Nursing Leadership Programs (46-50)

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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

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) kept hands lower than elbows
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:

a) notify the nursing supervisor
b) ask the secretary to telephone the physician
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
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

Nursing Leadership Programs
Answers and Rationale

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.

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Nursing Leadership Programs (1-5)

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Nursing Leadership Programs (51-55)

Nursing Leadership NCLEX Questions (41-45)

Welcome to Nursing Leadership NCLEX Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.

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?

a) a hitch was used to secure the restraint
b) the call light was placed within reach of 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:

a) enteric precautions should be instituted for the client
b) gloves and mask should be used when the in client's room
c) contact isolation should be initiated, because the diseases is highly contagious
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
b) determine whether or not the client would like a cup of coffee
c) admire the therapeutic relationship the second nurse has with the client
d) ask the second nurse to refrain from eating and drinking in the client area

Nursing Leadership NCLEX Questions:
Answers and Rationale

41) C
- 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.

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.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Nursing Leadership NCLEX Questions (1-5)

Or proceed to the next set of questions:

Nursing Leadership NCLEX Questions (46-50)