KAPLAN PREP

Question 1

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

Answer 1

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

Question 2

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?

1. Perform a sterile dressing change
2. Obtain vital signs
3. Stock supplies of syringes and dressings
4. Transfer a stable client to an x-ray

Answer 2

1. 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
2. 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.
3. is appropriate for a UAP
4. is appropriate for a UAP

Question 3

The nurse understands which document is a legal document and enforceable by law?

1. Standards of care
2. Code of ethics
3. Nurse practices act
4. Nursing organized by-laws

Answer 3

3. 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.
   - —————————————————————–
4. 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
5. 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
6. 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

Question 4

The nurse from the pediatric unit is assigned to the pediatric unit. Which client assignment is the most appropriate for the reassigning nurse?

1. A psychotic client who hears the devil saying, “Kill yourself.”
2. A suicidal client who voices a plan to jump off a bridge today
3. A client diagnosed with depression and a decreased appetite
4. An adolescent client who has vomited every day for 3 months

Answer 4

3. 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
   - ——————————————————————————
4. this client is unstable and unpredictable and is at high risk for self-harm
5. same as above
6. 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

Question 5

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?

1. Autocratic
2. Laissez-faire
3. Democratic
4. Situational

Answer 5

1. 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
   - ——————————————————————————
2. 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
3. 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
4. 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

Question 6

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?

1. the client is admitted with asthma
2. the client in balanced suspension traction for a fractured left femur
3. the client is admitted for intestinal bleeding
4. the client admitted for ingesting a grandparent’s ant-hypertensive medication

Answer 6

2. 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
   - ———————————————————————-
3. this is an unstable client with unpredictable outcomes. The nurse will assess the breath sounds and respiratory effort
4. This is an unstable and unpredictable client. The client requires frequent assessment of the nurse and collaboration with the healthcare team
5. 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

Question 7

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?

1. The nurse with a history of allergies to pollen and grass
2. The nurse with a history of allergies to bananas and kiwi
3. The nurse has a history of multiple surgeries
4. The nurse with a history or GI upset

Answer 7

4. 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

Question 8

The nursing team consists of 2 Nurses, 2 LPN/LVN, 2 UAP, which client assigned to the LPN/LVN does the LPN/LVN question?

1. the infant client requiring a bath prior to discharge
2. the infant client with a palpable olive-shaped mass in the epigastrium and frequent vomiting
3. the infant client requiring eye drops instilled
4. the infant client requiring a rectal temperature taken every 6 hours

Answer 8

2. CORRECT (the infant that has signs of pyloric stenosis)
   rationale:
   the client is not stable and requires further assessment
   —————————————————————————-
3. this task can be assigned to the UAP or LPN/LVN
4. Administration of eye drops is an appropriate assignment for the LPN/LVN
5. 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

Question 9

SOAP note stands for :

Answer 9

subjective, objective, assessment, plan

Question 10

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?

1. the staff will not be the first to accept a change, nor will they be the last
2. the staff will thrive on change and see it as an exciting adventure which can advance their careers
3. the staff will be open and receptive to new ideas and will be sought out by others
4. the staff will be openly negative about changes and adopt them only after most others have done so

Answer 10

1. 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)
   ———————————————————————————

Question 11

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?

1. consult an attorney
2. inform the potential employer that the nurse resigned
3. inform the new employer about the occurrences
4. ignore the request for a reference

Answer 11

3. 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
   - ——————————————————————————–

Question 12

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?

1. the client diagnosed with Crohn’s disease requiring a sterile dressing change
2. the client diagnosed with chronic kidney failure requiring intake and output
3. the client diagnosed with full-thickness burns to require IV morphine prior to a dressing change
4. The client diagnosed with cancer of the lung reporting a headache

Answer 12

2. CORRECT (the client diagnosed with chronic kidney failure requiring intake and output)
   - ——————————————————————
3. sterile dressing change should be assigned to the LPN/LVN
4. the RN should care for this client, IV medication is within the scope and practice of the RN
5. the patient requires a nursing assessment, the RN should care for this client as assessment falls within the scope of practice for the RN

Question 13

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?

1. coercive power
2. reward power
3. expert power
4. referent power

Answer 13

1. 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.
   ——————————————————————-
2. reward power is the ability to provide favors or promise money or other benefits (ex: manager would reward staff with promotions)
3. 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)
4. 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

Question 14

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?

1. autonomy
2. veracity
3. non-maleficence
4. beneficence

Answer 14

4. CORRECT (beneficence)
   rationale:
   beneficence is the action that promotes goodwill. This ethical principle requires the nurse to help clients meet all of their needs

Question 15

autonomy

Answer 15

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

Question 16

Veracity

Answer 16

is telling the truth completely. Intentionally deceiving a client is a violation of this principle

Question 17

Non-maleficence

Answer 17

is the principle to do no harm, It requires nurses to protect clients from danger and to protect clients who cannot protect themselves

Question 18

NAPs

Answer 18

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

Question 19

LPN/LVN assists

Answer 19

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

Question 20

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?

