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L&M 25
L&M 25
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Nursing Leadership and Management NCLEX Questions
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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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Nursing Leadership and Management NCLEX Questions
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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
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