SECE Pre-Test 1 - NCLEX - SECE

4/17/2020 SECE Pre-test 1: NCLEX - SECE
SECE Pre-test 1
Due No due date Points 20 Questions 20 Time Limit None
Allowed Attempts Unlimited
Take the Quiz Again
Attempt History
Attempt Time Score
LATEST Attempt 1 16 minutes 11.97 out of 20
Submitted Apr 17 at 4:06pm
Question 1 1 / 1 pts
The registered nurse is planning the client assignments for the day. Which
is the appropriate client assignment for the unlicensed assistive personnel
(UAP)?
A client requiring a colostomy irrigation
A client receiving continuous tube feedings
Correct!
A client who requires stool specimen collections
A client who has difficulty swallowing food and fluids
https://medpro.instructure.com/courses/38/quizzes/630 1/31
This question addresses content related to assignment-making

and delegation. Focus on the subject, the appropriate assignment
for the UAP. Work that is delegated to others must be done
consistent with the individual’s level of expertise and licensure or
lack of licensure. In this situation, the most appropriate assignment
for the UAP is to care for the client who requires stool specimen
collections. Colostomy irrigations and tube feedings are not
performed by UAP. The client with difficulty swallowing food and
fluids is at risk for aspiration. Remember, the health care provider
needs to be competent and skilled to perform the assigned task or
activity.
Review: assignment-making and delegation guidelines.
The nurse is developing an educational session on client advocacy for the

nursing staff. The nurse should include which interventions as examples
of the nurse acting as a client advocate? Select all that apply.
Obtaining an informed consent for a surgical procedure
Correct!
Providing information necessary for a client to make informed decisions
Correct!
Providing assistance in asserting the client’s human and legal rights if the
need arises
Correct!
Including the client’s religious or cultural beliefs when assisting the client in
making an informed decision
Correct!
Defending the client’s rights by speaking out against policies or actions
that might endanger the client’s well-being.
Rationale: In the role of client advocate, the nurse protects the

client’s human and legal rights and provides assistance in
asserting those rights if the need arises. The nurse advocates for
the client by providing information needed so that the client can
make an informed decision. The nurse needs to consider the
client’s religion and culture when functioning as an advocate and
when providing care. The nurse would include the client’s religious
or cultural beliefs in discussions about treatment plans so that an
informed decision can be made. The nurse also defends clients’
rights in a general way by speaking out against policies or actions
that might endanger the client’s well-being or conflict with his or
her rights. Informed consent is part of the primary health care
provider–client relationship; in most situations, obtaining the
client’s informed consent does not fall within the nursing duty. Even
though the nurse assumes the responsibility for witnessing the
client’s signature on the consent form, the nurse does not legally
assume the duty of obtaining informed consent.
Priority Nursing Tip: The nurse is a care provider who spends a

significant amount of time with the client, and therefore is in a
critical position to act as a client advocate.
Test-Taking Strategy: Focus on the subject, examples of the

nurse acting as a client advocate. Read each option carefully and
recall the definition of a client advocate. Remembering that in this
role the nurse protects the client’s human and legal rights and
provides assistance in asserting those rights if the need arises will
assist in selecting the correct examples.
The registered nurse (RN) planning the assignments for the day is leading
a team composed of a licensed practical nurse (LPN) and an unlicensed
assistive personnel (UAP). Based on licensure, which client is most
appropriate to assign to the LPN?
ou Answered A client diagnosed with dementia
orrect Answer A 1-day postoperative mastectomy client
A client who requires some assistance with bathing
A client who requires some assistance with ambulation
Rationale: Assignment of tasks must be implemented based on the

job description of the LPN and UAP, the level of education and
clinical competence, and state law. The 1-day postoperative
mastectomy client will need care that requires the skill of a
licensed nurse. The UAP has the skills to care for a client requiring
noninvasive care such as a client with dementia, a client who
requires some assistance with bathing, and a client who requires
some assistance with ambulation.
Priority Nursing Tip: Do not delegate an activity to anyone who

has never performed the task. Perform the activity with the
individual and teach her or him about the procedure for performing
it; this ensures client safety. Clients who are potentially unstable or
complicated need to be assigned to licensed staff.
Test-Taking Strategy: Note the strategic words, most appropriate.

