NCLEX : NCLEX
Study concepts, example questions & explanations for NCLEX
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Example Questions
Example Question #791 : Nclex
You are a new nurse taking care of a patient with congestive heart failure. You see an order to administer 500 mL of 0.9% normal saline over 6 hours. Later on in your shift, you realize that you mistakenly administered 2000 mL of 0.9% normal saline over 2 hours, and now the patient is slightly short of breath. Which of the following is the most appropriate next step?
Immediately contact your hospital's safety oversight committee
Immediately administer furosemide to diurese the patient
Do not tell anyone of the error since the patient is stable
Ask your co-nurses whether or not to inform the covering physician
Immediately inform the covering physician
Immediately inform the covering physician
The correct answer is "immediately inform the covering physician." This is the correct choice because in this case, a medical error was committed, and the most appropriate immediate course of action is to let the patient's covering physician know, so that they can determine what effect this may have on the patient, assess the patient, and determine what, if any, immediate intervention needs to be performed to ensure that the adverse effect on the patient is minimized.
While it is possible in this case, given that the patient has congestive heart failure, and that they may have been fluid overloaded by the administration of excess fluids, that they will need to be diuresed with furosemide, this medication cannot be administered without the order of the covering physician, and it would be inappropriate to administer furosemide without their orders.
While your hospital's safety oversight committee may ultimately need to be informed of this incident, the most immediate priority is patient safety, and as such, the patient's physician should be notified of the medical error before anyone else so that they can best manage any immediate consequences of the error.
It would be highly inappropriate to not inform anyone of the error, as an unintended dose of IV fluids was administered and this can be dangerous in a patient with congestive heart failure. Any delay, whether due to not telling anyone, or to conferring with co-nurses, in informing the supervising physician would be inappropriate and potentially dangerous to the patient.
Example Question #1 : Legal Responsibilities And Patient Rights
Which of the following nursing roles are eligible for prescriptive rights?
Critical care nurse
Nurse practitioner
Charge nurse
Registered nurse
Nurse practitioner
Of the nursing types listed, only nurse practitioners are can be authorized to write prescriptions for pharmaceutical drugs.
Example Question #131 : Ethics, Processing, And Care
Communicating patient values, preferences and expressed needs to other members of health care team is an example of what Quality and Safety in the Education of Nurses (QSEN) competency?
Patient-centered care
Safety
Evidence-based practice
Quality improvement
Patient-centered care
Communicating patient values, preferences and expressed needs to other members of health care team is an example of patient-centered care, which is defined as the act of recognizing the full agency of the patient by providing compassionate and coordinated care based on respect for patient preferences, values, and needs.
Example Question #3 : Legal Responsibilities And Patient Rights
Using tools such as algorithm flow charts and cause-effect analyses to make processes of care more explicit is an example of what Quality and Safety in the Education of Nurses (QSEN) competency?
Patient centered care
Evidence-based practice
Quality improvement
Safety
Quality improvement
Using tools such as algorithm flow charts and cause-effect analyses to make processes of care more explicit is an example of quality improvement, which is defined as the use of data to monitor the outcomes of treatment practices and other efforts to continuously improve the quality and safety of health care systems.
Example Question #4 : Legal Responsibilities And Patient Rights
Asking for help from a co-worker or superior is an example of what Quality and Safety in the Education of Nurses (QSEN) competency?
Teamwork and collaboration
Informatics
Evidence-based practice
Safety
Teamwork and collaboration
Asking for help from a co-worker or superior is an example of teamwork and collaboration, which is defined as the ability to function effectively within nursing or integrated teams. Skills should include the ability to have open, mutually respectful communication, shared decision making, and a focus on patient care.
Example Question #132 : Ethics, Processing, And Care
Using a checklist for tasks when doing an in-home visit is an example of what Quality and Safety in the Education of Nurses (QSEN) competency?
Evidence-based practice
Informatics
Safety
Teamwork and collaboration
Safety
Using a checklist for tasks when doing an in-home visit is an example of saftey, which is defined as employment of practices that minimize the risk of harm to patients and providers both by individual performance and the use of systems (such as checklists) to avoid errors.
Example Question #125 : Procedures And Care
Example Question #1 : Prevention And Risk Management
The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?
Orient client frequently
Providing a well-balanced diet
Use compression stockings or TED hose
Frequently turn and reposition patient while also providing skin care
Teach client the importance of coughing and deep breathing
Frequently turn and reposition patient while also providing skin care
There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.
Example Question #31 : General Care
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should __________.
wait until the patient care is complete and replace the mask
exchange the mask for a new mask immediately
place a new mask over the old mask
wipe with mask with a clean towel
dry the mask with the in-room hairdryer
exchange the mask for a new mask immediately
Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.
Example Question #1 : Prevention And Risk Management
The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse __________.
wears a single pair of sterile gloves
wears two pairs of sterile gloves
wears a pair of clean gloves under a pair of sterile gloves
wears two pairs of clean gloves
wears a single pair of clean gloves
wears a single pair of clean gloves
In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair.
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