Basahin mo yan rhandy pang Top board 2 dali..

Dali mo na
over the fibrinolysin and is deficit?
a) tells the client to scan the environment
b) approaches the client from the unaffected side
c) places the bedside articles on the affected side
d) moves the commode and cahir to the affected side
6. A nursing instructor asks the nursing student to describe the
definition of a critical path. Which of the following statements, if
made by the student, indicates a need for further understanding
regarding critical paths?
a) they are developed through the collaborative efforts of all
members of the health care team
b) they provide an effective way of monitoring care and for
reducing or controlling the length of hospital stay for the client
c) they are developed based on appropriate standards of care
d) they are nursing care plans and use the steps of the nursing
process
7. A community health nurse is working with a disaster relief
following a tornado. The nurse's goal for the community is to
prevent as much injury and death as possible from the
uncontrollable event. Finding safe housing for survivors,
providing support to families, organizing counseling, and
securing physical care when needed allexamples of which type
of prevention?
a) primary level of prevention
b) secondary level of prevention
c) tertiary level of prevention
d) aggregate care prevention
8. The nurse manager is planning to implement a change in the
nursing unit from team nursing to primary nursing. The nurse
anticipates that there will be resistance to the change during the
change process. The primary technique that the nurse would use
in implementing this change is which of the following?
a) introduce the change gradually
b) confront the individuals involved in the change process
c) use coercion to implement the change
d) manipulate the participants in the change process
9. A nurse manager is providing an educational session to
nursing staff members about the phases of viral hepatitis. The
nurse manager tells the staff that which clinical manifestation(s)
are primarily characteristic of preicteric phase?
a) right upper quadrant pain
b) fatigue, anorexia and nausea
c) jaundice, dark-colored urine, and clay-colored stools
d) pruritus
10. A nurse is preparing a plan of care for a client who will be
hospitalized for insertion of an internal cervical radiation implant.
Which nursing intervention should the nurse implement in
preparation for the arrival of the client?
a) prepare a private room at the end of the hallway
b) place a sign on the door that indicates that visitors are limited
to 60-minute visits

c) assign one primary nurse to care for the client during the
hospital stay
d) place a linen bag outside of the client's room for discarding
linens after morning care
11. A nursing student is developing a plan of care for a client with
a chest tube that is attached to a Pleur-Evac drainage system.
The nurse intervenes if the student writes which incorrect
intervention in the plan?
a) position the client in semi-fowler's position
b) add water to the suction chamber as it evaporates
c) tape the connection sites between the chest tube and
the drainage system
d) instruct the client to avoid coughing and deep breathing

12. A nurse is caring for a client who has just had a plaster leg
cast applied. The nurse would plan to prevent the development
of compartment syndrome is instructing the licensed practical
nurseassigned to care for the client to:
a) elevate the limb and apply ice to the affected leg
b) elevate the limb and cover the limb with bath blankets
c) place the leg in a slightly dependent position and apply ice to
the affected leg
d) keep the leg horizontal and apply ice to the affected leg
13. A registered nurse (RN) is supervising a licensed practical
nurse (LPN) administering an intramuscular (IM) injection of iron
to an assigned client. The RN would intervene if the LPN is
observed to perform which of the following?
a) changing the needle after drawing up the dose and before
injection
b) preparing an air lock when drawing up the medication
c) using a Z-track method for injection
d) massaging the injection site after injection
14. A nursing student develops a plan of care for a client with
paraplegia who has a risk for injury related to spasticity of the leg
muscles. On reviewing the plan, the co-assigned nurse identifies
which of the following as an incorrect intervention.
a) use of padded restraints to immobilize the limb
b) performing range of motion to the affected limbs
c) removing potentially harmful objects near the spastic limbs
d) use of prescribed muscle relaxants as needed
15. A registered nurse (RN) is observing a licensed practical
nurse (LPN) preparing a client for treatment with a continuous
passive motion (CPM) machine. Which observation by the RN
would indicate that the LPN is performing an incorrect action?
a) places the client's knee in a slightly externally rotated position
b) keeps the client's knee at the hinged joint of the machine
c) assesses the client for pressure areas at the knee and the
groin
d) checks the degree of extension and flexion and the speed of
the CPM machine per the physician's orders
16. A client who is mouth breathing is receiving oxygen by face
mask. The nursing assistant asks the registered nurse (RN) why

a water bottle is attached to the oxygen tubing near the wall

oxygen outlet. The RN responds that the primary purpose of this
feature is to:

b) administer mouth care

c) monitor intake and output
d) encourage coughing and deep breathing

a) prevent fluid loss from the lungs during mouth breathing

b) give the client added fluid via the respiratory rate
c) humidify the oxygen that is bypassing the client's nose
d) prevent the client from getting nosebleed

22. A nurse manager is reviewing with the nursing staff the

purposes for applying wrist and ankle restraints (security
devices) to a client. The nurse manager determines that further
review is necessary when a nursing staff member states that an
indication for the use of a restraint is to:

17. A nurse and a nursing assistant are assisting the respiratory

therapist to position a client for postural drainage. The
nursing assistant asks the nurse how the respiratory
therapists selects the position used for the procedure. The nurse
responds that a position is chosen that will use gravity to help
drain secretions from which of the following areas?
a) trachea
b) main bronchi
c) lobes
d) alveoli
18. A registered nurse (RN) is observing a licensed practical
nurse (LPN) caring for a deceased client whose eyes will be
donated. The RN intervenes if the LPN performs which action?
a) elevates the head of the bed
b) closes the client's eyes
c) places wet saline gauze pads and ice pack on the eyes
d) closes the client's eyes and places a dry sterile dressing over
the eyes
19. The nurse has recently been assigned to manage a
pulmonary progressive unit at a large urban hospital. The
nurse's leadership style is participative, with the belief that all
staff members assist in decision making and the development of
the unit's goals. The nurse is implementing which leadership
style?
a) democratic
b) laissez faire
c) auticratic
d) situational
20. A physician has written an order for a vest restraint to be
applied on a client from 10:00 pm to 7:00 am because the client
becomes disoriented during the night and is at risk for falls. At
11:00 pm, the charge nurse makes rounds on all of the clients
with the vest restraint, which observation by the charge nurse
would indicate that the nurse who cared for this client performed
an unsafe action in the use of the restraint?
a) a safety knot was used to secure the restraint
b) the client's record indicates that the restraint will be released
every 2 hours
c) the restraint was applied tightly
d) the call light was placed within reach of the client
21. A nursing student prepares a postoperative plan of care for a
client scheduled for hypophysectomy. The registered nurse
reviews the plan and informs the nursing student that the plan
needs to be corrected if which of the following was noted?
a) obtain daily weights

a) limit movement of a limb

b) keep the client in bed at night
c) prevent the violent client from injuring self and others
d) prevent the client from pulling out intravenous lines and
catheters
23. A hospitalized client with a diagnosis of anorexia
nervosa and in a state of starvation is in two-bed hospital room.
A newly admitted client will be assigned to this client's room.
Which client would be inappropriate to assign to this two-bed
room?
a) a client with pneumonia
b) a client who can perform self-care
c) a client with a fractured leg that is casted
d) a client who is scheduled for a diagnostic test
24. A multidisciplinary health care team is planning care for a
client with hyperparathyroidism. The nurse identifies which client
outcome to the health care team?
a) describes how to take antacids
b) restricts fluids to 1000 ml per day
c) describes how to take antidiarrheal medications
d) walks down the hall for 15 minutes, three times a day
25. A clinic nurse wants to develop a diabetic teaching program.
In order to meet the client's needs, the nurse must first:
a) assess the client's functional abilities
b) ensure that insurance will pay for participation in the program
c) discuss the focus of the program with the multidisciplinary
team
d) include everyone who comes into the clinic in the teaching
sessions
26. A nurse notes that a postoperative client has not been
obtaining relief from pain with the prescribed opioid analgesics
when a particular licensed practical nurse (LPN) is assigned to
the client. The appropriate action for the nurse to take is to:
a) reassign the LPN to the care of clients not receiving opioids
b) notify the physician that the client needs an increase in opioid
dosage
c) review the client's medication administration record
immediately and discuss the observations with the nursing
supervisor
d) confront the LPN with the information about the client having
pain control problems and ask if the LPN is using the opioids
personally
27. A medication nurse is supervising a newly hired licensed
practical nurse (LPN) during the administration of oral

pyridostigmine bromide (Mestinon) to a client with myasthenia

gravis. Which observation by the medication nurse would
indicate safe practice by the LPN?
a) asking the client to take sips of water
b) asking the client to lie down on his right side
c) asking the client to look up at the ceiling for 30 seconds
d) instructing the client to void before taking the medication
28. During orientation, a graduate nurse learns that the nursing
model of practice implemented in the facility is a primary nursing
approach. When the nurse attends report on the medical unit,
the nurse will verify with the staff which of the following
characteristics of primary nursing?
a) critical paths are used when providing client care
b) the nurse manager assigns tasks to the staff members
c) a registered nurse (RN) leads nursing staff in providing care to
a group of clients
d) a single RN is responsible for planning and providing
individualized nursing care to clients

a) any client has the right to refuse to participate in research

studies
b) collaboration with other disciplines is essential to the
successful practice of nursing
c) the cooperation of the physicians on staff must be ensured in
order for the project to succeed
d) the corporate nurse executive should be consulted, because
the project will take nursing time
33. A nurse manager has identified a problem on the nursing unit
and holds unit meetings for all shifts. The nurse manager
presents an analysis of the problem and proposals for actions to
team members and invites the team members to comment and
provide input. Which style of leadership is the nurse manager
specifically employing?
a) situational
b) laissez-faire
c) participative
d) authoritarian

29. A clinical nurse manager conducts an inservice educational

session for the staff nurses about case management. The
clinical nurse manager determines that a review of the material
needs to be done if a staff nurse stated that case management:

34. A charge nurse observes that a staff nurse is not able to

meet client needs in a reasonable time frame, does not problemsolve situations, and does not prioritize nursing care. The charge
nurse has the responsibility to:

a) manages client care by managing the client care environment

b) maximizes hospital revenues while providing for optimal client
care
c) is designed to promote appropriate use of hospital personnel
and material resources
d) represents a primary health prevention focus managed by a
single case manager

a) supervise the staff nurse more closely so that tasks are

completed
b) ask other staff members to help the staff nurse get the
work done
c) provide support and identify the underlying cause of the staff
nurse's problem
d) report the staff nurse to the supervisor so that something is
done to resolve the problem

30. A nurse manager is reviewing the critical paths of the clients

on the nursing unit. The nurse manager collaborates with each
nurse assigned to the clients and performs a variance analysis.
Which of the following would indicate the need for further action
and analysis?
a) a client is performing his own colostomy care
b) purulent drainage is noted from a postoperative wound
incision
c) a 1-day postoperative client has a temperature of 98.8F
d) a client newly diagnosed with diabetes mellitus is preparing
his own insulin for injection
31. Based upon a request made by the client's spouse and
children, a physician asks a nurse to discontinue the feeding
tube in a client who is in chronic debilitated and comatose state.
The nurse understands the legal basis for carrying out the order
and first checks the client's record for documentation of:
a) a court approval to discontinue the treatment
b) approval by the institutional Ethics Committee
c) a written order by the physician to remove the tube
d) authorization by the family to discontinue the treatment
32. A nurse plans to carry out a multidisciplinary research project
on the effects of immobility on client's stress levels. Of the
following statements, which principle is most important when
planning this project?

35. A registered nurse is preceptor for a new nursing graduate

and is observing the new nursing graduate organizethe client
assignment and daily tasks. The registered nurse intervenes if
the new nursing graduate does which of the following?
a) provide time for unexpected tasks
b) lists the supplies needed for a task
c) prioritizes client needs and daily tasks
d) plans to document task completion at the end of the day
36. A registered nurse is a preceptor for a new nursing graduate
an is describing critical paths and variance analysis to the new
nursing graduate. The registered nurse instructs the new nursing
graduate that a variance analysis is performed on all clients:
a) continuously
b) daily during hospitalization
c) every third day of hospitalization
d) every other day of hospitalization
37. When a nurse manager makes a decisions regarding the
management of the nursing unit without input from the staff, the
type of leadership style that the nurse manager is demonstrating
is:
a) autocratic

b) situational
c) democratic
d) laissez-faire

a) enteric precautions should be instituted for the client

38. A charge nurse knows that drug and alcohol use by nurses is
a reason for the increasing numbers ofdisciplinary cares by the
Board of Nursing. The charge nurse understands that when
dealing with a nurse with such an illness, it is most important to
assess the impaired nurse to determine:

c) contact isolation should be initiated, because the diseases is

highly contagious

a) the magnitude of drug diversion over time

b) if falsification of clients records occurred
c) the types of illegal activities related to the abuse
d) the physiological impact of the illness on practice
39. A nurse manager is planning to implement a change in the
method of the documentation system for the nursing unit. Many
problems have occurred as a result of the present
documentation system, and the nurse manager determines that
a change is required. The initial step in the process of change for
the nurse manager is which of the following?
a) plan strategies to implement the change
b) set goals and priorities regarding the change process
c) identify the inefficiency that needs improvement or correction
d) identify potential solutions and strategies for the change
process
40. A nurse receives a telephone call from the emergency
department and is told that a child with a diagnosis of tonicclonic seizures will be admitted to the pediatric unit. The nurse
prepares for the admission of the child and instructs assistant to
place which items at the bedside?
a) a tracheostomy set and oxygen
b) suction apparatus and an airway
c) an endotracheal tube and an airway
d) an emergency cart and laryngoscope
41. When assessing the client with the vest restraint (security
device) at the beginning of day shift, which observation by the
charge nurse would indicate that the nurse who placed the vest
restraint on the client failed to follow safety guidelines?

b) gloves and mask should be used when the in client's room

d) standard precautions are sufficient, because the disease is

transmitted sexually

43. A nursing assistant is caring for an older male client with

cystits who has an indwelling urinary catheter. The registered
nurse provides directions regarding urinary catheter care and
ensures that the nursing assistant:
a) loops the tubing under the client's leg
b) places the tubing below the client's knee
c) uses soap and water to cleanse the perineal area
d) keeps the drainage bag above the level of the bladder

44. A nurse is planning care for a client with acute

glomerulonephritis. The nurse instructs the nursing assistant to
do which of the following in the care of the client?
a) ambulate the client frequently
b) monitor the temperature every 2 hours
c) encourage a diet that is high in protein
d) remove the water pitcher from the bedside

45. A nurse watches a second nurse perform hemodialysis on a

client. The second nurse is drinking coffee and eating doughnut
next to the hemodialysis machine while talking with the client
about the client's week. The first nurse should:
a) get a cup of coffee and join in on the conversation

a) a hitch was used to secure the restraint

b) determine whether or not the client would like a cup of coffee

b) the call light was placed within reach of the client

c) admire the therapeutic relationship the second nurse has with

the client

c) the restraint was applied tightly across the client's chest

d) the client's record indicates that the restraint will be released
every 2 hours