Also, focus on the subject, client assignments for the LPN and
UAP. Think about the needs of each client to assist in determining
the assignment. Remember that the LPN will be performing at a
higher skill level than the UAP.
Question 4 0.67 / 1 pts
The nurse is delegating unit nursing tasks for the day. Which tasks should
the nurse delegate to the unlicensed assistive personnel (UAP)? Select
all that apply.
Correct!
Deliver fresh water to clients.
Correct!
Empty urine out of Foley bags.
orrect Answer Take temperatures, pulses, respirations, and blood pressures.
Count the substance control medications in the opioid medication supply.
Check the crash cart (cardiopulmonary resuscitation cart) for necessary

supplies using a checklist.
Check all intravenous (IV) solution bags on clients receiving IV therapy for
the remaining amounts of solution in the bags.
Rationale: Delegation is the transfer of responsibility for the

performance of an activity or task while retaining accountability for
the outcome. When delegating an activity, the nurse must consider
the educational preparation and experience of the individual. The
UAP is trained to perform noninvasive tasks and those that meet
basic client needs. The UAP is also trained to take vital signs.
Therefore, the appropriate activities to assign to the UAP would be
to deliver fresh water to clients; empty urine out of Foley bags; and
take temperatures, pulses, respirations, and blood pressures.
Although the UAP is trained in performing cardiopulmonary
resuscitation, the UAP is not trained to check a crash cart, and this
activity must be assigned to a licensed nurse. Any activities related
to medications and IV therapy must be delegated to a licensed
nurse.
Priority Nursing Tip: To ensure client safety, it is very important

for the nurse to delegate appropriately to the UAP. Most tasks that
are noninvasive can be assigned to the UAP.
Test-Taking Strategy: Focus on the subject, activities to be

delegated to a UAP. Recalling that a UAP is trained to perform
noninvasive tasks and that medication and IV therapy and any
activity that requires critical thinking skills must be delegated to a
licensed nurse will assist in answering this question.
In the middle of bathing a client, the unit secretary notifies the nurse that
there is an emergency telephone call. Which action should the nurse
implement to best assure client safety?
Quickly finish the bath before answering the call.
Immediately leave the client’s room and answer the call.
Correct!
Cover the client, place the call light within reach, and then leave to answer
the call.
Leave the door open and ask staff to monitor the client, and then leave to
answer the call.
Rationale: Because the telephone call is an emergency, the nurse

may need to answer it. To maintain privacy and safety, the nurse
covers the client and places the call light within the client’s reach.
Additionally, the client’s door should be closed or the room curtains
pulled around the bathing area. The other appropriate action is to
ask another nurse to accept the call. This, however, is not one of
the options. None of the other options effectively meet the client’s
safety needs.
Priority Nursing Tip: If it is necessary to leave the client’s

bedside, return the bed to low position, elevate side rails as
appropriate per state and agency policies, place the call light in the
client’s reach, and ensure that the client knows how to use it.
Test-Taking Strategy: Note the strategic word, best. Focus on the

subject, the need for the nurse to respond to an emergency call.
Eliminate option 1 because this delays the nurse responding.
Eliminate option 2 because this action does not provide client
safety. From the remaining options, recalling the rights of the client
and the principles related to safety will assist in eliminating option
4.
The nurse manager reviewing the purposes for applying restraints to a

client determines that further education is necessary when a nursing
staff member makes which statement supporting the use of a restraint?
“It limits movement of a limb during a painful procedure.”
“It prevents the violent client from injuring self and others.”
Correct!
“At night it keeps the client in bed instead of wandering about.”
“It is useful in preventing the client from pulling out intravenous lines.”
Rationale: Wrist and ankle restraints are devices used to limit the
client’s movement in situations when it is necessary to immobilize
a limb. Restraints are not applied to keep a client in bed at night
and should never be used as a form of punishment. Restraints are
applied to prevent the client from injuring self or others; pulling out
intravenous lines, catheters, or tubes; or removing dressings.
Restraints also may be used to keep children still and from injuring
themselves during treatments and diagnostic procedures. A
primary health care provider’s prescription is required for the use
of restraints, and state and agency procedures are always followed
when restraints are used.
Priority Nursing Tip: Assess the client with restraints applied

continuously to determine if the restraints remain necessary.
Test-Taking Strategy: Note the strategic words, further

