KAPLAN PREP Flashcards
What is the primary focus of the NCLEX-rn?
a. Performance appraisal
b. evaluation of nursing schools
c. Assessment of the minimum competency
d. Measurement of the quality of care
c. CORRECT (assessment of the minimum competency)
rationale:
measures minimum competency to perform safe client care as a new nursing graduate at the generalist level. It is adopted by all 50 states and Canada and is a United States examination
The nursing team consists of 2 nurses, 2 LPNs and 2 UAPs. The nurse considers the assignment appropriate if an LPN/LVN is required to complete which of the following tasks?
- Perform a sterile dressing change
- Obtain vital signs
- Stock supplies of syringes and dressings
- Transfer a stable client to an x-ray
- correct (perform a sterile dressing change)
rationale: LPN/LVNs assist with implementation of care, perform procedures, differentiate normal from abnormal, care for stable clients with predictable outcomes, have knowledge of asepsis and dressing changes, and may administer medications, which varies with educational background and state nurse practices act - is appropriate for a UAP: assist with direct care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable clients, and stocking supplies.
- is appropriate for a UAP
- is appropriate for a UAP
The nurse understands which document is a legal document and enforceable by law?
- Standards of care
- Code of ethics
- Nurse practices act
- Nursing organized by-laws
- Correct (nurse practices act)
rationale: Nurse practice acts a legal code and have the force of the lawfully behind them. The acts are specific statutes and are passed by the state legislature, which defines and regulate nursing practice within each state. The act addresses licensure and entry into practice requirements, define the scope of practice, and establish a Board of nursing for oversight and enforcement of the act.
- —————————————————————– - the standards of nursing care might be used as a criterion in legal activities such as malpractice lawsuits when the quality of the nursing practice is evaluated. If they are violated, disciplinary action by the state board of nursing can result on the basis of not acting professionally
- the code of ethics lists values and standards of conduct of a profession, serving to quide practice and decision making. It deals with the rightness and wrongness of actions
- By laws are secondary laws or rules that govern the internal affairs of an organization and don not have the force of law behind them
The nurse from the pediatric unit is assigned to the pediatric unit. Which client assignment is the most appropriate for the reassigning nurse?
- A psychotic client who hears the devil saying, “Kill yourself.”
- A suicidal client who voices a plan to jump off a bridge today
- A client diagnosed with depression and a decreased appetite
- An adolescent client who has vomited every day for 3 months
- CORRECT (a client diagnosed with depression and decreased appetite)
rationale: this is the most stable patient, exhibiting predictable behavior related to diagnosis. The nurse reassigned to an unfamiliar unit should be assigned a stable client with predictable outcomes
- —————————————————————————— - this client is unstable and unpredictable and is at high risk for self-harm
- same as above
- The behavior by the client describes bulimia, although the client is pediatric, the behavior indicates an unstable client and unpredictable outcome who requires skills of a nurse with psychiatric experience
The nurse manager is hired for a pediatric unit. The nurse manager states in a meeting, “I run my unit with a lot of control and make all the decisions.” The staff recognizes the nurse manager is practicing which leadership style?
- Autocratic
- Laissez-faire
- Democratic
- Situational
- CORRECT (autocratic)
rationale: an autocratic leader gives orders and makes decisions. This style may be an efficient way to run things and works best in time for a crisis. Autocratic leadership usually stifles creativity and decreases motivation for staff
- —————————————————————————— - Laissez-faire leader gives up control and turns overall decision-making to the group. Group members receive little or no direction. A laissez-faire leader can be effective if the group is highly motivated and mature and the tasks routine or uncomplicated
- Democratic leader is primarily concerned with the relationship and teamwork. It contributes to the growth and development of the staff because planning and decision-making are shared with the group
- This style of leader is determined by the situation and the needs of the staff. They are supportive, coaching, directing, delegating. the leader must be flexible and address the needs of the group
The nurse team caring for clients on the pediatric unit consists of 2 nurses, 2 LPN/LVNs, and 2 UAP. Which client does the nurse assign to the LPN/LVN?
