NURSING PRACTICE I
FOUNDATION OF PROFESSIONAL NURSING PRACTICE
1. While caring for an 8-year-old child with a broken wrist, the nurse notices red, raised
streaks on the child’s back. The child’s father enters the room and the child becomes
quiet and distant, leaning away from the father as he approaches. What is the best
nursing action?
a. Chart the child was probably beaten by the father
b. Notify the supervisor to report possible child abuse
c. Disregard suspicions and care for the immediate needs of the child
d. No action is required; there is no actual proof of abuse to the child
Answer: B
Rationale: Any suspected child abuse should be reported to the appropriate agencies.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
2. A nurse manager has been notified to obtain a bed for a client. Of the following
clients, which one would the nurse anticipate being able to discharge?
a. A client who had myocardial infarction 2 days ago. His vital signs are: BP 150/94
mmHg, pulse 84 beats/min and irregular, respiration 28 breaths/min, minimal chest pain
b. A client who underwent an abdominal aneurysm resection 3 days ago. His vital signs
are BP 130/88 mmHg, pulse 88 beats/min, respiration 22 breaths/min, and oral
temperature 101º F. He is beginning oral intake without problems
c. A client who has a subdural hematoma. He is lethargic; pulse is 60 beats/min,
respiration is 28 breaths/min, temperature is 99º F
d. A client who had abdominal surgery for a bowel obstruction 4 days ago. He has
bowel sounds, is taking fluids orally, has an abdominal Penrose drain, and is continuing
to experience abdominal pain.
Answer: D
Rationale: D represents the most stable client that could be discharged. Clients in A
and C are showing signs of being unstable with their diagnosis. The client in B is stable,
but because of the extensiveness of his surgery and because he had surgery only 3
days ago, he is a less likely candidate to move than the client in option D.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
3. Delegation is the process of transferring work to subordinates. A nurse-manager can
appropriately
delegate which task?
a. Scheduling staff assignments for the next month
b. Terminating a nursing assistant for insubordination
c. Deciding on salary increases for licensed practical nurses after they complete
,orientation
d. Telling a staff nurse to initiate disciplinary action aginst one of her peers
Answer: A
Rationale: Scheduling may be safely and appropriately delegated. Termination,
disciplinary action, and salary increases shouldn’t be delegated to staff, which doesn’t
have the power and the authority to take such actions
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 780
4. The nurse is planning assignments. Which task can be safely delegated to a nursing
assistant?
a. Obtain a stool specimen from a client with diarrhea
b. Assist client with a new colostomy in practicing his first colostomy irrigation
c. Evaluate the voiding pattern for a client who had a urinary retention catheter
removed
d. Obtain a dietary history from a client with peptic ulcer disease.
Answer: A
Rationale: The assignment in A has the most specific guidelines for performance. The
other procedures require assessment and judgment and should not be assigned to a
nursing assistant.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 614
5. A staff nurse on a busy pediatric unit is an excellent role model for her colleagues.
She encourages
them to participate in the unit’s decision-making process and helps them improve
their clinical skills.
This nurse is functioning effectively in which role?
a. Manager b. Autocrat c. Leader d. Authority
Answer: C
Rationale: A leader doesn’t have formal power and authority but influences the success
of a unit by being an excellent role model and by guiding, encouraging, and facilitating
professional growth and development.
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 778
6. A nurse-manager on an oncology unit has been informed that she must determine
which nursing
care delivery system is the best for efficient client care, client satisfaction, and cost
reduction.
Knowing that 2 or 3 registered nurses, 4 licensed practical nurses, and 5 nursing
assistants are
generally on duty on each shift and that the clients can be grouped fairly easily by
,geographic
location and client care needs, the nurse-manager and her staff appropriately decide
to implement
which nursing care delivery system?
a. Functional nursing c. Team Nursing
b. Case management d. Primary Nursing
Answer: C
Rationale: Team nursing is efficient and cost less to implement than primary or case
management systems. Because the staff members know each other well, they can
function effectively as a team. Although functional nursing is the most cost effective,
care is commonly fragmented and client satisfaction decreased. Case management and
primary nursing require more registered nurses than are available.
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 779
7. The charge nurse is planning assignments for the nursing staff. One of the staff
nurses is pregnant.