education is necessary. These words indicate a negative event
query and the need to select the option that identifies an
inaccurate use for restraints. Eliminate options 1 and 4 first
because they are comparable or alike. From the remaining
options, read each option carefully. Recalling the guidelines for the
use of restraints will direct you to the correct option.
Which findings documented in the history of an older client should require

the nurse to implement an accident prevention protocol? Select all that
apply.
Correct!
Range of motion is limited.
Correct!
Peripheral vision is decreased.
orrect Answer Transmission of hot impulses is delayed.
Correct!
The client reports incidences of nocturia.
High-frequency hearing tones are perceptible.
Correct!
Voluntary and autonomic reflexes are slowed.
Rationale: The physiological changes that occur during the aging

process increase the client’s risk for accidents. Musculoskeletal
changes include a decrease in muscle strength and function,
lessened joint mobility, and limited range of motion. Sensory
changes include a decrease in peripheral vision and lens
accommodation, delayed transmission of hot and cold impulses,
and impaired hearing as high frequency tones become less
perceptible. Nervous system changes include slowed voluntary
and autonomic reflexes. Genitourinary changes may include
nocturia.
Priority Nursing Tip: Age-related changes occur on an individual

basis, and one client may experience an age-related change to a
lesser extent than another client. The nurse must gather baseline
data and then assess for changes and determine the appropriate
course of action to compensate to promote client safety.
Test-Taking Strategy: Focus on the subject, accident prevention

in an older client. Reading each option carefully and keeping in
mind the factors that affect client safety will assist in answering the
question.
The nurse is developing a hospital policy on guidelines for telephone and

verbal prescriptions. Which guidelines should the nurse include in the
policy? Select all that apply.
ou Answered Avoid using all abbreviations.
Verbal prescriptions are rarely acceptable.
Correct!
Clarify any questions with the primary health care provider.
Correct!
Repeat the prescribed prescriptions back to the primary health care
provider.
Cosigning the prescription by the primary health care provider is not

necessary.
If the prescriber is the client’s primary health care provider, documentation

is unnecessary.
Rationale: To avoid misunderstandings, the nurse would always

clarify a telephone or verbal prescription with the health care
provider (HCP) if he or she had any questions about the
prescription and would repeat any prescribed prescriptions back to
the HCP. A telephone order (TO) or prescription involves a primary
HCP stating a prescribed therapy over the phone to the nurse. TOs
are frequently given at night or during an emergency and need to
be given only when absolutely necessary. Likewise, a verbal order
(VO) or prescription is acceptable when there is no opportunity for
the HCP to write the prescription such as in an emergency
situation. Additional guidelines for telephone and verbal
prescriptions include the following: clearly determine the client’s
name, room number, and diagnosis; indicate TO or VO, including
the date and time, name of the client, complete prescription, name
of the HCP giving the prescription, and nurse taking the
prescription; and have the HCP cosign the prescription within the
time frame designated by the health care agency (usually 24
hours).
Priority Nursing Tip: The nurse plays a vital role in maintaining

the safety of the client. The nurse is considered the “last line of
defense” for clients in terms of noting a prescription that may be
harmful to them.
Test-Taking Strategy: Focus on the subject, guidelines for taking

TOs and VOs. Eliminate option 5 because of the words not
necessary and option 6 because the prescription must indicate the
prescribing HCP. Next, reading each option carefully and thinking
about the legal issues related to primary health care providers’
prescriptions will assist you in answering correctly.
The nurse is assisting with the transfer of a client from the operating room
table to a stretcher. Which interventions should the nurse implement to
ensure client safety? Select all that apply.
Correct! Check the client’s level of consciousness.
Correct! Check wheel locks of the operating room table.
Complete the client transfer as quickly as possible.
Tell the client to move self from the table to the stretcher.
Correct!
Raise side rails after the client is positioned on the stretcher per agency
policy.
Rationale: As part of the safe transfer of a client after a surgical

procedure, the nurse should assess the client’s level of
consciousness and, if appropriate, let the client know that she or
he will be transferred from the operating room table to the
stretcher. The nurse checks the wheel locks of the table and the
stretcher to prevent any movement during the transfer. In addition,
the nurse raises the side rails per agency policy to prevent the
client from falling off the stretcher. This is important because the
client is likely to be sedated or disoriented and unable to protect
herself or himself from falling. Personnel avoid hurried movements
and rapid changes in position because hurried movements
predispose the client to hypotension; moreover, secure, deliberate
movement increases the security of the client. Because the client
remains affected by anesthesia, the client should not move herself
or himself.
Priority Nursing Tip: The nurse should always obtain additional