- the client is admitted with asthma
- the client in balanced suspension traction for a fractured left femur
- the client is admitted for intestinal bleeding
- the client admitted for ingesting a grandparent’s ant-hypertensive medication
- Correct (the client in balanced suspension traction for a fractured left femur)
rationale: this is a stable client with a predictable outcome. caring for a patient in balanced traction is a skill that may be performed by the LPN/LVN. The nurse will assure that the weights hang freely and frequently inspect the skin for skin breakdown. LPN/LVN assists with the implementation of care performs procedures, differentiates normal from abnormal, cares for stable clients with predictable outcomes, has knowledge of asepsis and dressing changes, and may administer medications. Medication administration varies with educational background and state nurse practice acts
- ———————————————————————- - this is an unstable client with unpredictable outcomes. The nurse will assess the breath sounds and respiratory effort
- This is an unstable and unpredictable client. The client requires frequent assessment of the nurse and collaboration with the healthcare team
- This is an unstable client with unpredictable outcomes at high risk for complications. This client requires frequent assessment by the nurse and collaboration with the healthcare team
The nurse collapses minutes after putting on latex gloves, and the cardiac team successfully resuscitates the nurse. The nurse manager discusses that certain workers may be at greater risk for latex allergies than others. After reviewing the medical histories of the nurses on the unit, the nurse manager determines which nurse can safely use latex products?
- The nurse with a history of allergies to pollen and grass
- The nurse with a history of allergies to bananas and kiwi
- The nurse has a history of multiple surgeries
- The nurse with a history or GI upset
- CORRECT (the nurse w/ a hx of GI upset)
rationale: this in not an indication that a nurse is at risk for latex allergies
—————————————————————————
1, 2, 3, all are risk for latex allergy
The nursing team consists of 2 Nurses, 2 LPN/LVN, 2 UAP, which client assigned to the LPN/LVN does the LPN/LVN question?
- the infant client requiring a bath prior to discharge
- the infant client with a palpable olive-shaped mass in the epigastrium and frequent vomiting
- the infant client requiring eye drops instilled
- the infant client requiring a rectal temperature taken every 6 hours
- CORRECT (the infant that has signs of pyloric stenosis)
rationale:
the client is not stable and requires further assessment
—————————————————————————- - this task can be assigned to the UAP or LPN/LVN
- Administration of eye drops is an appropriate assignment for the LPN/LVN
- Taking and recording vital signs is an appropriate assignment for the LPN/LVN or UAP. the nurse communicates expected parameters for vital signs and when to report findings to the nurse
SOAP note stands for :
subjective, objective, assessment, plan
An outside change agent consultant informs the nurse manager that most of the staff on the medical unit can be classified as “early majority” in terms of their behavioral patterns in response to change. The manager understands this to have which meaning?
- the staff will not be the first to accept a change, nor will they be the last
- the staff will thrive on change and see it as an exciting adventure which can advance their careers
- the staff will be open and receptive to new ideas and will be sought out by others
- the staff will be openly negative about changes and adopt them only after most others have done so
- CORRECT (the staff will not be the first to accept a change, nor will they be the last)
rationale:
early majority people have a preference for the status quo, or what has been done in the past. they will accept new ideas eventually, usually before the average person has done so. The listing of behavioral patterns in response to change proceeds from quickest to adopt to slowest to adopt (innovators, early adopters, early majority, late majority, laggards, rejectors)
———————————————————————————
The nurse was asked to resign after consistently failing to report changes in the client’s condition. The nurse subsequently applied for a staff nurse position in another hospital. Which action is BEST for the nurse manager to take when the potential new employer asks for a reference?
- consult an attorney
- inform the potential employer that the nurse resigned
- inform the new employer about the occurrences
- ignore the request for a reference
- CORRECT (inform the new employer about the occurrences)
rationale: the nurse manager will inform the potential employer that there was sufficient information to warrant discharge. Qualified privilege allows communication that occurs in good faith between persons who need to know. This allows employers to give factual, objective information
- ——————————————————————————–
The RN assesses clients for the day shift. The nursing team includes one RN, 2 LPN/LVNs, and 4 nursing assistant personnel (NAP). The nurse determines assignments are appropriate if which client is assigned to the NAP?
