Nursing Leadership and Management NCLEX Questions

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A registered nurse reviews a plan of care developed by a nursing
student for a client with depression and notes a nursing diagnosis
of impaired nutrition: less than body requirements. The registered
nurse asks the student to revise the plan if which incorrect inter-
D
vention is documented?
- The client should be asked which foods or drinks she likes, and
consultation with a dietitian also may be done. The client is more
a) offer small, high-calorie, high protein snacks frequently
likely to eat if the client has selected the foods and is given foods
throughout the day and evening
that she likes. Options A, B, and C are appropriate interventions
b) offer high protein, high-calorie fluids frequently throughout the
for the client with depression with this nursing diagnosis.
day and evening
c) remain with the client during meals
d) complete the food menu for the client during the depressed
period
A
- When caring for a paranoid client, the nurse must avoid any
A registered nurse reviews a plan of care developed by a nursing physical contact and should not touch the client. The nurse should
student for client with paranoia and notes a nursing diagnosis of ask the client's permission if touch is necessary because touch
Disturbed thought process. The registered nurse asks the nursing may be interpreted as a physical or sexual assault. The nurse
student to revise the plan if which incorrect intervention is docu- would use simple and clear language when speaking to the client
mented? to prevent misinterpretation and to clarify the nurse's intent and
actions. A warm approach is avoided because it can be frightening
a) sit with the client and hold the client's hand to a person who needs emotional distance. A matter-of-fact con-
b) avoid a warm approach when working with the client sistency is nonthreatening. Any anger and hostile verbal attacks
c) use simple and clear language when speaking to the client need to be diffused with a nondefensive stand. The anger that a
d) diffuse angry and hostile verbal attacks with a nondefensive paranoid client expresses is often displaced, and when the staff
stand becomes defensive, anger of both the client and staff escalates. A
nondefensive and nonjudgmental attitude provides an attitude in
which feelings can be explored more easily.
A registered nurse is discussing the characteristics of anorexia
nervosa with a nursing student. The registered nurse determines
that the nursing student needs to further research this disorder if
D
the student states that which of the following is a characteristic of
- As anorexia nervosa develops, personal relationships tend to
anorexia nervosa?
become more superficial and distant. Social contacts are avoided
because of the fear of being invited to eat and being discovered.
a) personal relationships tend to become more superficial and
The client is preoccupied with food and meal planning (especially
distant
for others), personal caloric intake throughout the day, and meth-
b) social contacts are avoided because of the fear of being invited
ods to avoid eating. Anorexic persons are likely to become very
to eat and being discovered
emaciated and will not maintain their near-normal body weight.
c) the client is being preoccupied with food and meal planning,
especially for others
d) the client will usually keep her weight near normal
An experienced emergency department nurse observes a new
nurse employed in the emergency department obtain the equip-
ment needed to draw a blood sample for a blood alcohol level on a B
client. The experienced emergency department nurse intervenes - Isopropyl alcohol or any antiseptic solution containing alcohol
if the new nurse plans to use which item? must not be used as a skin preparation before a blood alcohol
specimen is drawn. These agents may falsely elevate the blood
a) tourniquet alcohol level and render the test invalid. Option A, C and D identify
b) alcohol swabs items needed to obtain the blood specimen.
c) a blood-draw needle
d) a blood tube

A nurse administers digoxin (Lanoxin) 0.25 mg instead of the C

prescribed order of 0.125 mg. The nurse discovers the error while
charting the medication. The nurse completes an incident report
and notifies the physician of the incident. The nurse takes which
additional action?
a) gives the client a copy of the incident report
b) makes a copy of the incident report and sends it to the
physician's office
- The incident report is confidential and privileged information. It
should not be copied or placed in the chart or have any reference
made to it in the client's record. It is the physician's responsibility
to sign the incident report before it is sent to the risk-management
department. A copy should not be made or sent to the physician's
office. The incident report is not a substitute for a complete entry in
the client's record concerning the incident. A copy of the incident
report is not given to the client; however, the client should be