nursing staff assistance when moving a client or transferring a
client from a bed to a stretcher or other location.
Test-Taking Strategy: Focus on the subject, safety during client

transfer. Note the word quickly in option 3; this is likely to increase
the risk of client injury. Option 4 is unsuitable because of the
residual effects of anesthesia and also increases the risk of client
injury.
A client reporting abdominal pain has a diagnosis of acute abdominal

syndrome but the cause has not been determined. Which prescription
should the nurse question at this time?
orrect Answer Clear liquid diet only
ou Answered Insertion of a nasogastric tube
Administration of an analgesic
Insertion of an intravenous (IV) line
Rationale: Until the cause of the acute abdominal syndrome is

determined and a decision about the need for surgery is made, the
nurse would question a prescription to give a clear liquid diet. The
nurse can expect the client to be placed on NPO status and to
have an IV line inserted. Insertion of a nasogastric tube may be
helpful to provide decompression of the stomach. Pain
management with medications that do not alter level of
consciousness can decrease diffuse abdominal pain and rigidity,
help with localizing the pain, and lead to more prompt diagnosis
and treatment.
Priority Nursing Tip: Signs of perforation and peritonitis include

restlessness, guarding of the abdomen, distention and a rigid
abdomen, increased fever, chills, tachycardia, and tachypnea.
Test-Taking Strategy: Focus on the subject, undetermined

abdominal pain and the prescription that the nurse would question.
Think about the client’s diagnosis. Recalling that surgery may be a
necessary intervention should direct you to the correct option.
A friend of the parents of a newborn with a diagnosis of congenital

tracheoesophageal fistula contacts the home health nurse with an offer to
help. Which is the best nursing action at this time to address the needs
and rights of the family?
Correct!
Inform the friend to directly contact the family and offer assistance to them.
Request that the friend come to the client’s home during the next home
health visit.
Report the friend’s call to the nurse manager for referral to the client’s
social worker.
Assure the friend that there is no need for assistance since the nurse is
visiting daily.
Rationale: The nurse must uphold the client’s rights and does not
give any information regarding a client’s care needs to anyone who
is not directly involved in the client’s care. To request that the friend
come for teaching is a direct violation of the client’s right to privacy.
There is no information in the question to indicate that the family
desires assistance from the friend. To refer the call to the nurse
manager and social worker again assumes that the friend’s
assistance and involvement are desired by the family. Informing
the friend that the nurse is visiting daily is providing information
that is considered confidential. Option 1 directly refers the friend to
the family.
Priority Nursing Tip: The nurse must protect client confidentiality

at all times.

subject, confidentiality and the client’s right to privacy. Option 1 is
the only option that upholds the client’s rights.
The home health nurse is religiously opposed to homosexuality and

cannot care for a client diagnosed with human immunodeficiency virus
(HIV). The nurse then leaves the client’s home. Which statement
accurately identifies the nurse’s rights and actions? Select all that apply.
The nurse has the moral right to leave the client’s home at any time.
ou Answered
The nurse has a legal right to inform the client of any barriers to providing
care.
The nurse has a duty to protect self from client care situations that are
morally repellent.
Correct!
The nurse has a duty to provide competent care to assigned clients in a
nondiscriminatory manner.
orrect Answer
The nurse has the right to refuse to care for any client on religious grounds
if competent care coverage is arranged.
Rationale: The nurse has a duty to provide care to all clients in a

nondiscriminatory manner. Personal autonomy does not apply if it
interferes with the rights of the client. Refusal to provide care may
be acceptable if that refusal does not put the client’s safety at risk
and the refusal is primarily associated with religious objections, not
personal objection, to lifestyle or medical diagnosis. There is no
legal obligation to inform the client of the nurse’s personal
objections to the client. The nurse also has an obligation to
observe the principle of nonmaleficence (neither causing nor
allowing harm to befall the client).
Priority Nursing Tip: The client always has the right to

considerate and respectful care.
Test-Taking Strategy: Focus on the subject, client’s rights and the

