NCLEX Test: Foundation Of Practice Part I

1. A 3-year-old with eczema of the face and arms has not heeded the nurse's warning to stop scratching- or else!" the nurse finds the toddler scratching so intensely that the arms are bleeding. With great flurry, the ties the toddler's arms to crib sides, saying, "I'm going to teach you one way or another." In this situation, the nurse:

Has merely done the job with consideration accountability

Has used actions that can be interpreted as assault and battery

Had to protect the toddler’s skin and acted as any reasonably prudent nurse would do

Tried to explain to the toddler and rightly expected the toddler to understand and cooperate

The nurse's actions of tying the toddler's arms to the crib sides can be interpreted as assault and battery because it involves physical force and restraint without the toddler's consent or legal justification. This action goes beyond the scope of protecting the toddler's skin and can be seen as a violation of the toddler's rights and potentially harmful. The nurse should have explored alternative methods of managing the toddler's scratching behavior in a safe and ethical manner.

Explanation

The nurse's actions of tying the toddler's arms to the crib sides can be interpreted as assault and battery because it involves physical force and restraint without the toddler's consent or legal justification. This action goes beyond the scope of protecting the toddler's skin and can be seen as a violation of the toddler's rights and potentially harmful. The nurse should have explored alternative methods of managing the toddler's scratching behavior in a safe and ethical manner.

2. A client is admitted with the diagnosis of possible placenta previa. The nurse begins IV fluids, administers oxygen, and draws blood for laboratory tests as ordered. The client's apprehension is increasing, and she ask the nurse what is happening. The nurse tells her not to worry, that she is going to be all right, and everything is under control. The nurse's statements are:

Adequate, because all preparations are routine and need to explanation

Proper, because the client’s anxieties would be increaseif she knew the dangers

Correct, because only the physician should explain why treatment are being done

Questionable, because the client has the right to know what treatment is being given and why

The nurse's statements are questionable because the client has the right to know what treatment is being given and why. It is important for the nurse to provide clear and honest explanations to the client in order to reduce anxiety and promote trust in the healthcare team. Keeping the client informed about their treatment can also empower them to actively participate in their own care.

Explanation

The nurse's statements are questionable because the client has the right to know what treatment is being given and why. It is important for the nurse to provide clear and honest explanations to the client in order to reduce anxiety and promote trust in the healthcare team. Keeping the client informed about their treatment can also empower them to actively participate in their own care.

3. A 2 year-old child is admitted to the hospital with a diagnosis of pneumonia and is given antibiotics, fluids, and oxygen. The child's temperature continues, rise until reaches 103 F (39.4 C). The nurse calls the physician at the mother's request, but the physician sees no cause for alarm or change in treatment, even though the child has a history of convulsion during previous periods of high fever. Although concerned, the nurse takes no further action. Later the child has a convulsion that result in neurologic impairment of the left arm and leg. Legally:

The physician’s decision takes procedures over the nurse’s concern

The nurse’s failure to further question the physician placed the child at risk

The physician is totally responsible for the client’s health history and treatment regimen

High temperatures are common in children, and this situation presented little cause for undue concern

The nurse's failure to further question the physician placed the child at risk because the nurse had knowledge of the child's history of convulsions during previous periods of high fever. The nurse should have advocated for the child's safety by expressing their concerns and seeking further clarification from the physician. By not taking further action, the nurse allowed the child to remain at risk and ultimately led to the neurologic impairment of the left arm and leg.

Explanation

The nurse's failure to further question the physician placed the child at risk because the nurse had knowledge of the child's history of convulsions during previous periods of high fever. The nurse should have advocated for the child's safety by expressing their concerns and seeking further clarification from the physician. By not taking further action, the nurse allowed the child to remain at risk and ultimately led to the neurologic impairment of the left arm and leg.

4. A client with coronary artery diseases has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. In this situation:

Oxygen had not been ordered and therefore should not be administered

The nurse’s observations were sufficient to begin administration of oxygen

The symptoms were too vague for the nurse to diagnose a need for oxygen

The physician should have been called for an order before oxygen was begun

The sudden episode of cyanosis and change in respirations are indicative of a potential decrease in oxygenation. Oxygen administration is a standard intervention for patients with coronary artery disease experiencing such symptoms. The nurse's decision to start oxygen immediately is based on their assessment of the client's condition and the need for immediate intervention to improve oxygenation.

Explanation

The sudden episode of cyanosis and change in respirations are indicative of a potential decrease in oxygenation. Oxygen administration is a standard intervention for patients with coronary artery disease experiencing such symptoms. The nurse's decision to start oxygen immediately is based on their assessment of the client's condition and the need for immediate intervention to improve oxygenation.