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c) documents the incident in the client's record informed of the error, and this is usually done by the client's
d) places the incident report in the client's record physician.
A registered nurse is supervising a new nursing graduate who
B
is performing an irrigation on an assigned client with a buildup
- Irrigation solutions that are not close to the client's body tem-
of cerumen in the left ear. Which of the following observations
perature can be uncomfortable and may cause injury, nausea,
if made by the registered nurse would indicate that the nursing
and vertigo. The client is positioned so that the ear to be irrigated
graduate is performing the procedure correctly?
is facing downward because this allows gravity to assist in the
removal of the cerumen and solution. Following the irrigation,
a) the client is positioned with the ear to be irrigated facing upward
the client is to lie on the affected side for a period to finish the
b) the irrigating solution is warmed to 100F
drainage of the irrigating solution. A slow, steady stream of solution
c) a direct and slow steady stream of irrigation solution is directed
should be directed toward the upper wall of the ear canal and not
toward the eardrum
toward the tympanic membrane. Too much force could cause the
d) the client is positioned with the affected ear up following the
tympanic membrane to rupture.
irrigation
A nurse is performing a sterile wound irrigation on an assigned
client. A nursing assistant enters the client's room and tells the
C
nurse that a physician has telephoned and requests to speak to
- Because wound irrigation is a sterile procedure and a risk for
the nurse. The appropriate nursing action is which of the following?
infection exists with an open wound, it is most appropriate to
ask the nursing assistant to obtain a telephone number from the
a) finish the wound irrigation while the physician waits on the
physician so that the call can be returned. It is not appropriate to
telephone
ask a physician to wait while a procedure is being completed. It
b) cover the client and answer the telephone call
is best to return the call. Option D is not a responsibility of the
c) ask the nursing assistant to obtain a telephone number from the
nursing assistant.
physician so that the call can be returned after the wound irrigation
d) ask the nursing assistant to take a message
A case manager is reviewing the records of the clients in the
D
nursing unit. Which of the following documentation, if noted in a
- Variances are actual deviations or detours from the critical
client's record, would the nurse indicate as a positive variance?
path. Variances are either positive or negative and avoidable or
unavoidable, and may be caused by a variety of things. A positive
a) a client in skeletal traction has a temperature of 98.6F and the
variance occurs when the client has achieved maximum benefits
pin sites are clean and dry
and is discharged earlier than anticipated on her critical path.
b) a postoperative client is performing coughing and deep-breath-
Option 4 is the only option that specifically identifies a positive
ing exercises every hour
variance. Options A, B, and C demonstrate progression on a criti-
c) a client with congestive heart failure has clear breath sounds
cal path, but they are not specifically associated with the definition
d) a client with pneumonia is discharged to home 1 day earlier
of a positive variance.
than expected
A nurse is a member of a community task force on violence.
The task force recognizes that it has insufficient data to make
decisions about specific interventions. Using the nursing process,
the first activity that the nurse would suggest to the task force is
C
to:
- An assessment activity is always the first step in the nursing
process. Option C addresses assessment of community percep-
a) call other communities similar in size to determine what they
tions. Option A is a part of analysis from a variety of assessment
do
data, but is not specific to the subject of the question. Options B
b) develop a general educational program related to violence
and D are implementation measures.
c) conduct a community survey to assess community perceptions
regarding violence
d) develop a pamphlet on violence to be distributed to the com-
munity
A community health nurse has been assigned to be the leader of
a task force to identify interventions for teenagers from a local
community who are abusing drugs. At the first meeting of the
task force, the members express concern that more informa- A
tion is needed to determine appropriate measures for the target - Option A is the only option that addresses the subject of the
teenagers. The nurse would direct the group effectively by sug- question and will identify the additional information required by
gesting which of the following? the task force. Options B, C, and D do not provide the additional
information required in order for the task force to proceed with the
a) preparing a survey that can be distributed to community mem- necessary task of the group.
bers to determine their understanding of the drug abuse problem
b) initiating a drug abuse program in all of the schools
c) seeking out the teenage drug abusers and referring them to
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drug abuse centers
d) preparing posters that can be distributed to the schools
1. A registered nurse is discussing treatment for a client who is
hospitalized with acute systemic lupus erythematosus (SLE) with
a nursing student assigned to the client. The registered nurse
B
realized that the nursing student needs to research information
- Manifestations of acute SLE may include fever, muscu-
about the disease if the student states that which of the following
loskeletal aches and pains, butterfly rash on the face, pleur-
is a clinical manifestation of SLE?
al effusion, basilar pneumonia, generalized lymphadenopathy,
pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium,
a) fever
convulsions, psychosis, and coma.
b) bradycardia
c) butterfly rash on the face
d) muscular aches and pains
A nurse administers a fatal dose if a cardiac medication to a client.
During the subsequent investigation, it was determined that the
nurse did not check the client's vital signs before administering the
medication. This failure to complete an appropriate assessment is
D
addressed under which function on the Nurse Practice Act?
In the situation described in the question, acceptable standards of
care were not met (the nurse failed to adequately assess the client
a) defining the specific educational requirements for licensure
before administering a medication). Option D refers specifically
b) describing the scope of practice of licensed and unlicensed
to the situation described. Options A, B, and C do not relate to
care providers
standards of care.
c) recommending disciplinary action for nurses who violate the
law
d) identifying the process for disciplinary action if standards of
care are not met
A registered nurse is observing a nursing student prepare a client D
for a renal angiography. The registered nurse would intervene if - Renal angiography involves injection of a contrast medium.
the nursing student: Therefore, the procedure is invasive, and an informed consent for
the diagnostic procedure needs to be signed. A local anesthetic
a) checked circulation to the client's legs may be used at the needle insertion site, but an anesthesia con-
b) checked for client's allergies sent form is not necessary. The nurse checks for client allergies to
c) ensured that an informed consent for the diagnostic procedure determine whether the client has an allergy to the contrast medi-
was signed um. A baseline assessment of circulation to the legs is important to
d) ensured that an anesthesia consent was signed assist in monitoring for complications in the postprocedure period.
A nursing student is assigned to care for a child who has been
B
placed in Crutchfield tongs to stabilize a fracture in the cervical
- The purpose of Crutchfield tongs is to stabilize fractures or
area. The registered nurse reviews the plan of care developed
displaced vertebrae in the cervical and thoracic areas. Tongs are
by the student and discusses revising the plan if which incorrect
inserted on the sides of the scalp through drill holes. Traction pull
intervention is documented?
is always along the axis of the spine. The nurse should check the
tongs at least every 8 hours and as needed (PRN) for displace-
a) logroll the child when positioning
ment and looseness. The child can be repositioned by logrolling or
b) check the tongs every 24 hours for displacement and loose-
turned as a unit. Neurological status should be checked frequently
ness
because spinal cord injury frequently accompanies a cervical
c) monitor neurological status
injury. Pin care is done every shift.
d) perform pin care every shift
A nurse is performing an admission assessment on a client ad-
mitted to the hospital with a diagnosis of fever of unknown origin.
The nurse performs interventions based on the nurse practice act A
when the nurse: - Recording assessment data reflects the requirement of the
nurse practice act to maintain adequate records. Verbal informa-
a) enters the information on the client's record tion and notes on worksheets are not part of the client's permanent
b) writes the information on a worksheet record.
c) informs the supervisor of the client's vital signs
d) tells another nurse that the client has a high fever