42. A male client who is admitted to the hospital for an unrelated

medical problem is diagnosed with urethritis caused by
chlamydial infection. The nursing assistant assigned to the client
asks the nurse what measures are necessary to prevent
contraction of the infection during care. The nurse tells the
nursing assistant that:

d) ask the second nurse to refrain from eating and drinking in the
client area
46. A nurse is working in the emergency department of a small
local hospital when a client with multiple gunshot wounds arrives
by ambulance. Which of the following actions by the nurse is
contraindicated in the handling legal evidence?
a) initiate a chain of custody log
b) give clothing and wallet to the family
c) cut clothing along seams, avoiding bullet holes

d) place personal belongings in a labeled, sealed paper bag

and the charge nurse provides instructions and observes the

nurse using the cooling blanket. The charge nurse intervenes if
the nurse:

47. A registered nurse (RN) is orienting a nursing assistant to the

clinical nursing unit. The RN would intervene if the nursing
assistant did which of the following during a routine handwashing
procedure?

a) keeps the child uncovered to assist in reducing the fever

a) kept hands lower than elbows

c) keeps the child dry while on the cooling blanket to reduce the
risk of frostbite

b) dried from forearm down to fingers

c) washed continuously for 10 to 15 seconds
d) used 3 to 5 ml of soap from the dispenser

48. A registered nurse (RN) on the night shift assists a staff

member in completing an incident report for a client who was
found sitting on the floor. Following completion of the report, the
RN intervenes if the staff member prepares to:

b) places the cooling blanket on the bed and covers the blanket
with a sheet

d) checks the skin condition of the child before, during, and after
the use of the cooling blanket
52. A nursing instructor asks a nursing student to identify
situations that indicate a secondary level of prevention in health
care. Which situation, if identified by the student, would indicate
the need for further study of the levels of prevention?
a) teaching s stroke client how to use a walker
b) screening for hypertension in a community group

a) notify the nursing supervisor

c) screening for hyperlipidemia in a community group

b) ask the secretary to telephone the physician

d) encouraging a woman who is more than 40 years old to

obtain periodic mammograms

c) document in the nurse's notes that an incident report was filed

d) forward incident report to the Continuous Quality
Improvement Department

49. A physician visiting a client on the nursing unit is paged and

notified that the monthly physician's breakfast meeting is about
to start. The physician states to the nurse : "I'm in a hurry. Can
you write an order t decrease the atenolol (Tenormin) to 25mg
daily?" Which of the following is the appropriate nursing action?
a) write the order
b) call the nursing supervisor to write the order
c) inform the client of the change of medication
d) ask the physician to return to the nursing unit to write the
order
50. A registered nurse suspects that a colleague is substance
impaired and notes signs of alcohol intoxication in the colleague.
The Nurse Practice Act requires the registered nurse do which of
the following?
a) talk with the colleague

53. A charge nurse is supervising a new registered nurse (RN)

who is providing care to a client with end-stage heart failure. The
client is withdrawn and reluctant to talk, and she shows little
interest in participating in hygienic care or activities. Which
statement, if made by the new RN to the client, indicates that the
new RN requires further teaching regarding the use of
therapeutic communication techniques?
a) what are your feelings right now?
b) why don't you feel like getting up for your bath?
c) these dreams you mentioned, what are they like?
d) many clients with end-stage heart failure fear death
54. A nurse is observing a nursing assistant talking to a client
who is hearing impaired. The nurse would intervene if which of
the following is performed by the nursing assistant during
communication with the client?
a) the nursing assistant is speaking in a normal tone
b) the nursing assistant is speaking clearly to the client
c) the nursing assistant is facing the client when speaking
d) the nursing assistant is speaking directly into the impaired ear

b) call the impaired nurse organization

c) report the information to a nursing supervisor
d) ask the colleague to go to the nurse's lounge to sleep for a
while
51. A cooling blanket is prescribed for a child with a fever. A
nurse caring for the child has never used this type of equipment,

55. A charge nurse reviews the plan of care formulated by a new

nursing graduate for a child returning from the operating room
after a tonsillectomy. The charge nurse assists the new nursing
graduate with changing the plan if which incorrect intervention is
documented?

a) suction whenever necessary

b) offer clear, cool liquids when awake

nurse reviews the plan of care with the student and will instruct
the student to remove which of hte following interventions?

c) monitor for bleeding from the surgical site

d) eliminate milk or milk products from the diet
56. A nurse receives a telephone calls from emergency
department and is told that a client in leg traction will be admitted
to the nursing unit. The nurse prepares for the arrival of the client
and asks the nursing assistant to obtain which item that will be
essential for helping the client move in bed while in leg traction?

a) a foot board
b) extra pillows

a) keep all the lights on in the room at night

b) assist the client to ambulate in the hallway
c) monitor the client closely while the client is showering
d) push the lock-out button on the electric bed to keep the bed in
the lowest position

60. A client with active tuberculosis (TB) is to be admitted to a

medical-surgical unit. When planning a bed assignment, the
nurse:

c) a bed trapeze
d) an electric bed

a) plans to transfer the client to the intensive care unit

b) places the client in a private, well-ventilated room

57. A registered nurse is observing a nursing student auscultate

the breath sounds of a client. The registered nurse intervenes if
the nursing student performs which incorrect action?