5. In relation to obtaining an informed consent from a 17-year-old adolescent, the nurse should remember that the adolescent:

Does not have the legal capacity to give consent

Is not able to make an acceptable or intelligent choice

Is able to give voluntary consent when parents are not available

Will most likely be unable to choose between alternatives when asked to consent

In most jurisdictions, the legal age of consent is 18 years old. Therefore, a 17-year-old adolescent does not have the legal capacity to give consent. This means that healthcare providers should seek consent from the adolescent's parents or legal guardians instead.

Explanation

In most jurisdictions, the legal age of consent is 18 years old. Therefore, a 17-year-old adolescent does not have the legal capacity to give consent. This means that healthcare providers should seek consent from the adolescent's parents or legal guardians instead.

6. The primary purpose for regulating nursing practice is to protect:

The public

Practicing nurses

The employing agency

Professional standards

The primary purpose for regulating nursing practice is to protect the public. This means that the regulations and guidelines put in place for nursing practice are designed to ensure the safety, well-being, and quality of care provided to the general public. By regulating nursing practice, it helps to maintain professional standards, prevent harm to patients, and hold nurses accountable for their actions. Ultimately, the goal is to protect the public from any potential risks or dangers that may arise from nursing practice.

Explanation

The primary purpose for regulating nursing practice is to protect the public. This means that the regulations and guidelines put in place for nursing practice are designed to ensure the safety, well-being, and quality of care provided to the general public. By regulating nursing practice, it helps to maintain professional standards, prevent harm to patients, and hold nurses accountable for their actions. Ultimately, the goal is to protect the public from any potential risks or dangers that may arise from nursing practice.

7. A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client states, " The strap was worn just at the very spot where the strap snapped." The nurse is:

Exempt from any lawsuit because of the doctrine of respondeat superior

Totally and singly responsible for the obvious negligence because of failure to report defective equipment

Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client

Completely exonerated, because only the hospital, as principal employer, is primarily responsible for the quality and maintenance of equipment

The nurse is liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client. This means that both the nurse and the employer can be held responsible for the client's injury because they failed to ensure the equipment was in proper working condition and did not take appropriate measures to prevent harm to the client. The nurse should have reported the defective equipment and taken steps to ensure the client's safety during transport.

Explanation

The nurse is liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client. This means that both the nurse and the employer can be held responsible for the client's injury because they failed to ensure the equipment was in proper working condition and did not take appropriate measures to prevent harm to the client. The nurse should have reported the defective equipment and taken steps to ensure the client's safety during transport.

8. A newborn is admitted to the nursery. During the newborn assessment the nurse notes that the temperature, pulse, and respirations are within normal range. Other physical characteristics are also normal. The nurse record's all observations on the baby's chart. The nurse's actions were:

Correct, because the nurse met the requirements set forth in the Nurse Practice Act

Incorrect, because making this type of medical diagnosis is not within the purview of the nurse

Correct, because the assessment by the nurse is not equivalent to the physician’s assessment

Incorrect, because the initial assessment of the infant’s physical status is the responsibility of the physician

The correct answer is "Correct, because the nurse met the requirements set forth in the Nurse Practice Act." This is because the nurse's actions of assessing the newborn's vital signs and physical characteristics and recording them on the baby's chart align with the responsibilities outlined in the Nurse Practice Act. The Nurse Practice Act defines the scope of practice for nurses and includes tasks such as assessing and documenting patient data.

Explanation

The correct answer is "Correct, because the nurse met the requirements set forth in the Nurse Practice Act." This is because the nurse's actions of assessing the newborn's vital signs and physical characteristics and recording them on the baby's chart align with the responsibilities outlined in the Nurse Practice Act. The Nurse Practice Act defines the scope of practice for nurses and includes tasks such as assessing and documenting patient data.

9. A client with rheumatoid arthritis does not want cortisone even if it is prescribe and informs the nurse of this. Later the nurse attempts to administer cortisone that has been ordered by the physician. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later finds that it was cortisone. The client states an intent to sue. The decision in this suit would take into consideration the fact that:

The nurse should have notified the physician

The nurse is required to answer the client truthfully

The client has insufficient knowledge to make such decision

The physician’s order take precedence over a client’s preference

The decision in this suit would take into consideration the fact that the nurse is required to answer the client truthfully. By giving an evasive answer when asked about the medication, the nurse failed to fulfill their duty to provide honest and accurate information to the client. This breach of trust could be considered negligence on the part of the nurse, as they disregarded the client's explicit request to not receive cortisone. The client's intent to sue is justified as the nurse's actions resulted in harm and violated the client's autonomy and right to make informed decisions about their own healthcare.

Explanation

The decision in this suit would take into consideration the fact that the nurse is required to answer the client truthfully. By giving an evasive answer when asked about the medication, the nurse failed to fulfill their duty to provide honest and accurate information to the client. This breach of trust could be considered negligence on the part of the nurse, as they disregarded the client's explicit request to not receive cortisone. The client's intent to sue is justified as the nurse's actions resulted in harm and violated the client's autonomy and right to make informed decisions about their own healthcare.

