are often viewed as the team leader because of their coordination of patient care.
    290
14. Effective interprofessional collaboration requires mutual respect and trust from all team members.
15. Open communication improves the collaboration among the interprofessional team members.
16. The goal of interprofessional collaboration is to improve the quality of patient care.

Answer 11

2,3,4,5

Question 12

12. A registered nurse performs the following four steps in delegating a task to a nursing assistant. Place the steps in the order of appropriate delegation.
13. Do you have any questions about walking Mr. Malone?
14. Before you take him for his walk to the end of the hallway and back, please take and record his pulse rate.
15. In the next 30 minutes please assist Mr. Malone in room 418 with her afternoon walk.
16. I will make sure that I check with you in about 40 minutes to see how the patient did.

Answer 12

3,2,4,1

Question 13

13. Which example demonstrates a nurse performing the skill of evaluation?
14. The nurse explains the side effects of the new blood pressure medication ordered for the patient.
15. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering the pain medication.
16. After completing the teaching, the nurse observes a patient draw up and administer an insulin injection.
17. The nurse changes a patient’s leg ulcer dressing using aseptic technique.

Answer 13

3

Question 14

14. The nurse manager from the surgical unit was awarded the nursing leadership award for practice of transformational leadership. Which of the following are characteristics or traits of transformational leadership displayed by award winner? (Select all that apply.)
15. The nurse manager regularly rounds on staff to gather input on unit decisions.
16. The nurse manager sends thank-you notes to staff in recognition of a job well done.
17. The nurse manager sends memos to staff about decisions that the manager has made regarding unit policies.
18. The nurse manager has an “innovation idea box” to which staff are encouraged to submit ideas for unit improvements.
19. The nurse develops a philosophy of care for the staff.

Answer 14

1,2,4

Question 15

15. A nurse assesses patients and uses assessment findings to identify patient problems and develop an individualized plan of care. The nurse is displaying:
16. Organizational skills.
17. Use of resources.
18. Priority setting.
19. Clinical decision making.

Answer 15

4