c) assigns the client to a double room because intravenous

antibiotics will be administered
d) assigns the client to a double room and places a "strict
handwashing" sign outside the door

a) use the bell of the stethoscope

b) asks the client to sit straight up
c) places the stethoscope directly on the client's skin
d) has the client breathe slowly and deeply through the mouth

NCLEX for RN - Leadership and Management:

ANSWERS AND RATIONALE
1) C

58. A nurse has oriented a new employee to basic procedures

for continuous electrocardiogram (ECG) monitoring. The nurse
would intervene of the new employee did which of the following
while initiating cardiac monitoring on a client?

a) clipped small areas of hair under the area planned for

electrode placement
b) stated the need to change the electrodes and inspect the skin
every 24 hours
c) stated the need to use hypoallergenic electrodes for clients
who are sensitive
d) cleansed the skin with Betadine (povidone-iodine) before
applying the electrodes

59. A client has an order for seizure precautions, and a nursing

student develops a plan of care for the client. The registered

- In team nursing, nursing personnel are led

by a registered nurse leader in providing care
to a group of clients. Option A identifies
functional nursing. Option B identifies a
component of case management. Option D
identifies primary nursing.
2) D

- Confrontation is an important strategy to

meet resistance head on. Face-to-face
meetings to confront the issue at hand will
allow verbalization of feelings, identification of
problems and issues, and development of
strategies to solve the problem. Option A will
not address the problem. Option B may
produce additional resistance. Option C may
provide a temporary solution to the resistance
but will not address the concern
3) D
- The nurse should instruct the nursing
assistant to assess restraints and skin
integrity every 30 minutes. Agency guidelines
regarding the use of restraints should always
be followed.
4) D
- The wound should be cleansed with a sterile
solution and gently patted dry. A thin layer of
fibrinolysin and desoxyribonuclease (Elase) is
applied and covered with petrolatum gauze. If
a dry powder preparation is used, for best
effects, the solution should be prepared just
before use.
5) B
- Unilateral neglect is an unawareness of the
paralyzed side of the body, which increases
the clients risk for injury. The nurses role is to
refocus the clients attention to the affected
side. The nurse moves personal care items
and belongings to the affected side, as well as
the bedside chair and commode. The nurse
teaches the client to scan the environment to
become aware of that half of the body and
approaches the client from the affected side
to increase awareness further.
6) D
- Use the process of elimination and
knowledge regarding the definition and
purpose of critical paths to direct you to
option D. Note the strategic words in the
question, a need for further understanding.
These words indicate a negative event query
and ask you to select an option that is

incorrect.
If you had difficulty with this
question, review critical paths.
7) C
- Tertiary prevention involves the reduction of
the amount and degree of disability, injury,
and damage following a crisis. Primary
prevention means keeping the crisis from
occurring, and secondary prevention focuses
on reducing the intensity and duration of a
crisis during the crisis itself. There is no known
aggregate care prevention level.
8) A
- The primary technique that can used to
handle resistance to change during the
change process is to introduce the change
gradually. Confrontation is an important
strategy used to meet resistance when it
occurs. Coercion is another strategy that can
be used to decrease resistance to change but
is not always a successful technique for
managing resistance. Manipulation usually
involves a covert action, such as leaving out
pieces
of
vital
information
that
the
participants might receive negatively. It is not
the best method of implementing a change.
9) B
- In the preicteric phase, the client has
nonspecific complaints of fatigue, anorexia,
nausea, cough, and joint pain. Options A, C,
and D are clinical manifestations that occur in
the icteric phase. In the posticteric phase,
jaundice decreases, the color of urine and
stool return to normal, and the clients
appetite improves.
10) A
- The client with an internal cervical radiation
implant should be placed in a private room at
the end of the hall because this location
provides less of a chance of exposure of
radiation to others. The clients room should
be marked with appropriate signs that indicate
the presence of radiation. Visitors should be
limited to 30-minute visits. Nurses assigned to
this client should be rotated so that one nurse
is not consistently caring for the client and

exposing him or herself to excess amounts of

radiation. All linens should be kept in the
clients room until the implant is removed in
case the implant has dislodged and needs to
be located.
11) D
- It is important to encourage the client to
cough and deep breathe when a chest tube
drainage system is in place. This will assist in
facilitating appropriate lung re-expansion.
Water is added to the suction chamber as it
evaporates to maintain the full suction level
prescribed. Connections between the chest
tube and the drainage system are taped to
prevent accidental disconnection. The client is
positioned in semi-Fowlers to facilitate ease
in breathing.
12) A
- Compartment syndrome is prevented by
controlling edema. This is achieved most
optimally with the use of elevation and
application of ice. Options B, C, and D are
incorrect.
13) D
- The site should not be massaged after
injection because massaging could cause
staining of the skin. Proper technique for
administering iron by the IM route includes
changing the needle after drawing up the
medication and before giving it. An air lock
and Z-track technique both should be used.
The medication should be given in the upper
outer quadrant of the buttock, not in an
exposed area such as the arms or thighs.
14) A
- Range-of-motion exercises are beneficial in
stretching muscles, which may diminish
spasticity. Removing potentially harmful
objects is a good safety measure. Use of
muscle relaxants also is indicated if the
spasms cause discomfort to the client or pose
a risk to the clients safety. Use of limb
restraints will not alleviate spasticity and
could harm the client.
15) A

