Safe and Effective Care Environment NCLEX Review Questions Answers and Rationale

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1. Answer A. Advance directives are signed, witnessed documents that provide specific instructions for treatment if a client can’t give those instructions personally when required. Depending on the client’s wishes, they may or may not include DNR orders.

2. Answer B. When taking a medication order over the telephone, standard practice requires verbal verification of the order and the physician’s written signature within 24 hours. The nurse practice act doesn’t prohibit taking medication orders over the telephone

3. Answer C. The donor and recipient must have compatible blood and tissue types. They should be fairly close in size and age. When a living donor is considered, it’s preferable to have a relative donate the organ. Need is important but it can’t be the critical factor if a compatible donor isn’t available.

4. Answer A. The primary physician in charge of a client’s care must write an order for the restraint within 8 hours. In an emergency, a client who is a threat to himself or others may be restrained without an order. Voluntary clients have the right to leave against medical advice. A minor is treated the same as an adult regarding restraints.

5. Answer C. Although all of the options are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior are prerequisites for understanding and helping clients.

6. Answer B. When a nurse attempts to influence a family’s decision with her own opinions and values, the situation becomes one of overinvolvement on the nurse’s part and a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship.

7. Answer B. The nurse should determine the specific concerns of the client’s wife. Jumping to conclusions regarding the client’s need for a nursing home or other care placement options would be inappropriate. The nurse must tailor care to the client and family, focusing on their needs.

8. Answer C. When a nurse discovers substandard practice by another nurse, it’s always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn’t promote goodwill between nurses and can affect nursing care.

9. Answer B. The nurse violated confidentiality by informing the officer that the client wasn’t in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client’s confidentiality. Information can be legally withheld when a court order isn’t in place.

10. Answer D. Discharge planning should begin when a client is first admitted to the facility. Initially, discharge planning requires collecting information about the client’s home environment, support systems, functional abilities, and finances.

11. Answer C. Many clients are discharged from acute care settings so quickly that they don’t receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesn’t take precedence over ensuring proper colostomy care. Requesting Meals on Wheels and asking for an occupational therapy evaluation are important but can occur later in rehabilitation.

12. Answer C. Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should.

13. Answer D. Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client’s daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client’s medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn’t exist.

14. Answer A. The nurse has failed to respond immediately to the safety and privacy of a vulnerable client. Negligence is defined as an omission to do something a reasonable person would do. This nurse’s behavior is anything but sensitive, caring, or compassionate. Organization isn’t addressed in this situation.

15. Answer B. The client’s bill of rights addresses the client’s rights to information, informed consent, timely responses to requests for services, and treatment refusal. It’s a legal document and serves as a guideline for decision making by the nurse. Standards of nursing practice, the nurse practice act, and the code for nurses contain nursing practice parameters and primarily describe use of the nursing process in providing care.

16. Answer B. The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might to be detrimental to the client, the primary care provider should be informed of the client’s request. The client doesn’t need an attorney to view her chart. She also doesn’t need to wait until after discharge to view it.

17. Answer C. An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help a child with cerebral palsy eat and perform other activities of daily living. A registered dietitian manages and plans for the nutritional needs of children with cerebral palsy but isn’t trained in modifying or fitting utensils with assistive devices. A physical therapist is trained to help a child with cerebral palsy gain function and prevent further disability but not to assist the child in performing activities of daily living. A nursing assistant can help a child eat; however, the nursing assistant isn’t trained in modifying utensils.

18. Answer C. In Maslow’s hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer.

19. Answer C. It’s discriminatory and punitive for the nurse-manager to alter the staff nurse’s schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the nurse-manager to the labor relations board should be avoided. Institutional documentation should exist for such matters. It’s inappropriate for the physician to inform the staff nurse about what was said. Such action could create difficult relations on the unit and, thereby, affect nursing care.

20. Answer A. Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn’t acceptable to the client. It isn’t the responsibility of the surgeon to find an alternate. Jehovah’s Witnesses don’t believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client’s right of autonomy.

21. Answer B. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation where the nurses have unexpressed feelings and emotions. Although the other answers could be contributing to the problematic situation, they’re less likely to be the cause.

22. Answer C. Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren’t frameworks for nursing education and practice.

23. Answer B. After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability.

24. Answer D. Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client’s feelings is not. Stating that the client had a good day doesn’t provide precise enough information to be useful.

25. Answer A. Critical pathways are defined as a provision of care in a case management system. The pathways provide outcome-based guidelines for goal achievement within a designated length of stay. Critical pathways are to be used by the treatment team, not just by the physician. Pathways are designated lengths of stay, not therapies.

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