nurse’s ethical and legal responsibilities. Recognize that refusal to
care for a client on religious grounds is permitted if client coverage
is arranged. Note the words competent care and nondiscriminatory
in the correct choices. The remaining options are incorrect related
to the client’s rights and the nurse’s moral, religious, and legal
obligations.
A client asks the nurse to act as a witness for an advance directive. Which
is the best intervention for the nurse to implement?
Suggest the nurse manager as a witness.
Agree to sign the document as a witness.
ou Answered Notify the provider of the client’s request.
orrect Answer Help the client find an unrelated third party.
Rationale: An advance directive addresses the withdrawal or

withholding of life-sustaining interventions that can prolong life and
identifies the person who will make care decisions if the client
becomes incompetent. Two people unrelated to the client witness
the client’s signature and then sign the document signifying that
the client signed the advance directive authentically. Nurses or
employees of a facility in which the client is receiving care and
beneficiaries of the client should not serve as a witness because of
conflict of interest concerns. There is no reason to call the provider
unless the absence of the advance directive interferes with client
care.
Priority Nursing Tip: If the client signs an advance directive at the

time of hospital admission, it must be documented in the client’s
medical record.

subject, witness for a legal document. Eliminate option 1 because
it demonstrates the nurse’s reluctance to serve as the client’s
advocacy. Examine the remaining options and recall the nurse’s
role as a witness of a legal document.
A client with a diagnosis of leukemia asks the nurse questions about

preparing a living will. Which recommendation from the nurse should be
the best method of preparing this document?
Talk to the hospital chaplain.
Obtain advice from an attorney.
Consult the American Cancer Society.
Correct! Discuss the request with the primary health care provider (HCP).
Rationale: Living wills are legal documents known as advance

directives wherein the client delineates the withdrawal or
withholding of treatment when the client is incompetent. Living wills
should not be confused with a will that bequeaths personal
property and specifies other actions at the time of the client’s
death. The client starts the process of writing a living will by
discussing treatment options and other related issues with the
HCP. In addition, the client should discuss this issue with the
family. Although options 1 and 2 may be helpful, contacting them is
not the initial step because both professionals lack the medical
information the client needs to make an informed decision;
however, the lawyer may be involved after discussion with the
HCP and family. The American Cancer Society may have pertinent
information on living wills; however, the information is not
individualized to the client’s needs.
Priority Nursing Tip: A living will lists the medical treatment that a
client chooses to omit or refuse if the client becomes unable to
make decisions and is terminally ill.
Test-Taking Strategy: Note the strategic word, best. This

indicates an initial step. Remembering that the HCP is the primary
care person will assist in directing you to the correct option.
Contacts addressed in options 1, 2, and 3 may follow the
discussion with the provider.
Which clinical situation should the nurse identify as an example of

slander?
Correct!
The primary health care provider tells a client that the nurse “does not
know anything.”
The nurse tells a client that a nasogastric tube will be inserted if the client
continues to refuse to eat.
The nurse restrains a client at bedtime because the client gets up during
the night and wanders around.
The laboratory technician restrains the arm of a client refusing to have

blood drawn so that the specimen can be obtained.
Rationale: Defamation takes place when a falsehood is said

(slander) or written (libel) about a person that results in injury to
that person’s good name and reputation. Battery involves offensive
touching or the use of force by a perpetrator without the
permission of the victim. An assault occurs when a person puts
another person in fear of a harmful or offensive act.
Priority Nursing Tip: A tort is a civil wrong, other than a breach in

contract, in which the law allows an injured person to seek
damages from a person who caused the injury.
Test-Taking Strategy: Focus on the subject, the situation that

constitutes slander. Read the situation presented in each option
carefully. Recalling that slander constitutes verbal defamation will
direct you to the correct option.
A client with a diagnosis of subarachnoid hemorrhage secondary to

ruptured cerebral aneurysm has been placed on aneurysm precautions.
To promote safety, the nurse should ensure that which intervention is
provided to the client?
Liquid diet
Enemas as needed
ou Answered Help with ambulation
orrect Answer
Daily stool softeners
Rationale: Aneurysm precautions include a variety of measures

designed to decrease stimuli that could increase the client’s
intracranial pressure. Stool softeners should be provided, but
enemas should be avoided. Straining at stool is contraindicated
because it increases intracranial pressure. Other measures to
decrease stimuli include instituting dim lighting and reducing
environmental noise and stimuli. The remaining options are not
related to minimizing stimulation.
Priority Nursing Tip: An early sign of increased intracranial

pressure is a change in the level of consciousness.
Test-Taking Strategy: Focus on the subject, ruptured cerebral