1. assess the breathing pattern of an asthmatic client
2. Monitor a client who is expectorating rust-colored sputum
3. Administer codeine to a postoperative client
4. Bathe a client prior to the scheduled 0600 surgery

Answer 20

4. CORRECT (bathe a client prior to the 0600 surgery)
   rationale: this is a standard, unchanging procedure. The UAPs assist with direct care activities (ADLS)
   - —————————————————————————–
5. this is an assignment for the nurse
6. this is an assignment for the nurse
7. the nurse will administer codeine

Question 21

The nurse cant delegate clients who require?

Answer 21

assessment
teaching
or nursing judgment

Question 22

The Psychiatric nurse is presented with a group of clients in the emergency department. Which client needs immediate attention?

1. a young adult client who failed medical school and says, “My pain will be over soon.”
2. An adult client who is unable to talk in front of other people due to symptoms of anxiety
3. A middle-aged client who hears voices saying to harm others
4. A middle-aged client who is anxious after witnessing a murder

Answer 22

1. 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
   - —————————————
2. this client does not need immediate attention
3. This client should be the second client seen in this situation. the client is at risk for harming others
4. This client does not require immediate attention. The client may be experiencing PTSD syndrome

Question 23

What are some indications of anxiety?

Answer 23

increased pulse, increased blood pressure, increased respiration, perspiring and flushing and describe heat sensations

Question 24

The nurse on the cardiac unit recognizes which as the primary goal of managed care?

1. cost containment
2. Quality of client care
3. Ethical decision making
4. Teaching clients self-management skills

Answer 24

1. 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

Question 25

The nurse evaluates clients in the gastrointestinal clinic. WHich does the nurse see FIRST?

1. a middle-aged client diagnosed with IBS and reports cramping and loose stools
2. a young adult client reports not having a BM in 2 days
3. A school-aged client diagnosed with gastroenteritis who have had five diarrheal stools in 3 days
4. a newborn client experiencing projectile vomiting and irritability

Answer 25

4. CORRECT (a newborn client experiencing projectile vomiting)
   rationale: the client’s symptoms indicate pyloric stenosis. The infant is at risk for fluid and electrolyte imbalance and requires immediate attention
   - —–
5. these are symptoms of IBS and the nurse should encourage the client to eat meals at regular intervals, chew food slowly, and avoid drinking fluids with meals
6. the client may be constipated, the nurse should determine the client’s BM patterns and encourage fluids and fiber to increase roughage
7. this is the SECOND client the nurse should see. The client does not require immediate attention but a child with frequent diarrheal stools has the potential for dehydration. Real problems take priority over potential problems

Question 26

The nurse reporting suspected child abuse is legally operating under which concept?

1. Good samaritan
2. duty to disclose
3. discretionary powers
4. expert witness

Answer 26

2. CORRECT (Duty to disclose)
   rationale: reporting suspected or known incidents of child abuse is a mandate that must be followed by nurses in most states. This legal duty to disclose is confidential information to appropriate authorities protects the nurse from liability, as long as the nurse believed
   - ———————————————–
3. Good Samaritan acts or laws exist to provide civil immunity for individuals who give care at the scene of an emergency such as an accident or disaster.
4. Discretionary powers refers to the freedom a public officer has to choose courses of action that are within the limits of authority
5. Expert witness is a person who testifies in a courtroom on a subject upon which she/he has special knowledge and the purpose is usually to educate the court and jury about the subject being considered

Question 27

The nurse plans assignments for the day after receiving the night shift report. Which client does the nurse see FIRST?

1. an adolescent client who took 100 mg methylphenidate and has a blood pressure of 160/110
2. a young client who requires a metered-dose inhaler
3. a young client with a short arm cast on the left arm
4. a middle-aged client diagnosed with hypothyroidism requiring a TSH level

Answer 27

1. CORRECT (an adolescent client who took 100 mg methylphenidate and has a blood pressure of 160/110)
   rationale: this is the most unstable client. Methylphenidate is a CNS stimulant used for ADHD. The blood pressure is elevated. Assess the client for restlessness, dilated pupils, tremors, and possible tonic-clonic seizures
   - ————————-
2. this is not a priority but they may need it
3. there are no indications of complications with the cast or fracture. Assess the client for complications such as circulatory impairment and peripheral nerve damage. This is not the priority client. The client would be seen second to assess for possible complications of cast placement
4. Routine monitoring of TSH levels is required during initial medication therapy. This client is stable. Symptoms of hypothyroidism are decreased activity level, sensitivity to cold, obesity, and weight gain

Question 28

Which change strategy is most likely to be used by nurse managers who consider attitudes, values, and interpersonal relationships to be very important?

1. Normative-reeducative strategies
2. Empirical-rational strategies
3. Power-coercive strategies
4. Historical-futuristic strategies

Answer 28

1. CORRECT (Normative-reeducative strategies)

Question 29

The nurse provides care for clients in a gynecological clinic. Which client does the nurse see FIRST?