A nurse educator at the local community hospital is conducting C

an orientation session for nurses that are newly employed at the
hospital. The nurse educator informs the new nurses that the
policy of the hospital requires that nurses "float" to other nursing
departments when client census is high on other units. The nurse
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- Floating is an acceptable legal practice used by hospitals to
solve their understaffing problems. Legally a nurse cannot refuse
to float unless union contract guarantees that nurses can only
work in a specified area or the nurse can prove the lack of knowl-
 Nursing Leadership and Management NCLEX Questions
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educator advises the new nurses that if this situation arises and if
edge for the performance of assigned tasks. When encountered
the nurse is unfamiliar with the unit in which the nurse must "float"
with this situation, nurses should report to the unit and identify
to:
tasks that can be safely performed. The nursing supervisor and the
nurse educator may need to become involved in the situation at
a) refuse to float
some point if the nurse requires assistance or education regarding
b) call the nurse educator
a new skill, but the action that the nurse must take is identified in
c) report to the unit and identify tasks that can be safely performed
option C.
d) call the nursing supervisor
A staff nurse makes negative comments about a unit manager's
leadership style, and the unit manager overhears the staff nurse.
Which action by the unit manager would be appropriate? C
- Encouraging the staff nurse to discuss the comments will assist
a) tell the staff nurse to stop making the comments in identifying the concerns in a democratic way. Options A and D
b) propose a tentative solution regarding the comments, and are autocratic. Option B does not provide the opportunity for the
discuss it with the staff nurse staff nurse to directly share concerns.
c) encourage the staff nurse to discuss the comments
d) persuade the staff nurse to stop being so critical
A registered nurse is reviewing a plan of care developed by a nurs-
ing student for a client scheduled for keratoplasty. The registered D
nurse tells the nursing student that which intervention written in - Keratoplasty is done by removing damaged corneal tissue
the plan needs to be deleted because it is incorrect? and replacing it with corneal tissue from a human donor (live
or cadaver). Preoperative preparation of the recipient's eye may
a) obtain a specimen for culture and sensitivity of the eye with a include obtaining a culture and sensitivity with conjunctival swabs,
conjunctival swab instilling antibiotic ophthalmic medication, and cutting the eye-
b) instill antibiotic ophthalmic medication as prescribed lashes. Some ophthalmologists order a medication such as 2% pi-
c) cut the client's eyelashes locarpine to constrict the pupil (not dilate the pupil) before surgery.
d) administer medications that will dilate the pupil
A registered nurse is discussing the clinical manifestations of
Meniere's disease with a nursing student. The registered nurse
determines that the nursing student needs to further research
C
this disorder if the student states that which of the following is a
- The three characteristic symptoms of Ménière's disease are
manifestation of Meniere's disease?
tinnitus, sensorineural hearing loss on the involved side, and
severe vertigo accompanied by nausea and vomiting. Option C is
a) tinnitus
not associated with Ménière's disease.
b) sensorineural hearing loss on the involved side
c) conductive hearing loss on the involved side
d) vertigo accompanied by nausea and vomiting
A registered nurse reviews a plan of care developed by a nursing C
student for a client who will be returning from the operating room - Following mastoidectomy, the nurse should monitor vital signs
following a mastoidectomy. The registered nurse informs the stu- and inspect the dressing for drainage or bleeding. The nurse
dent that which intervention is incorrect? should monitor for signs of facial nerve injury to cranial nerve
VII. The nurse should also monitor the client for pain, dizziness,
a) monitor the client for pain, dizziness, or nausea or nausea. The head of the bed should be elevated, and the
b) keep the head of the bed elevated client should lie on the unaffected side. The client will probably
c) instruct the client to lie on the affected side have sutures, an outer ear packing, and a bulky dressing that is
d) monitor for signs of injury to cranial nerve VII removed on approximately the sixth postoperative day
A community health nurse is working with a group of clients at
risk for hypertension. In implementing interventions by levels of
prevention, which of the following would be a primary prevention
intervention that the nurse would use with this group?
C
- Primary prevention interventions are those measures that keep
a) Encouraging the clients to attend hypertension screening
illness, injury, or potential problems from occurring; therefore,
clinics
option C is correct. Options A,B, and D are secondary prevention
b) encouraging clients to visit their physician regularly
measures that seek to detect existing health problems or trends.
c) providing information regarding the decreased use of salt in the
diet
d) conducting a community-wide screening to detect individuals
with hypertension

