a nurse manager asks a nurse to work overtime because of a short staffing problem the nurse has made plans to do christmas shopping after work and doe

NCLEX-PN

NCLEX PN Test Bank

1. A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?

A. "I'm not working overtime today."
B. "I have plans after work and will not be able to work overtime."
C. "You know how I hate to work overtime."
D. "I will if you need me, but I am not happy about this."

Correct answer: B

Rationale: The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse should assertively communicate her unavailability for overtime without being confrontational. Option A, "I'm not working overtime today," is too blunt and may come across as rude. Option C, "You know how I hate to work overtime," is not assertive but rather passive-aggressive. Option D, "I will if you need me, but I am not happy about this," is a passive-aggressive response as it implies compliance while expressing discontent. Option B, "I have plans after work and will not be able to work overtime," is the most appropriate response as it clearly states the nurse's unavailability without unnecessary aggression.

2. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

A. "I should make sure he gets plenty of rest."?
B. "I should get him a medical alert bracelet."?
C. "I should lay him on his back during a seizure."?
D. "I should loosen his clothing during a seizure."?

Correct answer: C

Rationale: The correct answer is '"I should lay him on his back during a seizure."?' When a client is having a seizure, it is crucial to turn them onto their side to prevent aspiration of secretions. Placing them on their back can lead to potential airway compromise. Choices A, B, and D are correct statements that indicate a good understanding of caring for a child with a seizure disorder: ensuring rest, getting a medical alert bracelet for identification, and loosening clothing to facilitate breathing during a seizure.

3. A discharge planning nurse is making arrangements for a client with an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?

A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters.
B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.
C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility.
D. None of the above

Correct answer: B

Rationale: In this scenario, the priority is the safety and well-being of the client. The neighborhood facility's lack of experience in caring for a client with an epidural catheter for continuous opioid infusion raises concerns about the quality of care they can provide. Therefore, the most appropriate action for the discharge planning nurse is to explain the situation to the client and family and seek another long-term care facility that can provide the necessary care. Option A, arranging for immediate in-services, may not be feasible or timely, considering the urgent need for appropriate care. Option C, encouraging the family to hire private duty nurses, does not ensure the facility's overall capability to manage the client's complex needs. Option D, 'None of the above,' is not the best choice as the client's safety should be the priority in this situation.

4. A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a 'slow code' and let the client 'rest in peace' if she stops breathing. How should the nurse respond?

A. Telling the health care provider that the client would probably want to die in peace
B. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken
C. Telling the health care provider that all of the nurses on the unit agree with this plan
D. Telling the health care provider that 'slow codes' are not acceptable

Correct answer: D

Rationale: The nurse may not violate a family's request regarding the client's treatment plan. A 'slow code' is not acceptable, and the nurse should state this to the health care provider. The definition of a 'slow code' varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are inappropriate: Option A is speculative and does not address the issue directly; Option B does not challenge the unethical practice of a 'slow code'; Option C is irrelevant and does not address the ethical concerns raised by the health care provider's request.

5. Which situation is an example of the use of evidence-based practice in the delivery of client care?

A. Encouraging a client who has had a stroke to consume thickened liquids and soft foods
B. Picking up a dislodged radiation implant with long-handled forceps and placing it in a lead container to minimize radiation exposure
C. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin
D. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab

Correct answer: C

Rationale: Evidence-based practice is an approach that integrates client preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring sterile solution into a plastic-lined waste receptacle before using it for wound cleansing reflects evidence-based practice by preventing the entrance of harmful bacteria into the wound. Option A is incorrect because encouraging a stroke client to consume thickened liquids and soft foods is appropriate, not thin liquids and foods that pose a choking risk. Option B is incorrect as picking up a radiation implant with long-handled forceps to minimize radiation exposure is a safety measure, not evidence-based practice. Option D is incorrect because blowing on a fingerstick site after cleaning can recontaminate the site, which goes against best practices in infection control.