- In the use of a CPM machine, the leg should

be kept in a neutral position and not rotated
either internally or externally. The knee should
be positioned at the hinge joint of the
machine. The nurse should monitor for
pressure areas at the knee and the groin and
should follow the physicians orders and
institutional protocol regarding extension and
flexion and speed of the CPM machine.
16) C
- The purpose of the water bottle is to
humidify the oxygen that is bypassing the
nose during mouth breathing. The humidified
oxygen may help keep mucous membranes
moist but will not substantially alter fluid
balance (options A and B). A client who is
breathing through the mouth is not at risk for
nosebleeds.
17) C
- Postural drainage uses specific client
positions that vary depending on the affected
lobe(s). The positions usually involve having
the head lower than the affected lung
segment(s) to facilitate drainage of secretions.
Postural drainage often is done in conjunction
with
chest
percussion
for
maximum
effectiveness. The other options are incorrect.
18) C
- When a corneal donor dies, the eyes are
closed and gauze pads wet with saline are
placed over them with a small ice pack. Within
2 to 4 hours, the eyes are enucleated. The
cornea is usually transplanted with 24 to 48
hours. The head of the bed should also be
elevated. Placing dry sterile dressings over
the eyes serves no useful purpose.
19) A
- Democratic leadership is defined as
participative with a focus on the belief that all
members of the group have input into the
decision making process. This leader acts as a
resource person and facilitator. Laissez faire
leaders assume a passive approach, with the
decision making left to the group. Autocratic
leadership
dominates
the
group, with

maintenance of strong control over the group.

Situational leadership is based on the current
events of the day.
20) C
- Restraints should never be applied tightly
because that could impair circulation. The
restraint should be applied securely (not
tightly) to prevent the client from slipping
through the restraint and endangering himself
or herself. A safety knot should be used
because it can easily be released in an
emergency.
Restraints,
especially
limb
restraints, must be released every 2 hours (or
per agency policy) to inspect the skin for
abnormalities. The call light must always be
within the clients reach in case the client
needs assistance.
21) D
- Toothbrushing, sneezing, coughing, nose
blowing, and bending are activities that
should be avoided postoperatively in the
client who underwent a hypophysectomy.
These activities interfere with the healing of
the incision and can disrupt the graft. Options
A, B, and C are appropriate postoperative
interventions.
22) B
- Wrist and ankle restraints are devices used
to limit the client's movement in situations
when it is necessary to immobilize a limb.
They are applied to prevent the client from
injuring self or others; from pulling out
intravenous lines, catheters, or tubes; or from
removing dressings. Restraints also may be
used to keep children still and from injuring
themselves during treatments and diagnostic
procedures. Restraints are not applied to keep
a client in bed at night and should never be
used as a form of punishment.
23) A
- The client in a state of starvation has a
compromised immune system. Having a
roommate with pneumonia would place the
client at risk for infection. Options B, C, and D
are appropriate roommates.

24) D
Mobility
of
the
client
with
hyperparathyroidism should be encouraged as
much as possible because of the calcium
imbalance that occurs in this disorder and the
predisposition to the formation of renal calculi.
Fluids should not be restricted. Options A and
C are not specifically associated with this
disorder.
25) A
Nurse-managed
clinics
focus
on
individualized disease prevention and health
promotion and maintenance. Therefore the
nurse must first assess the clients and their
needs in order to effectively plan the program.
Options B, C, and D do not address the clients'
needs.
26) C
- In this situation, the nurse has noted an
unusual occurrence, but before deciding what
action to take next, the nurse needs more
data than just suspicion. This can be obtained
by reviewing the client's record. State and
federal labor and opioid regulations, as well as
institutional policies and procedures, must be
followed. It is therefore most appropriate that
the nurse discuss the situation with the
nursing supervisor before taking further
action. The client does not need an increase in
opioids. To reassign the LPN to clients not
receiving opioids ignores the issue. A
confrontation is not the most advisable action
because it could result in an argumentative
situation.
27) A
- Myasthenia gravis can affect the client's
ability to swallow. The primary assessment is
to determine the client's ability to handle oral
medications or any oral substance. Options B
and C are not appropriate. Option B could
result in aspiration and option C has no useful
purpose. There is no specific reason for the
client to void before taking this medication.
28) D

- Primary nursing is concerned with keeping

the nurse at the bedside actively involved in
direct care while planning goal-directed,
individualized client care. Option A identifies a
component of case management. Option B
identifies functional nursing. Option C
identifies team nursing.

- The proposed project is research and

includes human subjects. Although options B,
C, and D need to be considered, they are all
secondary to the overriding principle of the
legal and ethical practice of nursing that any
client has the right to refuse to participate in
research using human subjects.

29) D

33) C

Case
management
represents
an
interdisciplinary health care delivery system
to promote appropriate use of hospital
personnel and material resources to maximize
hospital revenues while providing for optimal
client care. It manages client care by
managing the client care environment.