1. a middle-aged client reporting varying a dry vaginal wall and painful intercourse
2. an adult client who had a hysterosalpingogram and is experiencing tachycardia and has a generalized rash
3. an adult client preparing for a cervical biopsy who reports feeling highly anxious
4. a young adult scheduled for a pap smear who reports heavy bleeding with menstruation

Answer 29

2. CORRECT (an adult client who had a hysterosalpingogram and is experiencing tachycardia and has a generalized rash)
   rationale: a hysterosalpingogram is an x-ray of the cervix, uterus, and fallopian tubes performed after the injection of a contrast medium. Tachycardia and rash indicate the client is having an allergic reaction and needs immediate attention. Prior to any diagnostic test in which contrast medium is used, the nurse should assess for allergy to shellfish or iodine
   - ———————————————
3. this does not require immediate attention and due to hormonal changes, these findings are not unusual
4. this client does not need immediate attention, but the anxiety should be addressed prior to the client undergoing the procedure. The client should be the second client seen. The health care provider usually performs a biopsy as a follow-up to suspicious Pap smear findings
5. Client does not need immediate attention, but look into the heavy bleeding and clarify and describe it

Question 30

The nurse is dissatisfied with the standard of care on the oncology unit. The nurse discusses this with other nurses and a local news station. Afterward, the nurse is asked to resign by the nurse manager. The nurse responds to the nurse manager, “You can’t fire me because I am protected by the whistle-blower law.” Which statement BEST describes why this nurse may be subject to being fired?

1. the nurse is working under a union contract
2. the nurse may not be covered by the whistle-blower law
3. the nurse follows the institution’s internal procedures
4. the nurse sends a copy of the complaint to the Director of Nursing

Answer 30

2. CORRECT (the nurse may not be covered by the whistle-blower law)
   rationale: this law varies from state to state and according to the subject matter

Question 31

Ten clients from a motor vehicle accident are transferred to the hospital. The nurse triages in the ED, which client does the nurse see FIRST?

1. a client with ecchymosis and lacerations to the facial area
2. a client who reports chest tightness and pressure
3. a client with a BP of 90/60 mmHg and apical pulse of 120 beats per minute
4. a client who reports dizziness and nervousness

Answer 31

3. CORRECT (a client with a BP of 90/60 mmHg and apical pulse of 120 beats per minute)
   rationale: this client is experiencing an actual problem and the vital signs indicate shock. This is the most unstable client
   - —————————————–
4. this client does not need immediate attention
5. this would be the SECOND client seen. Airway and breathing are high priority assessments and the client is at risk for potential problems
6. this is the most stable of the four clients
   * Using Maslow’s hierarchy of needs theory to prioritize client problems physiological needs take priority, actual problems require intervention before potential problems

Question 32

The nurse reviews documentation principles with newly assigned LPN/LVNs. Which document entry is an example reflecting subjective data?

1. T 99F, P 90 bpm, BP 128/88
2. CLient states, “ I have had pain in my stomach for three weeks now.”
3. Bowel sounds heard in all four quadrants
4. client ambulating with propulsion, unsteady gait

Answer 32

2. ## CORRECT (subjective data is information given by the client and reflects feelings and perceptions as well as concerns. It is best documented in the clients own words in quotes.the rest are objective data

Question 33

The charge nurse is having difficulty making an appropriate assignment for the nursing team. Which assessment by the supervisor helps the charge nurse make the assignment for the day shift?

1. “Describe the knowledge and skill level of each member of your team.”
2. “Do you know which assignment each staff member prefers?”
3. “How long has each staff member been employed on the unit?”
4. “Do you know if any staff members are working overtime today?”

Answer 33

1. CORRECT (describe the knowledge and skill level of each member of your team)
   rationale: the five rights of the delegation include:
2. right task
3. right circumstance
4. right person
5. right direction
6. right supervision
   - it is important to consider the knowledge and abilities of each staff member. Supervision consists of the initial direction (the delegation) and periodic inspection (reassessment and evaluation); both elements must be present to ensure effectiveness in entrusting an element of client care to another staff member

Question 34

The nurse educator wants to enhance the creative and critical thinking skills of the nurses on the medical-surgical unit. Which activity is BEST for the nurse educator to incorporate into an in-service in order to move towards this goal?

1. review of steps of critical pathways
2. demonstrations and return demonstrations
3. brainstorming experiences
4. true-false self-graded quizzes

Answer 34

3. CORRECT (brainstorming experiences) which involves participants freely, openly, quickly, expressing as many ideas about a problem area or issue as they can within a limited period of time. Criticism from themselves or anyone else is allowed during the process

Question 35

The nurse sees clients in the adolescent psychiatric clinic. Which client does the nurse see FIRST?

1. the school-aged client who reports impulsivity and poor attention span
2. the adolescent client who displays frequent loss of temper and agues with teachers
3. the adolescent client who wants to be a model and only drinks water and eats vegetables
4. the adolescent client who bullies, threatens, and intimidates others and frequently initiates physical fights

Answer 35

3. CORRECT (the adolescent client who wants to be a model and only drinks water and eats vegetables)
   rationale: this is the most unstable client with actual behaviors that could cause physical harm. The nurse should assess nutritional status and monitor for an eating disorder.
   - ———————–
4. this client is displaying ADHD and the behavior are not an immediate concern
5. the client is displaying oppositional-defiant disorder and has potential to hurt others and will need further assessment
6. the client would be the second client seen. the behaviors suggest a more immediate potential to harm others. the nurse will assess for conduct disorder

Question 36

The nursing team consists of 2 nurses, one LPN/LVN and 2 UAP. The nurse considers which assignment appropriate for the LPN/LVN to complete? (Select all that apply)?

