1. Angelina, an R.N., reports to work looking unkempt. Maegan, another R.N., approaches when she notices her using uncoordinated movements. Angelina’s breath reeks of peppermints and Maegan suspects Angelina may be intoxicated. What is the best initial nursing action for Maegan to take?
a. Call the supervisor and report Angelina.
b. Confront Angelina, saying that she feels she is intoxicated, and relieve her of her nursing duties immediately.
c. Ignore the situation.
d. Give Angelina a lecture about substance abuse and do nothing else.
2. Carol has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
a. To observe the type and amount of nasogastric tube drainage
b. Monitor the client for nausea or other complications
c. Irrigate the nasogastric tube with the ordered irrigant
d. Perform nostril and mouth care
3. Britney is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that:
a. a referral is needed to the psychiatrist who is to provide the client with answers
b. the client has a right to know about the prescribed medications
c. such education is an independent decision of the individual nurse whether or not to teach clients about their medications
d. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
4. James with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?
a. "I am sorry. Referral information can only be provided by the client’s providers"
b. "I can never give any information out by telephone. How do I know who you are?"
c. "Since this is a referral, I can give you this information"
d. "I need to get the client’s written consent before I release any information to you"
5. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is:
a. "I must document and report any important information."
b. "I can’t make such a promise."
c. "That depends on what you tell me."
d. "I must report everything to the treatment team."
6. Helen, a nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with:
a. Dopamine drip IV with vital signs monitored every 5 minutes
b. a myocardial infarction that is free from pain and dysrhythmias
c. a tracheotomy of 24 hours in some respiratory distress
d. a pacemaker inserted this morning with intermittent capture
7. A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first:
a. focus on reality orientation to place and person
b. assist with the report of the client’s complaint to the police
c. obtain more details of the client’s claim of abuse
d. document the statement on the client’s chart with a report to the manager
8. John, a client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to:
a. ask to not be assigned to this client or to work on another unit
b. tell the client that such behavior is inappropriate
c. inform the client that hospital policy prohibits staff to date clients
d. discuss the boundaries of the therapeutic relationship with the client
9. A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to:
a. keep the client’s room door cracked to minimize the distractions
b. assign 1 of the nursing staff to visit the client regularly
c. reassure the client that 1 staff person will check frequently if the client needs anything
d. arrange for each staff member to go into the client’s room to check on needs every hour on the hour
10. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
a. Assign an RN to provide total care of the client
b. Assign a nursing assistant to help the client with self-care activities
c. Delegate complete care to an unlicensed assistive personnel
d. Supervise a nursing assistant for skin care
11. A 24-year-old woman had surgery today. Her father, a physician but not her surgeon, enters the nursing station and asks for her chart. The best action for the nurse to take is:
a. to give him the chart as requested.
b. not to allow him to read the chart.
c. to ask the attending surgeon if it is permissible for him to read the chart.
d. to ask the client if she wants him to read her chart.
12. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client’s background because:
a. Normal patterns of behavior may be labeled as deviant, immoral, or insane
b. The meaning of the client’s behavior can be derived from conventional wisdom
c. Personal values will guide the interaction between persons from 2 cultures
d. The nurse should rely on her knowledge of different developmental mental stages
13. Robin, an adult male is scheduled for exploratory surgery this morning. After he is premedicated for surgery the nurse reviews his chart and discovers that he has not signed a consent form. The nurse’s action is based on which of the following understandings?
a. Since the client came to the hospital consent is implied even if the consent for the surgery has not been signed.
b. All invasive procedures require a consent form.
c. The nurse should have him sign a consent form immediately
d. The nurse should have the next of kin sign the necessary consent form
14. Zantac is ordered for an adult client. The nurse mistakenly administered Xanax. What is the most appropriate action for the nurse to take?
a. Notify the physician and document in the nurse’s notes that the physician was notified of the error.
b. Notify the supervisor, complete a medication error incident report, and document in the nurse’s notes that an incident report was completed
c. Notify the house supervisor, assess client carefully, and document only if adverse or untoward effects occur.
d. Notify the physician, complete an incident report, and document the notification of the physician and any assessments made.
15. A client with Guillain-Barré syndrome has been on a ventilator for three weeks, and can communicate only with eye blinks because of quadriplegia. The intensive care nursing staff sometimes have no time for this tedious communication process. The client’s family comes infrequently since they run a family-owned restaurant that does not close until visiting hours are over. How should the nurse respond to the family’s request for exemption from visiting hours?
a. Arrange for a volunteer to stay with the client during the day to provide for socialization needs and to facilitate communication with staff.
b. Explain to the family that consistency in enforcing rules is important to prevent complaints from the families of other clients.
c. Suggest that the family visit in shifts during the normal visiting hours, since the client needs to sleep at night.
d. Make an exception to visiting regulations because of the long-term nature of the client’s recovery and the need for family support.
16. An adult client has continued slow bleeding from the graft after repair of an abdominal aortic aneurysm. Because of the client’s unstable condition, he is in the intensive care unit where visitors are limited to the family. The client insists on having a visit from a medicine man whom the family visits regularly. How should the nurse interpret this request?
a. The principle of justice prohibits giving one client a privilege that other clients are not permitted.
b. Faith healers do not meet the standards for clergy exemption from visitation rules.
c. Medicine men are not approved by the hospital as legitimate health care providers.
d. Provision of holistic care requires that the client’s belief system is honored.
17. Mrs. Jefferson is an 88-year-old client at a long-term care facility. Prior to administering any medication or treatment to this client the nurse must confirm identity by:
a. asking the client if she is Mrs. Jefferson.
b. reading the client’s identification bracelet
c. reading the client’s medical record.
d. asking the roommate to state the client’s name.
18. After working with a very demanding client, a nursing assistant tells the nurse, "I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again." The nurse’s BEST response is:
a. "He has a lot of problems. You need to be patient with him."
b. "I will talk with him and try to figure out what to do."
c. "He is scared and taking it out on you. Let’s try to figure out what to do."
d. "Ignore him and get the rest of your work done. Someone else can take care of him tomorrow."
19. A client frequently compliments and invites the nurse to go out. The nurse should:
a. Minimize further contact with the client
b. Tell the client that his/her behavior is inappropriate
c. Tell the client that hospital policy prohibits dating clients
d. Discuss the boundaries of the relationship with the client
20. Which one of the following could be safely delegated by the nurse to the nursing assistant?
a. Observe a client’s self-administration of insulin
b. Cleanse and dress a small decubitus ulcer
c. Monitor a client’s response to physical therapy
d. Apply and care for a client’s rectal pouch
Answers and Rationale will be posted soon…
More NCLEX review soon…