- Participative leadership demonstrates an "inbetween" style, neither authoritarian nor

democratic style. In participative leadership,
the manager presents an analysis of problems
and proposals for actions to team members,
inviting
critique
and
comments.
The
participative leader then analyzes the
comments and makes the final decision. A
laissez-faire leader abdicates leadership and
responsibilities, allowing staff to work without
assistance, direction, or supervision. The
autocratic style of leadership is task oriented
and directive. The situational leadership style
utilizes a style depending on the situation and
events.

30) C
- Variances are actual deviations or detours
from the critical paths. Variances can be either
positive or negative, or avoidable or
unavoidable and can be caused by a variety of
things. Positive variance occurs when the
client achieves maximum benefit and is
discharged earlier than anticipated. Negative
variance occurs when untoward events
prevent a timely discharge. Variance analysis
occurs continually in order to anticipate and
recognize negative variance early so that
appropriate action can be taken. Option B is
the only option that identifies the need for
further action.

34) C
Option C empowers the charge nurse to assist
the staff nurse while trying to identify and
reduce the behaviors that make it difficult for
the staff nurse to function. Options A, B, and D
are punitive actions, shift the burden to other
workers, and do not solve the problem.

31) D

35) D

- The family or a legal guardian can make

treatment decisions for the client who is
unable to do so. Once the decision is made,
the physician writes the order. Generally, the
family makes decisions in collaboration with
physicians, other health care workers, and
other trusted advisors. Although a written
order by the physician is necessary, the nurse
first checks for documentation of the family's
request. Unless special circumstances exist, a
court order is not necessary. Although some
health care agencies may require reviewing
such requests via the Ethics Committee, this is
not the nurse's first action.

- The nurse should document task completion

continuously throughout the day. Options A, B,
and C identify accurate components of time
management.

32) A

36) A
- Variance analysis occurs continually as the
case manager and other caregivers monitor
client outcomes against critical paths. The
goal of critical paths is to anticipate and
recognize negative variance early so that
appropriate action can be taken. A negative
variance occurs when untoward events
preclude a timely discharge and the length of
stay is longer than planned for a client on a

specific critical path. Options B, C and D are

incorrect.

to have an emergency cart (which contains a

laryngoscope) at the bedside, but a cart
should be available in the treatment room or
on the nursing unit.

37) A

41) C

- The autocratic style of leadership is task

oriented and directive. The leader uses his or
her power and position in an authoritarian
manner to set and implement organizational
goals. Decisions are made without input from
the staff. Democratic styles best empower
staff toward excellence because this style of
leadership allows nurses to provide input
regarding the decision-making process and an
opportunity to grow professionally. The
situational leadership style utilizes a style
depending on the situation and events. The
laissez-faire style allows staff to work without
assistance, direction, or supervision.

- A vest restraint should never be applied

tightly because it could impair respirations. A
hitch knot may be used on the client because
it can easily be released in an emergency. The
call light must always be within the client's
reach in case the client needs assistance. The
restraint needs to be released every 2 hours
(or per agency policy) to provide movement.

38) D
- A nurse must be able to function at a level
that does not affect the ability to provide safe,
quality care. The highest priority is to
determine how the illness affects the nurse's
ability to practice. The other options will be
addressed if an investigation is carried out.
39) C
- When beginning the change process, the
nurse should identify and define the problem
that needs improvement or correction. This
important first step can prevent many future
problems, because, if the problem is not
correctly identified, a plan for change may be
aimed at the wrong problem. This is followed
by goal setting, prioritizing, and identifying
potential
solutions
and
strategies
to
implement the change.
40) B
- Tonic-clonic seizures cause tightening of all
body muscles followed by tremors. Obstructed
airway and increased oral secretions are the
major complications during and following a
seizure. Suction is helpful to prevent choking
and cyanosis. Options A and C are incorrect
because inserting an endotracheal tube or a
tracheostomy is not done. It is not necessary

42)D
- Chlamydia is a sexually transmitted disease.
Caregivers cannot acquire the disease during
administration
of
care,
and
standard
precautions are the only measure that needs
to be used.

43) C
- Proper care of an indwelling urinary catheter
is especially important to prevent prolonged
infection or reinfection in the client with
cystitis. The perineal area is cleansed
thoroughly using mild soap and water at least
twice a day and following a bowel movement.
The drainage bag is kept below the level of
the bladder to prevent urine from being
trapped in the bladder, and, for the same
reason, the drainage tubing is not placed or
looped under the client's leg. The tubing must
drain freely at all times.