1. obtain vital signs for the client immediately after ECT
2. assist the client with bathing and feeding
3. administer tube feeding for the client with dysphagia
4. discharge the client diagnosed with multiple sclerosis
5. teach the client how to administer a sub q injection
6. change the clean dressing for a client with a venous ulcer

Answer 36

3, 6 (CORRECT)
3- administer tube feedings
6-change the dressing
rationale: these two clients are appropriate assignments for the LPN/LVN and the nurse assigned them as they are stable clients with predictable outcomes
—————————————
1. nurses job and after the ECT, the nurse should orient the client, take BP, and respirations, and stay with the client during times of confusion. UAP can check vitals if the patient is stable, alert, oriented
2. appropriate for UAP
4. appropriate for the nurse, the nurse can’t delegate assessment, teaching, or nursing judgment
5. appropriate for the nurse, and same as number 4

Question 37

Four clients in the emergency department are reporting adverse effects from their medication. Which client does the nurse see first?

1. the client receiving clozapine and experiencing flu-like symptoms
2. the client receiving valproic acid and experiencing tremors
3. the client receiving lorazepam and experiencing abdominal discomfort
4. the client receiving methylphenidate who lost 5 lbs in 4 weeks

Answer 37

1. CORRECT (the client receiving clozapine and experiencing flu-like symptoms)
   rationale: this is an unstable client who may have agranulocytosis. Clozapine is an anti-psychotic; pregnancy risk B
   - ————————–
2. tremors are common when taking valproic acid, the HCP may order the levels to be checked
3. this client does not need immediate attention and lorazepam is an anti-anxiety and sedative-hypnotic medication
4. methylphenidate may cause decreased appetite and weight loss should be monitored this client does not need immediate attention

Question 38

The nurse is assigned to prioritize the care for clients in the psychiatric clinic. Which client does the nurse see first?

1. the adolescent client who was brought in by the police threatening to jump off a bridge and has access to a gun
2. the young adult client who lost 2 lbs this week only eating 2 meals
3. the middle-aged adult client with a history of depression who is out of fluoxetine
4. the older adult client whose spouse died 2 weeks ago and is experiencing insomnia and irritability

Answer 38

1. CORRECT
   rationale: using Maslow’s hierarchy of needs theory to prioritize, physiological issues take priority over psychological issues, This client is at risk for self-harm and must be seen first; observe for safety
   - —————-
2. weight loss is not excessive
3. the client needs a med refill, not urgent to be seen
4. maybe a normal part of grieving, the nurse should assess, but is not the priority.

Question 39

The nurse educator has just reviewed the concepts of group process roles with a group of nurse managers. One of the managers asks, “ Could you please explain what exactly is meant by the gatekeeper role?” Which response by the educator is best?

1. the gatekeeper decides who is to attend a meeting and who is not
2. the gatekeeper ensures that everyone has the opportunity to speak
3. the gatekeeper makes certain that the group starts and ends on time
4. the gatekeeper responds to interruptions from outside forces

Answer 39

2. CORRECT (gatekeeper ensures that everyone has the chance to speak)
   rationale: the gatekeeper is a group maintenance role (vs. task role) which focuses on keeping communication channels open and regulating communication within the group. The gatekeeper directly encourages or facilitates the participation of others, which has an impact on group acceptance of individual members, limits the time in order to regulate communication flow
   - ——–
3. this is role of group leader
4. this is more of the role of the group leader or of the standard-setter or rule-maker, which is a maintenance role that sets standards for group behavior
5. this is the responsibility of the actual group leader to help keep the group on task

Question 40

The nurse sees clients in the pediatric clinic. Which client does the nurse see FIRST?

1. the 5 yr old client diagnosed with autism and is displaying finger flapping
2. the 6 yr old client has enuresis and often urinates in the underwear
3. the 7 yr old client who is shy and has difficulty reading
4. the 9 yr old client who used a weapon against the parents and caused physical harm

Answer 40

4. CORRECT, this is an unstable client who is at risk for harm to self and others and needs to be seen first

Question 41

The nurse manager researches models of care delivery and decides to further explore primary nursing. The nurse manager identifies which model BEST describes primary nursing?

1. one nurse is responsible for the client’s total care throughout the client’s hospitalization
2. the staff members perform specific tasks for a large group of clients
3. the nurse leader is responsible for coordinating a group of licensed and unlicensed personnel to provide client care
4. a team of staff members is assigned to a specific area of the nursing unit and cares for clients in that area

Answer 41

1. CORRECT (one nurse is responsible for the client’s total care throughout the client’s hospitalization)
   rationale: the nurse is responsible for developing a plan of care and managing associate nurses and other staff who provide care to the client. This model of care increases professional job satisfaction for the nurse and increases client satisfaction. The disadvantage is that all nurses may not have the experience or educational background to provide total care
   - ——————-
2. this is a type of functional nursing (ex- medication nurse and treatment nurse)
3. this is team nursing (the team leader assigns each member specific responsibilities) the team is composed of a nurse, LPN, and UAP
4. this is an example of modular nursing, which is an updated version of team nursing. The focus is the layout of the nursing unit.

