NCLEX Practice Questions and Answers – Nursing Exam Review Study Guide

NCLEX: ETHICS, DELEGATION, N N




PRIORITIZATION, LEGAL N N




The new graduate nurse interviews for a position in a nursing department of a large health care
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agency that uses the approach of shared governance. Which of these statements best illustrate
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the shared governance model?
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A. Staff groups are appointed to discuss nursing practice and client education issues
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B. Non-nurse managers supervise nursing staff in groups of units
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C. Nursing departments share responsibility for client outcomes
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D. An appointed board oversees any administrative decisions - CORRECT ANSWER-C. Nursing
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departments share responsibility for client outcomes
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Shared governance or self-governance is a method of organizational design. It promotes
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empowerment of nurses to give them responsibility for client care issues and outcomes with
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other divisions in the agency.
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The triage nurse identifies that a 16-year-old client is legally married and has signed the consent
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form for treatment. What would be an appropriate action by the nurse?
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A. Refer the teenager to a community pediatric hospital emergency department
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,B. Proceed with the triage process in the same manner as any adult client
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C. Ask the teenager to wait until a parent or legal guardian can be contacted
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D. Withhold treatment until telephone consent can be obtained from their partner - CORRECT
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ANSWER-B. Proceed with the triage process in the same manner as any adult client
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Minors may become known as an "emancipated minor" through marriage, pregnancy, high
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school graduation, independent living or service in the military. Therefore, this married client
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has the legal capacity of an adult. Otherwise, the age for legal signatures is 18 years of age.
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The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a
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surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that
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apply.)
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A. the UAP empties the indwelling catheter bag for the client who had a transurethral resection
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of the prostate (TURP) yesterday
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B. The UAP applies moisture barrier cream to the client's excoriated perianal area
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C. The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in
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the hall
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D. The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue
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E. The UAP assists a client, who had a total knee replacement two days ago, to shave using a
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straight-edge razor - CORRECT ANSWER-C. The UAP assists a client, who received an IV narcotic
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analgesic 30 minutes ago, to ambulate in the hall
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D. The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue
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E. The UAP assists a client, who had a total knee replacement two days ago, to shave using a
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straight-edge razor
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, The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary
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catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the
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UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave
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clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee
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replacement surgery is probably taking an anticoagulant; only an electric razor should be used.
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Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail
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polish.
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A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would
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be the best initial action by the nurse manager?
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A. Schedule a staff conference, without the nurse present, to collect information
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B. Consult with human resources about the issue and needed actions
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C. Confront the nurse about the suspicions in a private meeting
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D. Counsel the employee to resign to avoid investigation and rumors - CORRECT ANSWER-B.
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Consult with human resources about the issue and needed actions
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The nurse manager needs to consult with human resources to determine the proper procedures
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for documenting and reporting the nurse's behavior. The nurse manager could also consult the
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EAP if one is available. If the staff nurse is also suspected of diversion, and a written policy
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exists, the nurse manager would follow these procedures. Attempts should be made to help the
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nurse with SUD by providing counseling and treatment for this disease.
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A client who is unconscious is brought to the emergency department by an ambulance. What
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document should the nurse give priority to when preparing the care for this client?
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A. A notarized original of the advance directive brought in by the partner
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B. Orders written by the health care provider in the emergency department
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C. The national statement of client rights and the client self-determination act
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D. The clinical pathway protocol of the agency and the emergency department - CORRECT
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ANSWER-A. A notarized original of the advance directive brought in by the partner
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