These questions are one of the NCLEX prep samples for Safe and Effective Care Management. This post has a 25 set of questions with the accompanying answers and rationale located at the bottom. If you want to answer all of our NCLEX questions interactively then be one of our member today. Click here to join. It’s Free.
1. Nurse Alice is giving report to a nursing assistant who will be caring for a client who has hand restraints. The nurse instructs the nursing assistant to assess the skin integrity of the restrained hands every:
a. 2 hours
b. 3 hours
c. 4 hours
d. 30 minutes
2. Gina, the nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique?
a. Using sterile sheets and linens
b. Performing strict hand-washing technique
c. Wearing gloves and a gown only when giving direct care to the client
d. Wearing protective garb, including a mask, gloves, cap, shoe covers, a gown, and plastic apron
3. Nurse Vincent is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. Sutilains (Travase) is being used to treat the ulcer. Which observation by the RN would indicate an inaccurate action by the newly hired nurse when performing the dressing change?
a. The nurse cleans the wound with a sterile solution
b. The nurse places the sutilains in the refrigerator following use
c. The nurse dries the wound and covers the sutilains application with a dry sterile dressing
d. The nurse moistens the wound with sterile normal saline and then applies the sutilains
4. Fibrinolysin and desoxyribonuclease (Elase) is prescribed to treat a skin ulcer, and the nurse is observing a nursing student perform the treatment. Nurse Emil intervenes if the nursing student is observed doing which of the following?
a. Applies a thin layer of medication
b. Cleans the wound with a sterile solution
c. Places petrolatum gauze over the fibrinolysin and desoxyribonuclease
d. Applies a thick layer of medication and covers with a dry sterile dressing
5. Ruth, a nursing student is caring for a client with a brain attack (stroke) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this 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 chair to the affected side
6. A community health nurse is working with disaster relief following a tornado. The nurse’s goal for the community is to prevent as much injury and death as possible form the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed are all examples of which type of prevention?
a. Primary level of prevention
b. Secondary level of prevention
c. Tertiary level of prevention
d. Aggregate care prevention
7. Perry, the nurse manager is planning to implement a change is 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
8. Terence, the 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 the preicteric phase?
a. Right upper quadrant pain
b. Fatigue, anorexia, and nausea
c. Jaundice, dark-colored urine, and clay-colored tools
9. Nurse Alma 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
10. Lou, 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
11. Nurse Larry 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 by instructing the licensed practical nurse assigned 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
12. Nurse Farrah 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
13. Sophie, a nursing student develops a plan of care for a client with paraplegia who has 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
14. Nurse Wayne 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 PLN 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
15. A client who is mouth breathing is receiving oxygen by face mask. Olive 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:
a. Prevent fluid loss from the lungs during mouth breathing
b. Give the client added fluid via the respiratory tree
c. Humidify the oxygen that is bypassing the client’s nose
d. Prevent the client form getting a nosebleed
16. Nurse Danica 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 therapist 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?
b. Main bronchi
17. Nurse Helen is observing a licensed practical nurse (LPN) caring for a decreased client whose eyes will be donated. The RN intervenes of 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 an ice pack on the eyes
d. Closes the client’s eyes and places a dry sterile dressing over the eyes
18. Nurse Hayden 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?
b. Laissez faire
19. Cole is the new unit nurse manager is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about performance improvement. The manager provides a plan that she developed, as well as a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leadership style do the new manager’s characteristics suggest?
20. Terry, new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice?
a. A task approach method is used to provide care to clients
b. Managed care concepts and tools are used in providing client care
c. An RN leads nursing personnel in providing care to a group of clients
d. A single RN responsible for providing nursing care to group of clients
21. The nurse manager has implemented a change in the method of the nursing delivery system form functional to team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach in dealing with the nursing assistant?
a. Ignore the resistance
b. Exert coercion with the nursing assistant
c. Provide a positive reward system for the nursing assistant
d. Confront the nursing assistant to encourage verbalization of feelings regarding the change
22. The nurse manager of a critical care unit must speak to a staff nurse about an employment issue, tardiness. Nearly every day during the past week, the staff nurse has been from 5 to 20 minutes late, missing portions of the daily client status conferences. The manager had verbally counseled the staff nurse 3 months prior to the latest incidence of tardiness about the same issue. When they meet, the nurse manager’s best approach to the staff nurse is to:
a. Send the staff nurse to the Human Resources Department for counseling
b. Ask the staff nurse to tell the manager about the facts surrounding the tardiness
c. Inform the staff nurse that, based on unreliability caused by tardiness issues, the nurse is terminated
d. Provide the staff nurse with a detailed notice of intent to terminate if any further incident of tardiness occurs
23. Oliver, 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 for 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
24. Dr. Smith 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 in the unit. When assessing the client with 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
25. Nurse Rhea is caring for a client with a diagnosis of impaired gas exchange. Which outcome is most appropriate based upon this nursing diagnosis?
a. The client maintains a reduced cough effort to lessen fatigue
b. The client restricts fluid intake to prevent overhydration
c. The client reduces daily activities to a minimum
d. The client has normal breath sounds in all lung fields