Question 42

The nurse discusses delegation with a new nurse. Which statement by the new nurse indicates an understanding of the meaning of delegation?

1. delegation means that the nurse is able to accept responsibility for the nursing actions and results
2. delegation occurs when the nurse assigns a specific function or aspect of client care to a licensed practical nurse (LPN/LVN) or UAP
3. delegation occurs when the nurse assigns a task the nurse does not have time to complete to another staff member
4. delegation means being obligated to accomplish the assigned work

Answer 42

2. CORRECT

1. this is an example of accountability

Question 43

The nurse reviews the care given by another nurse to a group of psychiatric clients. The nurse knows that this is what type of review?

1. peer review
2. quality review
3. performance appraisal
4. risk review

Answer 43

1. CORRECT (Peer review)
   rationale:
   peer review is the evaluation of an individual’s practice by colleagues who have similar education and experience is a peer review. The purpose is to provide the individual with feedback from the staff members who best understand the job requirements
   ————————
2. quality review is used to review the quality of client care to manage risks that are potentially considered poor standard of care
3. a performance appraisal is an evaluation of a nurse by a manager. It provides feedback to the employee in relation to individual performance
4. risk review identifies high-risk and problem-prone areas and develops a plan to correct against potential risks that would injure staff, clients, or visitors

Question 44

A client diagnosed with a stroke is admitted. The nurse notes the client has difficulty swallowing and requires assistance with bathing, toileting and feeding. The delegation is appropriate if the nurse delegates the tasks of bathing and toileting to which staff members?

1. UAP
2. the LPN/LVN
3. the speech therapist
4. the respiratory therapist

Answer 44

1. CORRECT (UAP)

Question 45

The nurse in the emergency department informs the client, “you will be seen in the next 30 minutes.” The client demands to see the Director of Nursing. Which action by the nurse is MOST appropriate?

1. report the situation to the nurse’s immediate supervisor
2. contact the health care providers supervisor
3. inform the client this is unreasonable behavior
4. contact the Director of nursing

Answer 45

1. CORRECT (report the situation to the nurse’s immediate supervisor)
   rationale: this follows the chain of command. The emphasis is on vertical relationships. The nurse reports to the nurse manager, who then reports to the director. The nurse reports problems and concerns to the next person with authority

Question 46

The nurse recruiter for a hospital addresses senior nursing students attending an open house in the facility. The recruiter states an advantage of working at the institution is they have recently implemented a clinical ladder system. Which is the BEST response by the recruiter?

1. a clinical ladder allows the nurse to stay at the bedside and still progress in the profession
2. a clinical ladder helps get supplies, medications, and lab samples up and down quickly to their destination
3. a clinical ladder provides each client with a customized step-by-step approach to managing illness
4. a clinical ladder provides a structure to enable a nurse to progress toward becoming a physician

Answer 46

1. CORRECT

Question 47

The nurse on the pediatric unit receives the night shift’s report and plans assignments for the day. Which client does the nurse see FIRST?

1. The client with leukemia reporting fatigue
2. the client diagnosed with Wilms tumor reporting thirst
3. the client diagnosed with hemophilia reporting joint pain
4. the client diagnosed with GERD reporting abdominal pain

Answer 47

3. CORRECT
   rationale: joint pain for a client diagnosed with hemophilia indicates acute bleeding into the joint. This client would need immediate intervention. Treatment includes administration of factor V111 and RICE (rest, ice, compression, and elevation)
   - ————-
4. this is expected of this
5. wilms tumor is a malignant neoplasm of the kidney
6. GERD is the backflow of gastric contents into the esophagus resulting from relaxation of the lower esophageal sphincter

Question 48

The nurse plans to delegate tasks to the unlicensed assistive personnel (UAP), Which task is within the UAP’s scope of practice and appropriate for the nurse to delegate?
(select all that apply)

1. obtain vital signs and document in the client’s medical record
2. feed the client and assess the risk for aspiration
3. assist the client with bathing and grooming
4. appropriately document the intake and output
5. perform a sterile dressing change on a central venous line
6. ensure the client takes all medication as scheduled

Answer 48

1, 3, 4

Question 49

The community health maternity nurse plans visits for the day. Which client does the nurse see FIRST?

1. the NB client who has an apgar score of 8 and 9
2. the NB with telangiectatic nevi
3. the NB with pallor
4. The NB client with a blood glucose of 60 mg

Answer 49

3. CORRECT (NB with pallor)
   rationale:
   pallor is an indication of respiratory distress in NB. The nurse should assess for expiratory grunting, retractions, decreased breath sounds, apnea, pallor, hypothermia, and poor muscle tone
   ———————-
4. apgar is assessed at one and five minutes after birth to assess a neonate’s adjustment to extrauterine life. The NB is assessed on the following indicators: Activity, pulse, grimace, appearance, and respiration (a score of 7-10 is normal)
5. these are stork bites
6. the blood glucose is 50-90 mg/dL in a neonate older than one day

Question 50

The nurse observes a student nurse give a presentation about incident reports. The nurse intervenes (what is not accurate of an incident report from options) if the nursing student states which situation requires an incident report?