A clinical nurse educator is conducting an educational session for

new nursing graduates and is discussing standards of care. The
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 Nursing Leadership and Management NCLEX Questions
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nurse educator determines that a graduate understands the pur-
pose of standards of care when the graduate states that standards
C
of care:
- The purpose of standards of care is to provide a broad direction
for the overall practice of nursing that applies to all nursing situ-
a) identify methods of treatment based on the most current
ations, across specialty areas, across the country. Standards of
technology
care include providing competent levels of care based on current
b) provide excellent care based on current medical research
practice. Options A, B, and D do not specifically describe stan-
c) include providing competent levels of care based on current
dards of care. Option A is specific to technology. Option B address-
practice
es medical research. Option D addresses specialty guidelines.
d) include providing care based on specialty guidelines for the
client's condition
A registered nurse (RN) is observing a new licensed practical
A
nurse (LPN) suctioning a client who has a diagnosis of acquired
- The RN is responsible for supervising procedures performed
immunodeficiency syndrome (AIDS). The RN would determine
by a new LPN to ensure that client safety is maintained and
that the LPN was performing the procedure safely if the RN ob-
that policies and procedural guidelines are adhered to. Standard
served that the LPN was wearing which of the following protective
precautions include use of gloves whenever there is actual or
devices?
potential contact with blood or body fluids. During suctioning the
nurse wears gloves, a mask, and protective eyewear or a face
a) gloves, mask, and protective eyewear
shield. Impervious gowns are worn in those instances when it is
b) gloves, gown, and mask
anticipated that there will be contact with a large amount of body
c) gown, mask, and protective eyewear
fluid or blood.
d) gloves, gown, and protective eyewear
A registered nurse (RN) is observing a nursing assistant ambu-
D
lating a client with right-sided weakness. The RN would determine
- When walking with clients, the nurse should stand on the affected
that the nursing assistant was performing the procedure safely if
side and grasp the security belt in the midspine area of the small
the nurse observed the nursing assistant:
of the client's back. The nurse should position the free hand at the
shoulder area so that the client can be pulled toward the nurse
a) standing behind the client
in the event that there is a forward fall. The client is instructed to
b) standing in front of the client
look up and outward rather than at the feet. Options A,B, and C
c) standing on the left side of the client
are incorrect.
d) standing on the right side of the client
C
A registered nurse (RN) is observing a new licensed practical
- The RN is responsible for supervising certain procedures per-
nurse (LPN) administer a deep intramuscular injection in the
formed by an LPN to ensure that client safety is maintained. The
dorsogluteal site of a client. The RN determines that the LPN is
dorsogluteal site or gluteus medius muscle is the desired site for
performing the procedure correctly if the LPN:
deep intramuscular injections. A prone toe-in position will promote
internal rotation of the hips, which will relax the muscle and make
a) administers the injection 2 inches below the acromial process
the injection less painful. Option D is incorrect and will not relax
b) administers the injection in the thigh
the muscle. Option A describes the administration of an injection
c) positions the client in a prone toe-in position
into the deltoid muscle. Option B describes an injection into the
d) positions the client in a Sims' position
vastus lateralis or rectus femoris muscle.

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