NCLEX REVIEW - MANAGEMENT OF CARE
Questions and Answers
1.A client is being prepped for a surgical procedure and the nurse is
reviewing the informed consent with the client. The client asks, "Is there any
other way to take care of this without having surgery?" The nurse has a duty
to first:
1) Reassure the client that the surgery is the best treatment option
2) Tell the client if they don't want the surgery, they don't have to have it
3) Notify the surgeon that the client has additional questions about
alterna- tives to surgery
4) Call the surgeon and cancel the surgery until the consent form is signed
ANS: 3
Rationale:
The client has a right to an explanation of the treatment and its expecte
results, an- ticipated risks and benefits, possible alternative treatment
options and all questions answered before a consent form is signed.
Remember, the client is not asking you for your opinion. The client is
asking about alternative treatments for the condition. Notify the
appropriate health care provider if the client needs additional informatio
that you cannot answer. Once the client has all the necessary informatio
then they can decide not to sign the informed content and cancel the
surgery.
2.A nurse is named in a lawsuit. Which of these factors will offer the
best protection for that nurse in a court of law?
1) Clinical specialty certification by an accredited organization
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,2) Complete and accurate documentation of assessments and interventions
3) Above-average performance reviews prepared by nurse manager
4) Sworn statement that health care provider orders were followed
ANS: 2
Rationale:
The medical record is a legal document. Documentation should include
all steps of the nursing process; it must be complete, accurate, concise
and in chronological order. Inaccurate or incomplete documentation will
raise red flags and may indi- cate the nurse failed to meet the
standards of care. The attorney will review the medical record with the
nurse before giving a deposition (sworn pretrial testimony). Above-
average performance reviews could be considered supporting
information.
Certification is an "extra" based on the nurse's initiative; it is, however,
unrelated to accurate charting.
3.The new graduate nurse interviews for a position in a nursing
department of a large health care agency that uses the approach of shared
governance. Which of these statements best illustrate the shared
governance model?
1) Staff groups are appointed to discuss nursing practice and client
education issues
2) Non-nurse managers supervise nursing staff in groups of units
3) Nursing departments share responsibility for client outcomes
4) An appointed board oversees any administrative decisions
ANS: 3
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, Rationale:
Shared governance or self-governance is a method of organizational
design. It promotes empowerment of nurses to give them responsibility
for client care issues and outcomes with other divisions in the agency.
4.The registered nurse (RN) and the unlicensed assistive person (UAP)
are caring for clients on a surgical unit. Which action(s) by the UAP
warrant immediate intervention? (Select all that apply.)
1) The UAP empties the indwelling catheter bag for the client who had
a transurethral resection of the prostate (TURP) yesterday
2) The UAP applies moisture barrier cream to the client's excoriated
perianal area
3) The UAP assists a client, who received an IV narcotic analgesic 30
minutes ago, to ambulate in the hall
4) The UAP applies a fingertip pulse oximeter on a client whose fingernail
is painted dark blue
5) The UAP assists a client, who had a total knee replacement two days
ago, to shave using a straight-edge razor
ANS: 3, 4, 5
Rationale:
The UAP can perform a number of nursing tasks, such as emptying an
indwelling urinary catheter bag and applying moisture barrier cream
after peri care. However, it is unsafe for the UAP to ambulate a client
who recently received an IV push narcotic. Although UAP can shave
clients, it is unsafe to shave someone using a straight-edge razor
because a client who had knee replacement surgery is probably taking
an anticoagulant; only an electric razor should be used. Pulse oximeter
readings must be done on a finger that is warm and free from dark
3/
27
Questions and Answers
1.A client is being prepped for a surgical procedure and the nurse is
reviewing the informed consent with the client. The client asks, "Is there any
other way to take care of this without having surgery?" The nurse has a duty
to first:
1) Reassure the client that the surgery is the best treatment option
2) Tell the client if they don't want the surgery, they don't have to have it
3) Notify the surgeon that the client has additional questions about
alterna- tives to surgery
4) Call the surgeon and cancel the surgery until the consent form is signed
ANS: 3
Rationale:
The client has a right to an explanation of the treatment and its expecte
results, an- ticipated risks and benefits, possible alternative treatment
options and all questions answered before a consent form is signed.
Remember, the client is not asking you for your opinion. The client is
asking about alternative treatments for the condition. Notify the
appropriate health care provider if the client needs additional informatio
that you cannot answer. Once the client has all the necessary informatio
then they can decide not to sign the informed content and cancel the
surgery.
2.A nurse is named in a lawsuit. Which of these factors will offer the
best protection for that nurse in a court of law?
1) Clinical specialty certification by an accredited organization
1/
27
,2) Complete and accurate documentation of assessments and interventions
3) Above-average performance reviews prepared by nurse manager
4) Sworn statement that health care provider orders were followed
ANS: 2
Rationale:
The medical record is a legal document. Documentation should include
all steps of the nursing process; it must be complete, accurate, concise
and in chronological order. Inaccurate or incomplete documentation will
raise red flags and may indi- cate the nurse failed to meet the
standards of care. The attorney will review the medical record with the
nurse before giving a deposition (sworn pretrial testimony). Above-
average performance reviews could be considered supporting
information.
Certification is an "extra" based on the nurse's initiative; it is, however,
unrelated to accurate charting.
3.The new graduate nurse interviews for a position in a nursing
department of a large health care agency that uses the approach of shared
governance. Which of these statements best illustrate the shared
governance model?
1) Staff groups are appointed to discuss nursing practice and client
education issues
2) Non-nurse managers supervise nursing staff in groups of units
3) Nursing departments share responsibility for client outcomes
4) An appointed board oversees any administrative decisions
ANS: 3
2/
27
, Rationale:
Shared governance or self-governance is a method of organizational
design. It promotes empowerment of nurses to give them responsibility
for client care issues and outcomes with other divisions in the agency.
4.The registered nurse (RN) and the unlicensed assistive person (UAP)
are caring for clients on a surgical unit. Which action(s) by the UAP
warrant immediate intervention? (Select all that apply.)
1) The UAP empties the indwelling catheter bag for the client who had
a transurethral resection of the prostate (TURP) yesterday
2) The UAP applies moisture barrier cream to the client's excoriated
perianal area
3) The UAP assists a client, who received an IV narcotic analgesic 30
minutes ago, to ambulate in the hall
4) The UAP applies a fingertip pulse oximeter on a client whose fingernail
is painted dark blue
5) The UAP assists a client, who had a total knee replacement two days
ago, to shave using a straight-edge razor
ANS: 3, 4, 5
Rationale:
The UAP can perform a number of nursing tasks, such as emptying an
indwelling urinary catheter bag and applying moisture barrier cream
after peri care. However, it is unsafe for the UAP to ambulate a client
who recently received an IV push narcotic. Although UAP can shave
clients, it is unsafe to shave someone using a straight-edge razor
because a client who had knee replacement surgery is probably taking
an anticoagulant; only an electric razor should be used. Pulse oximeter
readings must be done on a finger that is warm and free from dark
3/
27