1. the client has a prescription for citalopram to be administered. The administers clonazepam
2. at 1000 the nurse notes the client’s blood pressure is 80/50 and pulse is 110 bpm, health care provider notified at 1300
3. the client falls while ambulating to the bathroom and reports right hip pain
4. the healthcare provider prescribes digoxin to be administered at 0900. the nurse administers the medication at 0920

Answer 50

4. CORRECT (this would not be considered an incident. A medication is considered on time if it is administered 30 minutes before or up to 30 minutes after the time prescribed)

Question 51

The nursing team caring for clients on the pediatric unit consists of one nurse, 2 LPN, and 3 UAP. Which client does the nurse assign to the UAP?

1. the client who needs help socializing with other children
2. the client requiring an 0800 insulin injection
3. the client requiring calcium disodium ededate for elevated lead levels
4. the client reporting abdominal tenderness in the RLQ

Answer 51

1. CORRECT

Question 52

The charge nurse supervises the care of clients on the medical-surgical unit. The charge nurse determines care is appropriate if which task is delegated to the UAP?

1. the client is diagnosed with a peptic ulcer requiring the morning dose of famotidine
2. the client diagnosed with COPD needing vital signs to be taken
3. the client diagnosed with type 2 diabetes requiring discharge instructions
4. the client on the day of surgery requiring a sterile dressing change

Answer 52

2. CORRECT (the client diagnosed with COPD needing vital signs to be taken)

Question 53

The nurse receives the assignment for the day shift. Which client is appropriate for the nurse to delegate to the LPN/LVN with 30 years of experience?

1. the adult client reporting chest pain and dyspnea
2. the pediatric client with an abdominal mass that is firm and deep and confined to one side
3. the pediatric client reporting polyuria and polydipsia
4. the adult client 3 days postoperative requiring a dressing change

Answer 53

4. CORRECT (the adult client 3 days post-operative requiring a dressing change)

Question 54

4 injured firefighters are transferred to the hospital. The nurse triages in the ER, which client does the nurse see FIRST?

1. a firefighter with carbon monoxide poisoning
2. a firefighter diagnosed with a superficial partial-thickness burn to the hands
3. a firefighter diagnosed with anxiety who is having palpitation
4. a firefighter diagnosed with lacerations to the right side of the face and ear

Answer 54

1. CORRECT (the firefighter with carbon monoxide poisoning)

Question 55

The nurse received a report on 4 clients in the medical-surgical unit. Based on the report received, which client does the nurse prioritize to see first?

1. the client diagnosed with HF who received 800 mL of IV fluid in 2 hours
2. the client diagnosed with lung cancer who has a blood calcium level of 12.5 mg/dL
3. the client diagnosed with HTN, whose current BP is 162/84 and requires a dose of captopril
4. the client who is post-operative after a laminectomy to get out of bed for the first time

Answer 55

1. CORRECT (the client diagnosed with HF and received 800 mL of IV fluids in 2 hours)
   rationale: a client with HF must be assessed immediately for circulatory overload, and would be the client seen first
   - ———————————-
2. this one would be seen 2nd
3. stable
4. stable

Question 56

The nurse manager plans to conduct a performance appraisal. The nurse manager knows which action is MOST important during the interview phase?

1. Discuss mutual social interests with the staff member initially to put the staff member at ease
2. emphasize areas of needed improvement and specific actions to take to address these
3. maintain the focus on job position requirements, standards of care, and actual employee behaviors
4. highlight which personality traits and attitudes of the employee are helpful and which are not

Answer 56

3. CORRECT (maintain the focus of job requirements, standards of care, and actual employee behaviors)
   rationale: This is the most important one out of the four choices–> a performance of appraisal should be based on job position analysis and requirements, care standards and expectations, and specific, objective, and verifiable employee behaviors. This ensures proper focus, facilitates clear communication, and is highly defensible legally.

Question 57

The nurse enters the room of a client admitted for evaluation of a convulsive disorder. The family members present report the client just had a seizure. After determining vital signs are normal and there are no injuries, then placing the client in a side-lying position, which action does the nurse take next?

1. interviews the family about what they observed, including the duration of the seizure, and accurately documents their responses using their own words
2. Explores the feelings of the family regarding witnessing the seizure activity now and in the past
3. documents that the family witnessed a seizure but the nurse did not, and records the vital signs of the client
4. instructs the family to call the nurse next time, completes a root cause analysis sand notifies the healthcare provider

Answer 57

1. CORRECT this is the best you want to elicit more details from the family on the seizure and record their observations in their own words

Question 58

The student nurse discusses the causes of malpractice suits with the instructor. The instructor intervenes if the student includes which occurrence as an example of malpractice?