Which client would not be appropriate to assign to this nurse?
a. Child with brain tumor being treated with radiation
b. Infant with respiratory syncytial virus receiving ribavirin
c. Toddler who is HIV+ and has an opportunistic respiratory tract infection
d. Child with leukemia who is receiving Oncovin (Vincristine) and Zyloprim (allopurinol)
Answer: B
Rationale: Involves contact with a medication that is teratogenic and is classified as
Pregnancy Risk category X. The other clients do not pose a risk to the pregnant nurse.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
8. A nurse-manager appropriately behaves as an autocrat in which situation?
a. Planning vacation time for staff
b. Directing staff activities if a client has a cardiac arrest
c. Evaluating a new medication administration process
d. Identifying the strengths and weaknesses of a client education video
Answer: B
Rationale: In a crisis situation, the nurse- manager should take command for the
benefit of the client. Planning vacation time and evaluating procedures and client
resources require staff input characteristic of a democratic or participative manager.
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 781
9. There are phases in the change process to be considered, the first one should be:
a. Refreezing b. Unfreezing c. Changing d. Resisting
, Answer: B
Rationale: In the change process the first step is unfreezing followed by moving and
refreezing.
Source: Guide to Nursing Management and Leadership by Ann Tomey, 6 th edition,
2000, page 273
10. Form of communication that travels from staff and lower middle level management
personnel and
continues up the organizational hierarchy is:
a. Downward b. Upward c. Matrix d. Grapevine
Answer: B
Rationale: Upward communication emanates from subordinates and goes upward.
Source: Nursing Management towards Quality Care by Lydia Venzon, 2 nd edition, page
102
11. What is a key component in a quality assurance program?
a. Patient satisfaction questionnaire
b. Determination of criteria to meet standards
c. Case management for continuity of care
d. An acuity system for client classification
Answer: B
Rationale: In a quality assurance program, there must be standards from which to
measure progress. Criteria are established to obtain objective measurement.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
12. Which of the following tools can be most helpful in the evaluation of staff
performance?
a. Performance assessment c. Performance audit
b. Performance standard d. Performance appraisal
Answer: D
Rationale: Performance appraisal is a control process in which employee’s
performance is evaluated against standards. It is the most valuable tool in controlling
human resources and productivity.
Source: Nursing Management towards Quality Care by Lydia Venzon, 2 nd edition, page
128
13. A storm has prevented most of the staff members from getting to work on a busy
medical-surgical
unit. One registered nurse, 2 licensed practical nurses, and 3 nursing assistants
have been able to
work. The nurse-manager must decide which nursing care delivery system should
be
FOUNDATION OF PROFESSIONAL NURSING PRACTICE
1. While caring for an 8-year-old child with a broken wrist, the nurse notices red, raised
streaks on the child’s back. The child’s father enters the room and the child becomes
quiet and distant, leaning away from the father as he approaches. What is the best
nursing action?
a. Chart the child was probably beaten by the father
b. Notify the supervisor to report possible child abuse
c. Disregard suspicions and care for the immediate needs of the child
d. No action is required; there is no actual proof of abuse to the child
Answer: B
Rationale: Any suspected child abuse should be reported to the appropriate agencies.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
2. A nurse manager has been notified to obtain a bed for a client. Of the following
clients, which one would the nurse anticipate being able to discharge?
a. A client who had myocardial infarction 2 days ago. His vital signs are: BP 150/94
mmHg, pulse 84 beats/min and irregular, respiration 28 breaths/min, minimal chest pain
b. A client who underwent an abdominal aneurysm resection 3 days ago. His vital signs
are BP 130/88 mmHg, pulse 88 beats/min, respiration 22 breaths/min, and oral
temperature 101º F. He is beginning oral intake without problems
c. A client who has a subdural hematoma. He is lethargic; pulse is 60 beats/min,
respiration is 28 breaths/min, temperature is 99º F
d. A client who had abdominal surgery for a bowel obstruction 4 days ago. He has
bowel sounds, is taking fluids orally, has an abdominal Penrose drain, and is continuing
to experience abdominal pain.
Answer: D
Rationale: D represents the most stable client that could be discharged. Clients in A
and C are showing signs of being unstable with their diagnosis. The client in B is stable,
but because of the extensiveness of his surgery and because he had surgery only 3
days ago, he is a less likely candidate to move than the client in option D.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
3. Delegation is the process of transferring work to subordinates. A nurse-manager can
appropriately
delegate which task?
a. Scheduling staff assignments for the next month
b. Terminating a nursing assistant for insubordination
c. Deciding on salary increases for licensed practical nurses after they complete
,orientation
d. Telling a staff nurse to initiate disciplinary action aginst one of her peers
Answer: A
Rationale: Scheduling may be safely and appropriately delegated. Termination,
disciplinary action, and salary increases shouldn’t be delegated to staff, which doesn’t
have the power and the authority to take such actions
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 780
4. The nurse is planning assignments. Which task can be safely delegated to a nursing
assistant?
a. Obtain a stool specimen from a client with diarrhea
b. Assist client with a new colostomy in practicing his first colostomy irrigation
c. Evaluate the voiding pattern for a client who had a urinary retention catheter
removed
d. Obtain a dietary history from a client with peptic ulcer disease.