aneurysm with subarachnoid hemorrhage. With this condition,
there is a need to reduce environmental stimuli and prevent
increased intracranial pressure. Options 1 and 3 can be eliminated
first because these items will not effectively minimize stimulating
the client. From the remaining options, eliminate option 2 because
administration of an enema will increase intracranial pressure.
During the admission process of a client being admitted for surgery, the
client asks the nurse if a living will, prepared 3 years ago, remains in
effect. Which response is most appropriate for the nurse to provide the
client?
“Yes, a living will never expire.”
“You need to speak with an attorney.”
“I will call someone to answer your question.”
Correct!
“If it accurately reflects your situation and wishes.”
Rationale: The client should discuss the living will with the primary
health care provider (HCP) on a regular basis to ensure that it
contains the client’s current wishes and desires based on the
client’s current health status. Option 1 is incorrect. Although the
client can consult an attorney if the living will must be changed, the
accurate nursing response is to tell the client that a living will
should be reviewed. Option 3 is not at all helpful to the client and
is, in fact, a communication block and places the client’s question
on hold.
Priority Nursing Tip: On admission to a health care facility, the

nurse should determine whether an advance directive exists and
ensure that it is part of the client’s medical record.
Test-Taking Strategy: Note the strategic words, most appropriate.

Eliminate options 1 and 3 first because they are nontherapeutic
and place the client’s question on hold. Also note the closed-ended
word “never” in option 1. From the remaining options, it is
necessary to know that the document is reviewed on a regular
basis with the HCP.
A hospitalized client is found lying on the floor next to the bed. Once the
client is cared for, the nurse completes an incident report. Which written
statements exemplify correct documentation on the report? (Refer to
exhibit.) Select all that apply.
3425
orrect Answer 2456
1236
ou Answered 123456
Rationale: An incident report is a tool used by health care facilities

to document situations that have caused harm or have the
potential to cause harm to clients, employees, or visitors. The
nurse who identifies the situation initiates the report. The report
identifies the people involved in the incident, including witnesses;
describes the 2456 event; and records the date, time, location,
factual findings, actions taken, and any other relevant information.
The primary health care provider is notified of the incident and
completes the report after examining the client. Documentation on
the report should always be as factual as possible and needs to
avoid accusations. Because the client was found lying on the floor,
it is unknown whether the client actually fell out of bed.
Additionally, the nurse does not know that the client climbed over
the side rails when the nurse was out of the room.
Priority Nursing Tip: An incident (unusual occurrence) report is

considered a legal document and should not be placed in the
client’s chart after completion. It should be maintained and filed in
a designated area as determined by agency procedure.
Test-Taking Strategy: Focus on the subject, correct

documentation on the incident report. Recalling that
documentation on the report should always be as factual as
possible and must avoid accusations will assist in answering this
question.
A home care nurse is visiting an older client recovering from a mild stroke
affecting the left side. The client lives alone but receives regular
assistance from the daughter and son, who both live within 10 miles. To
assess for risk factors related to safety, which actions should the nurse
take? Select all that apply.
Correct! Assess the client’s visual acuity.
Correct! Observe the client’s gait and posture.
Correct! Evaluate the client’s muscle strength.
Correct!
Look for any hazards in the home care environment.
Ask a family member to move in with the client until recovery is complete.
Request that the client transfer to an assisted living environment for at

least 1 month.
Rationale: To conduct a thorough client assessment, the nurse

assesses for possible risk factors related to safety. The
assessment should include assessing visual acuity, gait and
posture, and muscle strength because alterations in these areas
place the client at risk for falls and injury. The nurse should also
assess the home environment, looking for any hazards or
obstacles that would affect safety. Asking a family member to
move in with the client until recovery is complete and requesting
that the client transfer to an assisted living environment for at least
1 month are not assessment activities. Additionally, nothing in the
question indicates that these actions are necessary; therefore,
these options are unrealistic and unreasonable.
Priority Nursing Tip: Age-related changes occur on an individual

basis, and one client may experience an age-related change to a
lesser extent than another client. The older client who has suffered
a stroke will be at a higher risk for injury related to age-related
changes.
Test-Taking Strategy: Focus on the subject, assessing for risk

factors related to safety after a stroke. Note that options 5 and 6
are unrelated to the subject of the question.
Which action demonstrates a situational leadership style by the nurse