1. failure to warn a potential employer of a nurses incompetence
2. failure to staff a unit adequately
3. failure to ensure that nurses are practicing in a competent manner
4. failure to document within 30 minutes after a change in clients condition

Answer 58

4. CORRECT
   rationale:
   failure to report and failure to document can lead to malpractice suits the nurse is required to document in a timely fashion but not required to document within 30 minutes

Question 59

the nurse understands that risk management, within the context of managed care, focuses on what principle?

1. educate clients about managing risk factors that would predispose to certain health conditions
2. Teach employees how to take risks safely in their personal and professional lives
3. Propose risk-taking activities for the institution that will enhance its public image
4. Prevent and minimize institutional and treatment factors that could lead to legal liability

Answer 59

4. Correct (prevent and minimize institutional and treatment factors that could lead to legal liability)
   rationale:
   risk management programs focus on loss prevention and loss control (liability control). They are problem-focused and identify, evaluate, develop plans for and take corrective action against potential risks that would injure clients, staff, or visitors. The overall purpose is to avoid lawsuits or at least minimize their effects
   —————————————
   1,2,3 are not a focus of risk management in managed care

Question 60

The community health nurse plans visit for the day. Which client does the nurse see FIRST?

1. the client diagnosed with type 2 diabetes reporting GI upset after taking chlorpropamide
2. the client reporting vomiting after chemotherapy
3. the client with a tonometer reading of 21 mm Hg
4. the client with a laryngectomy reporting a greenish-yellow discharge

Answer 60

4. CORRECT (the client with a laryngectomy reporting a greenish-yellow discharge )
   rationale:
   this is the most unstable client as the findings suggest an actual infection or complication. The nurse should assess breath sounds and the amount, color, and character of the drainage
   ———————————————-
5. chloropropamide is an oral hypoglycemic, these are common adverse effects
6. vomiting is a common side effect of chemotherapy, so this client does not need immediate attention
7. a tonometer measures the intraocular pressure and is used to diagnose glaucoma.

Question 61

Children from a school bus accident are transferred to the hospital. The nurse triages in the emergency department (ED). Which child client does the nurse see FIRST?

1. the client with a superficial partial-thickness burn to the arm
2. the client with deep partial-thickness on 10% of the total body surface area
3. the client with small lacerations to the arms and legs
4. the client reporting severe elbow pain

Answer 61

2. CORRECT (the client with deep partial-thickness burns on 10% of the total of body surface area)
   rationale:
   this is the most critically injured client. A major burn can be life-threatening to a child due to loss of fluid and possible airway compromise. Complications may result from inhalation injury, hypovolemia, and shock
   ——————————
3. this client does not need immediate attention
4. the client does not require immediate attention.
5. the client may have a fracture of the arm and would be second seen. This client does not require immediate attention and the injury does not place the child at immediate risk of complications

Question 62

if there is a problem and your a nurse, who is next in the chain of command?

Answer 62

the nurse manager

Question 63

Floating

Answer 63

• sending a nurse from one unit to another
• from regular unit assignments to short-staffed areas
• some facilities have in-house nursing floating pools
• a nurse cant refuse a float
• it is understood that an experienced nurse working in an unfamiliar are is better than no nurse at all

Question 64

The nurse provides care for clients in the child psychiatric clinic. Which client does the nurse see FIRST?

1. the client with auditory hallucinations
2. the client expressing worry about leaving the parent to go to school
3. the client receiving haloperidol experiencing blurry vision and dry mouth
4. the client with a lithium level of 0.8 mEq/L

Answer 64

1. CORRECT (the client with auditory hallucinations)
   rationale:
   this is the most unstable client. The nurse will see this client first to determine if hallucinations are telling the client to harm self or others
   —————————————
2. the client is experiencing separation anxiety
3. Haloperidol is an antipsychotic medication. Blurry vision and dry mouth are common adverse effects this client would be seen second
4. the normal range for lithium is 0.8-1.2 mEq/L

Question 65

The nurse receives a report and addresses assigned clients on the unit. It is MOST appropriate for the nurse to assign which client to the care of the LPN/LVN?

1. the client newly admitted with a diagnosis of myocardial fraction, recovering from a heart catheterization
2. the client with a diagnosis of heart failure who also expresses frequent suicidal thoughts
3. the client diagnosed with full-thickness burns covering 40% of the body
4. the client diagnosed with COPD who requires ambulation twice during the evening

Answer 65

4. CORRECT (the client diagnosed with COPD who requires ambulation twice during the evening)
   rationale:
   the LPN/LVN assists with implementation of the plan 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 medication. This varies with educational background and state nurse practice acts. This client is appropriate to delegate after the initial nursing assessment. the nurse may wish to reinforce COPD teaching to the LPN/LVN, and will be required to reassess the client status throughout the shift

Question 66

The pediatric community health nurse plans visit for the day. Which client does the nurse see FIRST?

