NCLEX -Health Care Systems NCLEX Study
Questions | NSG 3645 Comprehensive Review with
Rationales
An 85-year-old client is admitted to a home health care agency following a hospitalization. The
client needs assistance with activities of daily living (ADLs). During the admission process, the
nurse develops a plan of care for this client. Place the steps in the case management process in
the correct order by dragging and dropping the options below.
-12345 Identification of nursing problems
-12345 Evaluation of progress towards the client's home care goals
-12345 Assessment of biophysical and sociocultural considerations
-12345 Reassessment of health status and ADL ability
-12345 Complete referrals for assistance with ADLs
1. -Assessment of biophysical and sociocultural considerations
2. -Identification of nursing problems
3. -Complete referrals for assistance with ADLs
4. -Reassessment of health status and ADL ability
5. -Evaluation of progress towards the client's home care goals
Case management is a collaborative process that follows the nursing process and assesses,
plans, implements, coordinates, monitors and evaluates options and services to meet an
individual's health needs. When a client is admitted to a home health care agency, an
assessment is conducted to ensure continuity of care between the hospital and the home health
agency. The nurse should follow the nursing process and first asses the biophysical (i.e.,
physiologic) and sociocultural (i.e., interpersonal) considerations. Then the nurse can use this
information to identify nursing problems. Once the problems are identified the nurse can make
referrals as appropriate. After these referrals have been implemented, the nurse should
reassess the client's health status and ADL abilities. Finally, the nurse should evaluate the
client's progress toward their home care goals.
After a stressful shift at the hospital, the nurse writes the following post on their personal
social media account: "Today was a rough day. One of my clients was in a terrible car crash and
hemorrhaged. I felt so bad for the family." Which consequence could result from the nurse
posting this information online?
a. The nurse could be reprimanded for not first clearing the post with the hospital's
administration team.
,b. The information was posted without mention of personal identifiers, so legally no
consequences can follow.
c. The nurse could be asked to post a disclaimer that they do not represent the hospital on this
social media account.
d. The nurse could be terminated from employment at the hospital for breach of client
confidentiality.
d. The nurse could be terminated from employment at the hospital for breach of client
confidentiality.
Many health care facilities have adopted a social media policy. It is important to understand
that nurses can be terminated (i.e., fired) for posting personal information about clients online,
because this is an invasion of privacy. In addition to being a Health Insurance Portability and
Accountability Act (HIPAA) violation, the Health Information Technology for Economic and
Clinical Health Act (HITECH Act) gives state's attorneys the right to pursue violations of client
privacy. Maintaining confidentiality is an important aspect of professional behavior. Sharing
personal information or gossiping about others violates nursing ethical codes and practice
standards.
At a monthly staff meeting, the nurse manager is discussing quality improvement initiatives on
the hospital nursing unit. Which is an example of a quality improvement outcome indicator?
a. The amount of time it takes for nurses to administer medications
b. The frequency of postoperative wound infections on the unit
c. The number of clients who receive smoking cessation information
d. The percentage of clients who have Medicare insurance
The charge nurse in the emergency department receives a radio call from Emergency Medical
Services (EMS) stating that there has been a large structure fire with multiple victims. Which
action should the charge nurse take first, before the victims start to arrive?
a. Call for a medical evacuation helicopter to be on standby.
b. Notify the nursing supervisor and request additional staff.
c. Prepare the trauma room and lay out supplies.
d. Activate the disaster plan
,The charge nurse observes a new nurse inserting an indwelling urinary catheter on a female
client who is experiencing urinary retention. After the nurse inserts the catheter, no urine
outflow appears. Which action should the charge nurse take?
a. Remove and re-lubricate the catheter and assist the nurse with re-insertion.
b. Leave the catheter in place and check for urine output in 15 minutes.
c. Ask the nurse to withdraw and redirect the catheter anteriorly toward the pubic bone.
d. Remove the catheter and have the nurse get a new catheter and insertion kit.
A client is being prepped for a surgical procedure and the nurse is reviewing the consent form
with the client. The client asks, "Is there any other way to take care of this without having
surgery?" What should the nurse do next?
a. Notify the surgeon that the client has additional questions about the surgery.
b. Tell the client if they don't want the surgery, they don't have to have it.
c. Notify the operating room and cancel the surgery.
d. Reassure the client that the surgery is the best treatment option.
a. Notify the surgeon that the client has additional questions about the surgery.
The client should only sign the consent form after all their questions are answered. Notify the
appropriate health care provider if the client needs additional information about the surgery.
Once the client has all the necessary information, they can then decide not to sign the
informed consent form and the surgery can be cancelled. Offering false reassurance violates
the client's right to autonomy. Cancelling the surgery is premature at this time.
A client's family member calls for an update on the client's condition. What should the nurse
do first before providing information to the caller?
a. Call the physician to verify the client's condition before updating the caller.
b. Decline the caller's request and notify the nurse supervisor of a potential HIPAA violation.
c. Check with the client and obtain permission to provide the caller with the requested
information.
d. Ask the family member who is currently visiting the client if it is okay to release the
information.
c. Check with the client and obtain permission to provide the caller with the requested
information.