manager?
The nurse manager delegates tasks to each team member.
The nurse manager allows team members to work without supervision.
ou Answered
The nurse manager invites team members to provide input about a unit
problem.
orrect Answer
The nurse manager quickly delegates activities to team members during
an emergency situation.
Rationale: The situational leadership style uses a style depending

on the situation and events. This type of leadership style is used in
emergency situations when the nurse manager needs to quickly
delegate activities to achieve a successful outcome for the
situation. A laissez-faire leader abdicates leadership and
responsibilities, allowing staff to work without assistance, direction,
or supervision. Participative leadership demonstrates an “in-
between” style, neither authoritarian nor democratic. In
participative leadership, the manager presents an analysis of
problems and proposals for actions to team members, inviting
critique and comments. The participative leader then analyzes the
comments and makes the final decision. The autocratic style of
leadership is task oriented and directive.
Priority Nursing Tip: The nurse is always responsible for his or

her actions when providing care to a client.
Test-Taking Strategy: Focus on the subject, style of leadership,

noting the words situational leadership. Recalling that a situational
leadership style uses a style depending on the situation and
events will direct you to the correct option.

SECE Pre-Test 1 - NCLEX - SECE

Uploaded by

Copyright:

Available Formats

You might also like

SECE Pre-Test 1 - NCLEX - SECE

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

SECE Pre-Test 1 - NCLEX - SECE

Uploaded by

Copyright:

Available Formats

4/17/2020 SECE Pre-test 1: NCLEX - SECE

Take the Quiz Again

Submitted Apr 17 at 4:06pm

A client requiring a colostomy irrigation

A client receiving continuous tube feedings

A client who has difficulty swallowing food and fluids

This question addresses content related to assignment-making

Review: assignment-making and delegation guidelines.

The nurse is developing an educational session on client advocacy for the

Obtaining an informed consent for a surgical procedure

Providing information necessary for a client to make informed decisions

Rationale: In the role of client advocate, the nurse protects the

Priority Nursing Tip: The nurse is a care provider who spends a

Test-Taking Strategy: Focus on the subject, examples of the

ou Answered A client diagnosed with dementia

orrect Answer A 1-day postoperative mastectomy client

A client who requires some assistance with bathing

A client who requires some assistance with ambulation

Rationale: Assignment of tasks must be implemented based on the

Priority Nursing Tip: Do not delegate an activity to anyone who

Test-Taking Strategy: Note the strategic words, most appropriate.

Question 4 0.67 / 1 pts

orrect Answer Take temperatures, pulses, respirations, and blood pressures.

Count the substance control medications in the opioid medication supply.

Check the crash cart (cardiopulmonary resuscitation cart) for necessary

Rationale: Delegation is the transfer of responsibility for the

Priority Nursing Tip: To ensure client safety, it is very important

Test-Taking Strategy: Focus on the subject, activities to be

Quickly finish the bath before answering the call.

Immediately leave the client’s room and answer the call.

Rationale: Because the telephone call is an emergency, the nurse

Priority Nursing Tip: If it is necessary to leave the client’s

Test-Taking Strategy: Note the strategic word, best. Focus on the

The nurse manager reviewing the purposes for applying restraints to a

“It limits movement of a limb during a painful procedure.”

Priority Nursing Tip: Assess the client with restraints applied

Test-Taking Strategy: Note the strategic words, further

Question 7 0.8 / 1 pts

Which findings documented in the history of an older client should require

orrect Answer Transmission of hot impulses is delayed.

High-frequency hearing tones are perceptible.

Rationale: The physiological changes that occur during the aging

Priority Nursing Tip: Age-related changes occur on an individual

Test-Taking Strategy: Focus on the subject, accident prevention

Question 8 0.5 / 1 pts

The nurse is developing a hospital policy on guidelines for telephone and

ou Answered Avoid using all abbreviations.

Verbal prescriptions are rarely acceptable.

Cosigning the prescription by the primary health care provider is not

If the prescriber is the client’s primary health care provider, documentation

Rationale: To avoid misunderstandings, the nurse would always

Priority Nursing Tip: The nurse plays a vital role in maintaining

Test-Taking Strategy: Focus on the subject, guidelines for taking

Correct! Check the client’s level of consciousness.

Correct! Check wheel locks of the operating room table.

Complete the client transfer as quickly as possible.

Rationale: As part of the safe transfer of a client after a surgical