1. the school-aged client with a blood lead level of 9ug/dL
2. the school-aged client who is aggressive towards siblings when angry
3. the preschool client with elevated temperature, cough, and fine crackles
4. the infant client who had a pyloromyotomy 4 weeks ago

Answer 66

3. CORRECT (the preschool client with elevated temperature, cough, and fine crackles)
   rationale:
   this is an unstable client requiring immediate intervention. The nurse should assess and monitor respiratory status and notify the HCP
   ——————————————-
4. this is elevated but does not require immediate attention. Blood levels (lead) of or above 5 ug/dL require further testing or monitoring
5. the client does not need immediate attention. the client and family should be further evaluated
6. there is no complication

Question 67

In an effort to heighten staff awareness about group process, the nurse manager plans an in-service focused on the roles people take in groups. Which is the description of the function of the coordinator role?

1. the coordinator arranges the room and furniture, distributes handouts, operates audiovisual equipment, and obtains what is needed
2. the coordinator clarifies relationships between various ideas and suggestions
3. the coordinator relieves tension in conflict situations between group members
4. the coordinator observes the group process and gives evaluative interpretations of dynamics in the group

Answer 67

2. CORRECT (the coordinator clarifies relationships between various ideas or suggestions)
   rationale:
   the coordinator is a group task role that focuses on bringing together and clarifying relationships between varied ideas and/or suggestions. This role tries to find the common links between the various ideas of group members
   ———————-
3. describes the procedural technician
4. this describes the group maintenance role of the harmonizer
5. describes the group maintenance role of group observer

Question 68

situational leadership style is determined by the ?

Answer 68

specific situation and needs of the group. This style includes: 
directing
coaching 
supporting
delegating

Question 69

Autocratic leadership style ?

Answer 69

gives orders and makes all decisions. This can be an efficient way to run things, but this style usually stifles creativity and decreases the motivation of the group. An autocratic leadership style works best in times of crisis

Question 70

Laissez-faire leadership style?

Answer 70

gives up control and turns all decision-making to the group. the group receives little or no direction. this is effective with a group that is highly motivated and mature

Question 71

democratic leadership style?

Answer 71

is primarily concerned with relationships and teamwork. Planning and decision-making are shared with the group. this type of leadership style contributes to the growth and development of the staff

Question 72

if a nurse assigns another nurse to the new patient with an MI and the assigned nurse makes a medication error. The assigning nurse knows that which statement is true?

1. when a nurse assigns care to another nurse, only accountability is transferred
2. when a nurse assigns care to another nurse, both accountability and responsibility are transferred
3. when a nurse assigns care to another nurse, only responsibility is transferred
4. the assigned nurse does not have the accountability or responsibility

Answer 72

2. CORRECT ( when a nurse assigns care to another nurse, both accountability and responsibility are transferred)
   rationale:
   the nurse can only assign clients to another nurse. Both accountability and responsibility are transferred at that time
   —————————————-

Question 73

When a nurse is assinged to another unit what is good to keep in mind when assigning that nurse to clients?

Answer 73

making sure the patients are stable with expected outcomes to a reassigned nurse

• also consider the knowledge and abilities of this staff member
• supervision consists of the initial direction and periodic inspection (when a nurse from OB is transferred to work in the ER and is assigned to a client that is 20 weeks gestation reporting a small amount of vaginal bleeding and the maternity nurse has the knowledge and abilities to care for this client)

Question 74

Delegation is ?

Answer 74

the reassignment of responsibility for the performance of a job from one person to the other
-although the responsibility for the task is transferred, the accountability for the process or outcome of the task remains with the delegator.

Question 75

What is OSHA’s requirement s if a nurse is stuck with a needle?

Answer 75

the employer should offer immediate, confidential evaluation and treatment and any follow-up required if the employee is exposed to blood-borne pathogens

Question 76

When triaging what should a nurse keep in mind when deciding who to see FIRST?

Answer 76

in traige, one must help those with a chance of survival who need the most immediate help first.
ex: a young adult client with burns to the chest and face area, the client is responsive to stimuli and the airway is patent
(the airway may be compromised. In triage the nurse must see the most unstable client that the nurse has the capability to help first)

Question 77

Coercive power in nurse manager/directors?

Answer 77

has the ability to punish or threaten pain or harm, which may be physical, economic or psychological

Question 78

Reward power in nurse managers/directors?

Answer 78

the director states that if you all agree with me, you will get a lunch pass at the hospital’s expense
-reward power is the ability to provide favors promise money, or other benefits. the definition of power is the ability to influence other people in an effort to achieve goals

Question 79

Personal power in nurse managers/directors?

Answer 79

derives from a high degree of self-confidence

Question 80

Referent power?

Answer 80

results from the follower’s desire to identify with a powerful person. For example, a student nurse may identify with the charge nurse

Question 81

30 victims of an explosion will be transported to the hospital in 10 minutes, who does the nurse notify first?

Answer 81

the nursing supervisor will be notified as they are the next person in the chain of command (in authority) in the event of an emergency response to a disaster. The supervisor will implement an emergency management plan which includes assignments and tasks needed to respond to a specific type of event

Question 82

what is the concern in a client that has been throwing up everyday for the last 3 months?

Answer 82

high risk for fluid and electrolyte imbalances, dehydration, eating disorders and altered nutrition