The nurse must have permission from the client to release information to the caller. If the
client is unable to give permission and has a power of attorney for health care (POAH), then
information shall only be given to the POAH. Family members can obtain updates from that
, person. Remember, it is difficult to know who is calling over the phone. The nurse should also
be familiar with the organization's policy on requests for information over the phone.
A client with Parkinson's disease is prescribed benztropine (Cogentin). For which of the
following should the nurse call the health care provider immediately?
a. The client is exhibiting bradykinesia and slurred speech.
b. The client has a history of primary angle-closure glaucoma.
c. The client's heart rate increased from 80 to 95 beats per minute.
d. The client is complaining of dizziness when standing up.
b. The client has a history of primary angle-closure glaucoma.
The nurse must be able to recognize adverse drug effects and contraindications of medications
commonly prescribed for the client with Parkinson's disease. Common clinical manifestations
of Parkinson's disease include bradykinesia (slow movement), dysarthria (slurred speech) and
orthostatic hypotension, caused by the loss of the neurotransmitter dopamine. The goal of
pharmacotherapy is to restore the functional balance of dopamine and acetylcholine. This is
achieved by giving dopaminergic drugs and cholinergic blockers.
Benztropine is an anticholinergic medication used in the treatment of Parkinson's disease that
blocks excess cholinergic stimulation in the brain and reduces muscular tremors and rigidity.
Tachycardia is a potential adverse drug event, but a heart rate increase of 15 bpm is within
acceptable limits. Due to their blocking actions of the parasympathetic nervous system,
anticholinergics are contraindicated with glaucoma, where they can cause an increase in
intraocular pressure (IOP), which can lead to vision loss and blindness.
The new graduate nurse interviews for a nursing position on a hospital unit that uses a shared
governance model. Which description best illustrates this concept?
a. The manager of the nursing unit develops and implements changes on the unit.
b. Nurses work together to implement changes and share responsibility for client outcomes.
c. The hospital's executive team determines the standards of nursing care.
d. Nurses and physicians collaborate to discuss client care standards.
b. Nurses work together to implement changes and share responsibility for client outcomes.
Shared governance or self-governance is a method of organizational design. It promotes the
empowerment of nurses and gives them responsibility for client care issues and outcomes.
Chaired by senior clinical nursing staff, these groups are empowered to establish and maintain
standards of nursing care and practice on their unit. The committees review and establish
standards of care, develop policy and procedures, resolve client satisfaction issue, and/or
Questions | NSG 3645 Comprehensive Review with
Rationales
An 85-year-old client is admitted to a home health care agency following a hospitalization. The
client needs assistance with activities of daily living (ADLs). During the admission process, the
nurse develops a plan of care for this client. Place the steps in the case management process in
the correct order by dragging and dropping the options below.
-12345 Identification of nursing problems
-12345 Evaluation of progress towards the client's home care goals
-12345 Assessment of biophysical and sociocultural considerations
-12345 Reassessment of health status and ADL ability
-12345 Complete referrals for assistance with ADLs
1. -Assessment of biophysical and sociocultural considerations
2. -Identification of nursing problems
3. -Complete referrals for assistance with ADLs
4. -Reassessment of health status and ADL ability
5. -Evaluation of progress towards the client's home care goals
Case management is a collaborative process that follows the nursing process and assesses,
plans, implements, coordinates, monitors and evaluates options and services to meet an
individual's health needs. When a client is admitted to a home health care agency, an
assessment is conducted to ensure continuity of care between the hospital and the home health
agency. The nurse should follow the nursing process and first asses the biophysical (i.e.,
physiologic) and sociocultural (i.e., interpersonal) considerations. Then the nurse can use this
information to identify nursing problems. Once the problems are identified the nurse can make
referrals as appropriate. After these referrals have been implemented, the nurse should
reassess the client's health status and ADL abilities. Finally, the nurse should evaluate the
client's progress toward their home care goals.
After a stressful shift at the hospital, the nurse writes the following post on their personal
social media account: "Today was a rough day. One of my clients was in a terrible car crash and
hemorrhaged. I felt so bad for the family." Which consequence could result from the nurse
posting this information online?
a. The nurse could be reprimanded for not first clearing the post with the hospital's
administration team.
,b. The information was posted without mention of personal identifiers, so legally no
consequences can follow.
c. The nurse could be asked to post a disclaimer that they do not represent the hospital on this
social media account.
d. The nurse could be terminated from employment at the hospital for breach of client
confidentiality.
d. The nurse could be terminated from employment at the hospital for breach of client
confidentiality.
Many health care facilities have adopted a social media policy. It is important to understand
that nurses can be terminated (i.e., fired) for posting personal information about clients online,
because this is an invasion of privacy. In addition to being a Health Insurance Portability and
Accountability Act (HIPAA) violation, the Health Information Technology for Economic and
Clinical Health Act (HITECH Act) gives state's attorneys the right to pursue violations of client
privacy. Maintaining confidentiality is an important aspect of professional behavior. Sharing
personal information or gossiping about others violates nursing ethical codes and practice
standards.