Answer: A
Rationale: The assignment in A has the most specific guidelines for performance. The
other procedures require assessment and judgment and should not be assigned to a
nursing assistant.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 614
5. A staff nurse on a busy pediatric unit is an excellent role model for her colleagues.
She encourages
them to participate in the unit’s decision-making process and helps them improve
their clinical skills.
This nurse is functioning effectively in which role?
a. Manager b. Autocrat c. Leader d. Authority
Answer: C
Rationale: A leader doesn’t have formal power and authority but influences the success
of a unit by being an excellent role model and by guiding, encouraging, and facilitating
professional growth and development.
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 778
6. A nurse-manager on an oncology unit has been informed that she must determine
which nursing
care delivery system is the best for efficient client care, client satisfaction, and cost
reduction.
Knowing that 2 or 3 registered nurses, 4 licensed practical nurses, and 5 nursing
assistants are
generally on duty on each shift and that the clients can be grouped fairly easily by
,geographic
location and client care needs, the nurse-manager and her staff appropriately decide
to implement
which nursing care delivery system?
a. Functional nursing c. Team Nursing
b. Case management d. Primary Nursing
Answer: C
Rationale: Team nursing is efficient and cost less to implement than primary or case
management systems. Because the staff members know each other well, they can
function effectively as a team. Although functional nursing is the most cost effective,
care is commonly fragmented and client satisfaction decreased. Case management and
primary nursing require more registered nurses than are available.
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 779
7. The charge nurse is planning assignments for the nursing staff. One of the staff
nurses is pregnant.
Which client would not be appropriate to assign to this nurse?
a. Child with brain tumor being treated with radiation
b. Infant with respiratory syncytial virus receiving ribavirin
c. Toddler who is HIV+ and has an opportunistic respiratory tract infection
d. Child with leukemia who is receiving Oncovin (Vincristine) and Zyloprim (allopurinol)
Answer: B
Rationale: Involves contact with a medication that is teratogenic and is classified as
Pregnancy Risk category X. The other clients do not pose a risk to the pregnant nurse.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
8. A nurse-manager appropriately behaves as an autocrat in which situation?
a. Planning vacation time for staff
b. Directing staff activities if a client has a cardiac arrest
c. Evaluating a new medication administration process
d. Identifying the strengths and weaknesses of a client education video
Answer: B
Rationale: In a crisis situation, the nurse- manager should take command for the
benefit of the client. Planning vacation time and evaluating procedures and client
resources require staff input characteristic of a democratic or participative manager.
Source: NCLEX-RN Questions and Answers made Incredibly Easy, 2 nd edition, 2003,
page 781
9. There are phases in the change process to be considered, the first one should be:
a. Refreezing b. Unfreezing c. Changing d. Resisting
, Answer: B
Rationale: In the change process the first step is unfreezing followed by moving and
refreezing.
Source: Guide to Nursing Management and Leadership by Ann Tomey, 6 th edition,
2000, page 273
10. Form of communication that travels from staff and lower middle level management
personnel and
continues up the organizational hierarchy is:
a. Downward b. Upward c. Matrix d. Grapevine
Answer: B
Rationale: Upward communication emanates from subordinates and goes upward.
Source: Nursing Management towards Quality Care by Lydia Venzon, 2 nd edition, page
102
11. What is a key component in a quality assurance program?
a. Patient satisfaction questionnaire
b. Determination of criteria to meet standards
c. Case management for continuity of care
d. An acuity system for client classification
Answer: B
Rationale: In a quality assurance program, there must be standards from which to
measure progress. Criteria are established to obtain objective measurement.
Source: Illustrated Study Guide for the NCLEX-RN Exam by JoAnn Zerweck, 6 th
edition, page 615
12. Which of the following tools can be most helpful in the evaluation of staff
performance?
a. Performance assessment c. Performance audit
b. Performance standard d. Performance appraisal
Answer: D
Rationale: Performance appraisal is a control process in which employee’s
performance is evaluated against standards. It is the most valuable tool in controlling
human resources and productivity.
Source: Nursing Management towards Quality Care by Lydia Venzon, 2 nd edition, page
128
13. A storm has prevented most of the staff members from getting to work on a busy
medical-surgical
unit. One registered nurse, 2 licensed practical nurses, and 3 nursing assistants
have been able to
work. The nurse-manager must decide which nursing care delivery system should
be