44) D
- A client with acute glomerulonephritis
commonly experiences fluid volume excess
and fatigue. Interventions include fluid
restriction as well as monitoring weight and
intake and output. The client may be placed
on bed rest or at least encouraged to rest,
because a direct correlation exists between
proteinuria, hematuria, edema, and increased
activity levels. The diet is high in calories but

low in protein. It is unnecessary to monitor the

temperature as frequently as every 2 hours.
45) D
- A potential complication of hemodialysis is
the acquisition of dialysis-associated hepatitis
B. This is a concern for clients (who may carry
the virus), client families (at risk from contact
with the client and with environmental
surfaces), and staff (who may acquire the
virus from contact with the client's blood).
This risk is minimized by the use of standard
precautions, appropriate handwashing and
sterilization procedures, and the prohibition of
eating, drinking, or other hand-to-mouth
activity in the hemodialysis unit. The first
nurse should ask the second nurse to stop
eating and drinking in the client area.
46) D
- Basic rules for handling evidence include
limiting the number of people with access to
the evidence, initiating a chain of custody log
to track handling and movement of evidence,
and carefully removing of clothing to avoid
destroying evidence. This usually includes
cutting clothes along seams, while avoiding
areas where there are obvious holes or tears.
Potential evidence is never released to the
family to take home.
47) B
- Proper handwashing procedure involves
wetting the hands and wrists and keeping the
hands lower than the forearms so that water
flows toward the fingertips. The nurse uses 3
to 5 mL of soap and scrubs for 10 to 15
seconds, using rubbing and circular motions.
The hands are rinsed and then dried, moving
from the fingers to the forearms. The paper
towel is then discarded, and a second one is
used to turn off the faucet to avoid hand
contamination.
48) C
- Nurses are advised not to document the
filing of an incident report in the nurses' notes
for legal reasons. Incident reports inform the
facility's administration of the incident so that

risk management personnel can consider

changes
that
might
prevent
similar
occurrences in the future. Incident reports also
alert the facility's insurance company to a
potential claim and the need for further
investigation. Options A, B, and D are
accurate interventions.
49) D
- Nurses are encouraged not to accept verbal
orders from the physician because of the risks
of error. The only exception to this may be in
an emergency situation, and then the nurse
must follow agency policy and procedure.
Although the client will be informed of the
change in the treatment plan, this is not the
appropriate action at this time. The physician
needs to write the new order. It is
inappropriate to ask another individual other
than the physician to write the order.
50) C
- Nurse Practice Acts require reporting the
suspicion of impaired nurses. The Board of
Nursing has jurisdiction over the practice of
nursing and may develop plans for treatment
and supervision. This suspicion needs to be
reported to the nursing supervisor, who will
then report to the Board of Nursing.
Confronting the colleague may cause conflict.
Asking the colleague to go to the nurses'
lounge to sleep for awhile does not safeguard
clients.
51) A
- While on a cooling blanket, the child should
be covered lightly to maintain privacy and
reduce shivering. Options B, C, and D are
important interventions to prevent shivering,
frostbite, and skin breakdown.

52) A
- Secondary prevention focuses on the early
diagnosis and prompt treatment of disease.
Tertiary prevention is represented by
rehabilitation services. Options B, C, and D
identify screening procedures. Option A
identifies a rehabilitative service.

53) B
- When the nurse asks a "why" question of the
client, the nurse is requesting an explanation
for feelings and behaviors when the client
may not know the reason. Requesting an
explanation is a nontherapeutic
communication technique. In option A, the
nurse is encouraging the verbalization of
emotions or feelings, which is a therapeutic
communication technique. In option C, the
nurse is using the therapeutic communication
technique of exploring, which involves asking
the client to describe something in more detail
or to discuss it more fully. In option D, the
nurse is using the therapeutic communication
technique of giving information. Identifying
the common fear of death among clients with
end-stage heart failure may encourage the
client to voice concerns.
54) D
- When communicating with a hearingimpaired client, the nurse should speak in a
normal tone to the client and should not
shout. The nurse should talk directly to the
client while facing the client, and he or she
should speak clearly. If the client does not
seem to understand what is being said, the
nurse should express the statement
differently. Moving closer to the client and
toward the better ear may facilitate
communication, but the nurse needs to avoid
talking directly into the impaired ear.
55) A
- After tonsillectomy, suction equipment
should be available, but suctioning is not
performed unless there is an airway
obstruction. Clear, cool liquids are
encouraged. Milk and milk products are
avoided initially because they coat the throat;
this causes the child to clear the throat,
thereby increasing the risk of bleeding. Option
C is an important intervention after any type
of surgery.
56) C

- A trapeze is essential to allow the client to

lift straight up while being moved so that the
amount of pull exerted on the limb in traction
is not altered. A foot board and extra pillows
do not facilitate moving. Either an electric bed
or a manual bed can be used for traction, but
this does not specifically assist the client with
moving in bed.
57) A
- The bell of the stethoscope is not used to
auscultate breath sounds. The client ideally
should sit up and breathe slowly and deeply
through the mouth. The diaphragm of the
stethoscope, which is warmed before use, is
placed directly on the client's skin, not over a
gown or clothing.

58) D
- The skin is cleansed with soap and water
(not Betadine), denatured with alcohol, and
allowed to air-dry before electrodes are
applied. The other three options are correct.
59) A
- A quiet, restful environment is provided as
part of seizure precautions. This includes
undisturbed times for sleep, while using a
nightlight for safety. The client should be
accompanied during activities such as bathing
and walking, so that assistance is readily
available and injury is minimized if a seizure
begins. The bed is maintained in low position
for safety.
60) B
- According to category-specific (respiratory)
isolation precautions, a client with TB requires
a private room. The room needs to be wellventilated and should have at least six
exchanges of fresh air per hour and should be
ventilated to the outside if possible. Therefore,
option 2 is the only correct option.