Principles of Delegation NCLEX. Complete Questions & Answers.

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Principles of Delegation NCLEX 1. A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possibl... e treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? 2. Which action by the nurse represents the ethical principle of beneficence? • The nurse administers an immunization to a child even though it may 3. The nursing instructor asks a student to name an example of false imprisonment. Which of the following situations reflects a violation of this client right? 4. A nurse and a nursing assistant enter a client s room to provide care and find the client lying on the floor. The nurse should first:\ 5. Which of the following actions exemplifies the use of evidence-based practice in the delivery of client care? 6. The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are part of the nurse s new role? Select all that apply. 7. The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type of audit?\ 8. A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client s necklace? 9. A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should: 10. A nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? 11. A physician writes a medication prescription in a client s record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the physician, who states that this is the dose that the client takes at home and that it is acceptable for this client s condition. What is the appropriate action for the nurse to take? 12. A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client s lung has reexpanded and notifies the physician. The physician verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. The nurse should first: 13. A nurse calls a physician to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The physician, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? 14. A nurse is assisting a physician in assessing a hospitalized client. During the assessment, the physician is paged to report to the recovery room. The physician leaves the client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? 15. A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client’s advocate by: 16. A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, “The medication is needed to prevent the spread of infection, and if you don’t take it orally I will have to give it to you in an intramuscular injection.” Which of the following statements accurately describes the nurse’s response to the client? 17. A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. The most appropriate action for the nurse is to: 18. A nurse calls a physician to question a prescription written for a higher-than-normal dosage of morphine sulfate. The physician changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency s guidelines in the client s record. Which other statement does the nurse document in the nursing notes? 19. A charge nurse on the 11 pm–to–7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. The charge nurse would most appropriately: 20. A client asks a nurse about the procedure for becoming an organ donor. The nurse tells the client: 21. A nurse enters a client’s room to administer a medication that has been prescribed by the physician. The client asks the nurse about the medication. Which response by the nurse is appropriate? 22. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse in charge. Which action by the nurse in charge is appropriate? 23. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? 24. A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should: 25. A nurse is taking a morning break with the unit secretary in the nurses’ lounge. The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary? 26. A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should: 27. A physician informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The physician tells the nurse to perform a slow code and let the client rest in peace if she stops breathing. How should the nurse respond? 28. A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig s disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that: 29. A man who is visiting his wife in a long-term care facility for people with Alzheimer’s disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital physician that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember? 30. A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands that: 31. A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? 32. A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? 33. A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply. 34. A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply. 35. A nurse working the 7 am to 3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first? 36. A nurse has delegated several nursing tasks to staff members. The nurse’s primary responsibility after delegation of the tasks is: 37. A case manager is reviewing progress notes in a client s medical record. Which notation indicates the need for follow-up? 38. The nurse reviewing a client s record sees that the following medications are prescribed. Which medication should the nurse plan to administer first? 39. A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict? 40. A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply. 41. A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply. 42. A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will she plan to care for first? 43. A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client s record indicate an unexpected outcome and the need for follow-up? Select all that apply. 44. A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is: 45. A nurse planning care for her assigned clients understands that the purpose of the hospital’s standards of care is to: 46. A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. The RN would conclude that the nursing assistant is performing the procedure incorrectly after observing that the nursing assistant: 47. A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client s deltoid muscle. The RN determines that the LPN is performing the procedure correctly if the LPN: 48. A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding? 49. The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant? 50. A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict? 51. A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (unlicensed assistive personnel)? 52. A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment? 53. A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? 54. A case manager is reviewing notations made in clients’ records. Which note indicates an unexpected outcome and the need for immediate follow-up? 55. A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral? 56. A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant? 57. A nurse is assigned to care for four clients. Which client should the nurse assess first? 58. A nurse is planning the client assignments for the shift. Which client should the nurse assign to the nursing assistant? 59. A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if he: 60. A new nurse employed at a community hospital is reading the organization’s mission statement. The new nurse understands that this statement: 61. A nurse, newly employed by a home health agency, is told that the organization’s decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in: 62. A nurse employed in a community hospital as a nurse manager understands that in this position, the term authority most appropriately refers to: 63. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply. 64. A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client’s injury, the nurse should: 65. A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply. 66. In which situation is the nurse upholding the ethical principle of fidelity? 67. Which of the following situations is an example of the use of evidence-based practice in the delivery of client care? 68. A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client? 69. A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager? 70. A nurse manager arrives at work and is immediately faced with several activities that require his attention. Which activity will the nurse manager attend to first? 71. A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse’s behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse manager to deal with this situation? 72. A physician repeatedly asks a nurse to write his verbal prescriptions in his clients charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the physician tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? 73. A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem? 74. A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation? 75. A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member? 76. A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse? 77. A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? 78. A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse leader would most appropriately manage this issue by: 79. A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following? 80. A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately: 81. A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first? 82. A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? 83. A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first: 84. An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first? 85. A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart so that he will: 86. A physician asks the nurse who is caring for a client with a new colostomy to ask the hospital’s stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of his: 87. A nurse manager discusses staff empowerment with the nursing team. The nurse manager explains that staff empowerment: 88. A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team does the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility? 89. The nurse notes that a physician has documented the following prescription in a client s record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take? 90. A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse tells the client that: 91. An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client’s parents but is unsuccessful. In regard to informed consent for the surgery: 92. A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act? 93. A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client’s record reflects the correct use of guidelines for documentation? 94. A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act to: 95. A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first? 96. A nurse is performing suctioning through an adult client’s tracheostomy tube. The nurse notes that the client’s oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next? 97. A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first? [Show More]

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