NCLEX Prep for Safe and Effective Care Management (ANSWERS & RATIONALE)

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1. 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.

2. C. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used. Protective garb, including gloves, caps, masks, shoe covers, gowns, and plastic aprons need to be worn when in the client’s room and when directly caring for the client.

3. C. The wound should be cleansed with a sterile solution before treatment. The nurse then thoroughly moistens the wound with normal saline or sterile water, applies a thin film of sutilains extending ¼ to ½ inch beyond the area to be debrided, and then applies a loose thin dressing. The ointment should be refrigerated.

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 client’s risk for injury. The nurse’s role is to refocus the client’s 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. 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.

7. 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.

8. 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 client’s appetite improves.

9. 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 client’s 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 client’s room until the implant is removed in case the implant has dislodged and needs to be located.

10. 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-Fowler’s to facilitate ease in breathing.

11. A. Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and application of ice.

12. 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.

13. 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 client’s safety. Use of limb restraints will not alleviate spasticity and could harm the client.

14. 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 physician’s orders and institutional protocol regarding extension and flexion and speed of the CPM machine.

15. 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.

16. 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.

17. D. 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.

18. 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.

19. A. The autocratic leader is focused, maintains strong control, makes decisions, and, addresses all problems. Furthermore, the autocrat dominates the group and commands rather than seeks suggestions or input. In this situation, the manager addresses a problem (performance improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her.

20. C. 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.

21. 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.

22. D. In general, the process for corrective action begins with an oral reprimand and then a written reprimand. In addition to the written reprimand, the manager should be prepared to work with the staff nurse to develop a plan of action. The manager must notify the staff nurse, in writing, of the potential for termination based on tardiness. If this were the first instance, the manager would ask the staff nurse to describe the facts surrounding the tardiness in order for the manager to assist the staff nurse with problem-solving strategies or to examine the need for moving the staff nurse to a different shift, if indicated. Managers are expected to deal with personnel issues, and tardiness is a frequent problem that managers face. Human resources serves as a support to the actions of the manager, but does not assume the role of dealing with the employee. Managers must give notice prior to termination as a risk management strategy.

23. 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

24. 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 client’s reach in case the client needs assistance.

25. D. If the interventions are effective, breath sounds should return to normal. The client should be able to cough effectively and should be encouraged to increase activity, as tolerated. Fluid intake should thin secretions.

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