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61. A client is scheduled for bronchoscopy, and the registered nurse reviews the plan of care written by a nursing student. The registered nurse discusses revision of the plan with the nursing student if which incorrect intervention was documented?
a) removing any dentures
b) removing contact lenses
c) letting the client eat or drink
d) obtaining a signed informed consent
62. A physician prescribes a chemotherapeutic medication dose that the nurse believes is too high. The nurse calls the physician, but the physician has left the office for the weekend. The nurse appropriately:
a) reschedules the client's chemotherapy until the following week
b) telephones the answering service and confers with the on-call physician
c) withholds giving the medication until the physician's partner makes rounds the following day
d) checks with the pharmacist, who agrees the dose is too high, and then reduces the dose accordingly
63. A medication nurse is supervising a newly hired nurse who is administering pyridostigmine (Mestinon) orally to a client with myasthenia gravis. Which observation by the medication nurse indicates safe practice by the newly hired nurse before administering this medication?
a) asking the client to take a sips of water
b) asking the client to lie down on her 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
64. A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs instructions in the use of therapeutic communication skills?
a) you are very quiet today
b) what are your feelings right now?
c) why don't you feel like getting up?
d) tell me more about your difficulty with sleeping at night
65. A nurse is observing a nursing assistant care for an older client who had a hip pinned following a fracture 4 days ago. To prevent client injury, the nurse intervenes in the care if the nursing assistant:
a) leave the side rails down
b) ensures that the nightlight is working
c) answers the nurse call signal promptly
d) places the nurse call signal within reach
Leadership NCLEX Questions
Answers and Rationale
- The client is not allowed to eat or drink for usually 6 to 8 hours (or as specified by the physician) before the procedure. The client must sign an informed consent, because the procedure is invasive. If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to the client.
- If the nurse believes a physician's order to be in error, the nurse must clarify the dosage with the client's physician or the physician's substitute before administering the medication. Checking with the pharmacist can assist the nurse in determining whether the dose ordered is incorrect, but the nurse or pharmacist cannot alter the dose without a revised prescription from a licensed health care provider with prescriptive authority. Withholding the medication until the following day is incorrect. Chemotherapy agents must be administered in the proper combinations or sequence in order to be effective. Rescheduling the client's chemotherapy is also incorrect. Chemotherapy must be administered on a specific schedule for maximum effect with minimum adverse effects. Additionally, only a prescriber can withhold or reschedule chemotherapy.
- Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to swallow. Options B and C are not appropriate. In this situation, there is no reason for the client to lie down to swallow medication or to look up at the ceiling. Additionally, lying down could place the client at risk for aspiration. There is no specific reason for the client to void before taking medication.
- When a "why" question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option A, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option B, the LPN is encouraging identification of emotions or feelings. In option D, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
- Safe nursing actions intended to prevent injury to the client include keeping the side rails up, bed in low position, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call bell minimizes the chance that the client will try to get up alone, which could result in a fall. Nightlights are built into the lighting systems of most facilities, and these bulbs should be routinely checked to see that they are functional.
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Leadership NCLEX Questions (1-5)