Management of Care NCLEX Questions Answers and Rationale

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1.    Answer B. Calling the supervisor is a secondary measure after confronting the nurse and relieving the nurse of her duties. You cannot always assume the supervisor will be immediately available, and client safety should be addressed first. When another nurse is unable to perform her nursing duties due to substance abuse, she should not be allowed to continue them, as client safety is a primary concern. Ignoring the situation is against the professional code of conduct for nurses. Angelina needs to be relieved of her duties. She probably would not benefit from a lecture in her condition.
2.    Answer D. Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require evaluation.
3.    Answer B. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
4.    Answer D. In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared.
5.    Answer B. Secrets are inappropriate in therapeutic relationships and are counterproductive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
6.    Answer B. This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client.
7.    Answer C. Obtain more details of the client’s claim of abuse. The advocacy role of the professional nurse as well as the legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, further assessment, before documentation or the reporting of the complaint.
8.    Answer D. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
9.    Answer B. Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed.
10.    Answer D. Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
11.    Answer B. The nurse must maintain the client’s right of confidentiality. Since he is not the client’s physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. Since he is not the client’s physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. It is not the attending surgeon who can give permission for him to review the chart, it is the client. The client must give written permission for unauthorized persons to review her chart. This client had surgery today and is probably not alert enough to give legal permission, which must be written.
12.    Answer A. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities
13.    Answer B. It cannot be legally assumed that the client consents to a procedure for which he has not given consent. This is not legally defensible. All invasive procedures require informed consent. The surgery is prescheduled and described as exploratory and therefore is not an emergency. If the client is an adult and has not been declared incompetent the client must sign the form. This client should not have surgery performed without written consent. The nurse must notify the physician immediately. The client has been premedicated for surgery and is not alert. He cannot give legal consent when under the influence of mind-altering drugs. The client is an adult and there is no evidence that he has been declared incompetent to make his own decisions. The surgery is exploratory. There is no indication it is for an immediately life-threatening condition. It is not appropriate to ask the next of kin to sign his consent form.
14.    Answer D. In addition to notifying the physician and documenting it, the nurse should complete an incident report. The physician must be notified. An incident report should be completed. However, no record of the incident report should appear in the nurse’s notes. The physician must be notified. An incident report should be completed. However, no record of the incident report should appear in the nurse’s notes. The physician must be notified of the medication error. An incident report should be completed. However, no record of the incident report should appear in the nurse’s notes. The nurse should document that the physician was notified and any assessments completed.
15.    Answer D. The need for family support is vital to prevent discouragement and depression. A volunteer will not take the place of family. The need for family support is vital to prevent discouragement and depression, even at the risk of offending the families of other patients. Loss of a breadwinner during the lengthy recovery process may add financial problems for the family. Guillain-Barré syndrome is characterized by the onset of ascending paralysis, which may include respiratory muscles. Persons with Guillain-Barré syndrome may remain ventilator-dependent for weeks, but have full consciousness. The prognosis for recovery from Guillain-Barré syndrome is good, but is very much dependent upon the level of supportive care during the acute stage.
16.    Answer D. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff.
17.    Answer B. An alert, oriented client should be asked to state her full name so that there is no confusion in identity. The ID bracelet will confirm identity when the client is not alert or oriented to person. Reading the name on the client’s ID bracelet is the most accurate way to confirm identity. Reading the client’s medical record will not confirm identity. The roommate is not an accurate source for client identification.
18.    Answer C. This response explains the clients behavior without belittling the nursing assistant’s feelings. The nursing assistant is encouraged to help solve the problem with the nurse.
19.    Answer D. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
20.    Answer D. The RN may delegate the application and care of rectal pouches to a nursing assistant, who should be capable of performing this task .

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