- the client diagnosed with Crohn’s disease requiring a sterile dressing change
- the client diagnosed with chronic kidney failure requiring intake and output
- the client diagnosed with full-thickness burns to require IV morphine prior to a dressing change
- The client diagnosed with cancer of the lung reporting a headache
- CORRECT (the client diagnosed with chronic kidney failure requiring intake and output)
- —————————————————————— - sterile dressing change should be assigned to the LPN/LVN
- the RN should care for this client, IV medication is within the scope and practice of the RN
- the patient requires a nursing assessment, the RN should care for this client as assessment falls within the scope of practice for the RN
The nurse manager wants to implement a 3-day work week on the nursing schedule. The nurse manager states, “anyone who doesn’t go along with the change will not receive vacation time this year.” The staff identifies that the nurse manager is demonstrating which type of power?
- coercive power
- reward power
- expert power
- referent power
- CORRECT (coercive power)
rationale:
coercive power is derived from fear and the ability to punish. this type of leader uses power to influence staff in order to achieve goals.
——————————————————————- - reward power is the ability to provide favors or promise money or other benefits (ex: manager would reward staff with promotions)
- expert power derives from the knowledge and skills that one has developed (ex: a nurse instructing a client about how to manage diabetes and expert power)
- The basis for referent power is the desire of a follower to be like a leader (ex: students would emulate the behavior of nursing instructors and staff nurses
The nurse notices a client diagnosed with major depression crying in the day room. The nurse puts a hand over the client’s shoulder and states, “Lets talk about it.” Which ethical principle describes the nurse’s action?
- autonomy
- veracity
- non-maleficence
- beneficence
- CORRECT (beneficence)
rationale:
beneficence is the action that promotes goodwill. This ethical principle requires the nurse to help clients meet all of their needs
autonomy
is the right to choose and the freedom to make decisions for oneself. It is accomplished by providing information and supporting the client’s choices
Veracity
is telling the truth completely. Intentionally deceiving a client is a violation of this principle
Non-maleficence
is the principle to do no harm, It requires nurses to protect clients from danger and to protect clients who cannot protect themselves
NAPs
assist with direct client care activities (bathing, transferring, ambulation, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable clients, and stocking supplies) assign standard, unchanging procedures, delegation in the reassignment of responsibility for the performance of a job from one person to another, the responsibility for the task is transferred, but the accountability for the process or outcome of the task remains with the delegator
LPN/LVN assists
LPN/LVN assists with the implementation of care performs procedures, differentiates normal from abnormal, cares for stable clients with predictable outcomes, has knowledge of asepsis and dressing changes, and may administer medications. Medication administration varies with educational background and state nurse practice acts
The nurse receives an assignment for the night shift. Which task is appropriate for the nurse to delegate to the UAP with 20 years of experience?
- assess the breathing pattern of an asthmatic client
- Monitor a client who is expectorating rust-colored sputum
- Administer codeine to a postoperative client
- Bathe a client prior to the scheduled 0600 surgery
- CORRECT (bathe a client prior to the 0600 surgery)
rationale: this is a standard, unchanging procedure. The UAPs assist with direct care activities (ADLS)
- —————————————————————————– - this is an assignment for the nurse
- this is an assignment for the nurse
- the nurse will administer codeine
The nurse cant delegate clients who require?
assessment
teaching
or nursing judgment
The Psychiatric nurse is presented with a group of clients in the emergency department. Which client needs immediate attention?
- a young adult client who failed medical school and says, “My pain will be over soon.”
- An adult client who is unable to talk in front of other people due to symptoms of anxiety
- A middle-aged client who hears voices saying to harm others
- A middle-aged client who is anxious after witnessing a murder
- Correct ( a young adult client who failed medical school and says, “my pain will be over soon.”
rationale: the client is indicating thoughts of suicide and is at immediate risk for self-harm. The nurse should place the client in immediate one to one observation and stay with the client to help control self-destructive impulses
- ————————————— - this client does not need immediate attention
- This client should be the second client seen in this situation. the client is at risk for harming others
- This client does not require immediate attention. The client may be experiencing PTSD syndrome
What are some indications of anxiety?
increased pulse, increased blood pressure, increased respiration, perspiring and flushing and describe heat sensations
The nurse on the cardiac unit recognizes which as the primary goal of managed care?
- cost containment
- Quality of client care
- Ethical decision making
- Teaching clients self-management skills
- CORRECT (cost containment)
rationale: the goal of managed care is reduced healthcare costs and the focus is on client outcomes. It uses an interdisciplinary approach, employing clinical or critical pathways (care maps) as foundations for care activities and timelines. Monitoring medical usage is critical in managed care
2, 3, and 4 are not goals of managed care