At a monthly staff meeting, the nurse manager is discussing quality improvement initiatives on
the hospital nursing unit. Which is an example of a quality improvement outcome indicator?
a. The amount of time it takes for nurses to administer medications
b. The frequency of postoperative wound infections on the unit
c. The number of clients who receive smoking cessation information
d. The percentage of clients who have Medicare insurance
The charge nurse in the emergency department receives a radio call from Emergency Medical
Services (EMS) stating that there has been a large structure fire with multiple victims. Which
action should the charge nurse take first, before the victims start to arrive?
a. Call for a medical evacuation helicopter to be on standby.
b. Notify the nursing supervisor and request additional staff.
c. Prepare the trauma room and lay out supplies.
d. Activate the disaster plan
,The charge nurse observes a new nurse inserting an indwelling urinary catheter on a female
client who is experiencing urinary retention. After the nurse inserts the catheter, no urine
outflow appears. Which action should the charge nurse take?
a. Remove and re-lubricate the catheter and assist the nurse with re-insertion.
b. Leave the catheter in place and check for urine output in 15 minutes.
c. Ask the nurse to withdraw and redirect the catheter anteriorly toward the pubic bone.
d. Remove the catheter and have the nurse get a new catheter and insertion kit.
A client is being prepped for a surgical procedure and the nurse is reviewing the consent form
with the client. The client asks, "Is there any other way to take care of this without having
surgery?" What should the nurse do next?
a. Notify the surgeon that the client has additional questions about the surgery.
b. Tell the client if they don't want the surgery, they don't have to have it.
c. Notify the operating room and cancel the surgery.
d. Reassure the client that the surgery is the best treatment option.
a. Notify the surgeon that the client has additional questions about the surgery.
The client should only sign the consent form after all their questions are answered. Notify the
appropriate health care provider if the client needs additional information about the surgery.
Once the client has all the necessary information, they can then decide not to sign the
informed consent form and the surgery can be cancelled. Offering false reassurance violates
the client's right to autonomy. Cancelling the surgery is premature at this time.
A client's family member calls for an update on the client's condition. What should the nurse
do first before providing information to the caller?
a. Call the physician to verify the client's condition before updating the caller.
b. Decline the caller's request and notify the nurse supervisor of a potential HIPAA violation.
c. Check with the client and obtain permission to provide the caller with the requested
information.
d. Ask the family member who is currently visiting the client if it is okay to release the
information.
c. Check with the client and obtain permission to provide the caller with the requested
information.
The nurse must have permission from the client to release information to the caller. If the
client is unable to give permission and has a power of attorney for health care (POAH), then
information shall only be given to the POAH. Family members can obtain updates from that
, person. Remember, it is difficult to know who is calling over the phone. The nurse should also
be familiar with the organization's policy on requests for information over the phone.
A client with Parkinson's disease is prescribed benztropine (Cogentin). For which of the
following should the nurse call the health care provider immediately?
a. The client is exhibiting bradykinesia and slurred speech.
b. The client has a history of primary angle-closure glaucoma.
c. The client's heart rate increased from 80 to 95 beats per minute.
d. The client is complaining of dizziness when standing up.
b. The client has a history of primary angle-closure glaucoma.
The nurse must be able to recognize adverse drug effects and contraindications of medications
commonly prescribed for the client with Parkinson's disease. Common clinical manifestations
of Parkinson's disease include bradykinesia (slow movement), dysarthria (slurred speech) and
orthostatic hypotension, caused by the loss of the neurotransmitter dopamine. The goal of
pharmacotherapy is to restore the functional balance of dopamine and acetylcholine. This is
achieved by giving dopaminergic drugs and cholinergic blockers.
Benztropine is an anticholinergic medication used in the treatment of Parkinson's disease that
blocks excess cholinergic stimulation in the brain and reduces muscular tremors and rigidity.
Tachycardia is a potential adverse drug event, but a heart rate increase of 15 bpm is within
acceptable limits. Due to their blocking actions of the parasympathetic nervous system,
anticholinergics are contraindicated with glaucoma, where they can cause an increase in
intraocular pressure (IOP), which can lead to vision loss and blindness.
The new graduate nurse interviews for a nursing position on a hospital unit that uses a shared
governance model. Which description best illustrates this concept?
a. The manager of the nursing unit develops and implements changes on the unit.
b. Nurses work together to implement changes and share responsibility for client outcomes.
c. The hospital's executive team determines the standards of nursing care.
d. Nurses and physicians collaborate to discuss client care standards.
b. Nurses work together to implement changes and share responsibility for client outcomes.
Shared governance or self-governance is a method of organizational design. It promotes the
empowerment of nurses and gives them responsibility for client care issues and outcomes.
Chaired by senior clinical nursing staff, these groups are empowered to establish and maintain
standards of nursing care and practice on their unit. The committees review and establish
standards of care, develop policy and procedures, resolve client satisfaction issue, and/or