10. The best definition of a tort is:

The application of force to the person of another by a reasonable individual

An illegality committed by one person against the property or person of another

Doing something that a reasonable person under ordinary circumstances would not do

An illegality committed against the public and punished by the law through the courts

The best definition of a tort is an illegality committed by one person against the property or person of another. This definition accurately captures the essence of a tort, which is a civil wrong that causes harm or injury to another person or their property. It implies that the action is unlawful and results in legal liability for the person who committed the tort.

Explanation

The best definition of a tort is an illegality committed by one person against the property or person of another. This definition accurately captures the essence of a tort, which is a civil wrong that causes harm or injury to another person or their property. It implies that the action is unlawful and results in legal liability for the person who committed the tort.

11. When teaching staff about the legal terminology used in child abuse, the nurse emphasizes that the team battery means:

A legal wrong committed by one person against the property of another

Maligning the character of an individual while threatening to do bodily harm

The application of force to the person of another person without lawful justification

Doing something that a reasonable person with the same education or preparation would not do

The correct answer is "The application of force to the person of another person without lawful justification." Battery refers to the intentional and unlawful application of force or physical contact upon another person without their consent. It involves the use of force or violence against someone, resulting in physical harm or injury. This explanation aligns with the legal definition of battery in the context of child abuse.

Explanation

The correct answer is "The application of force to the person of another person without lawful justification." Battery refers to the intentional and unlawful application of force or physical contact upon another person without their consent. It involves the use of force or violence against someone, resulting in physical harm or injury. This explanation aligns with the legal definition of battery in the context of child abuse.

12. An example of an intentional tort would be:

Malpractice

Negligence

Breach of duty

False imprisonment

False imprisonment is an intentional tort because it involves intentionally confining or restraining someone against their will without lawful justification. This can include physical restraint, such as locking someone in a room, or psychological restraint, such as threatening someone to prevent them from leaving. In order to prove false imprisonment, the plaintiff must demonstrate that they were unlawfully detained and that the defendant intended to confine them.

Explanation

False imprisonment is an intentional tort because it involves intentionally confining or restraining someone against their will without lawful justification. This can include physical restraint, such as locking someone in a room, or psychological restraint, such as threatening someone to prevent them from leaving. In order to prove false imprisonment, the plaintiff must demonstrate that they were unlawfully detained and that the defendant intended to confine them.

13. A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in the storeroom and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes Legally:

A child needed to have limits set to control the crying

The child had a right to remain in the room with the other children

Keeping the child segregated alone for more than 30 minutes was to long

The other children had to be considered, so the child needed to be removed

The correct answer is that the child had a right to remain in the room with the other children. This is because legally, children have the right to be included and participate in activities with their peers. Segregating the child in the storeroom for an extended period of time goes against this right and is not an appropriate solution to the disruptive behavior.

Explanation

The correct answer is that the child had a right to remain in the room with the other children. This is because legally, children have the right to be included and participate in activities with their peers. Segregating the child in the storeroom for an extended period of time goes against this right and is not an appropriate solution to the disruptive behavior.

14. A client who has been told she needs a hysterectomy for cervical cancer is upset about being unable to have more children. The nurse should:

Evaluate her willingness to pursue adoption

Encourage her to focus on her own recovery

Emphasize that she does have two children already

Ensure that all treatment options have been explored

The nurse should ensure that all treatment options have been explored because it is important to provide the client with all available options before making a decision about her treatment. This includes discussing alternative treatments, seeking a second opinion, or exploring any potential fertility preservation options. By doing so, the nurse can help the client make an informed decision and address her concerns about not being able to have more children.

Explanation

The nurse should ensure that all treatment options have been explored because it is important to provide the client with all available options before making a decision about her treatment. This includes discussing alternative treatments, seeking a second opinion, or exploring any potential fertility preservation options. By doing so, the nurse can help the client make an informed decision and address her concerns about not being able to have more children.

15. When obtaining consent for surgery, initially the nurse should:

Explain the risks involved in the surgery

Explain that obtaining the signature is routine for any surgery

Evaluate if the client’s knowledge level is sufficient to give consent

Witness the signature because this is what the nurse’s signature documents

When obtaining consent for surgery, it is important for the nurse to evaluate if the client's knowledge level is sufficient to give consent. This is because the client needs to have a clear understanding of the risks involved in the surgery and the implications of their decision. By assessing the client's knowledge level, the nurse can ensure that the client is fully informed and capable of making an informed decision about their healthcare. Witnessing the signature and explaining the risks and routine nature of obtaining the signature are also important steps, but evaluating the client's knowledge level takes precedence in ensuring informed consent.

Explanation

When obtaining consent for surgery, it is important for the nurse to evaluate if the client's knowledge level is sufficient to give consent. This is because the client needs to have a clear understanding of the risks involved in the surgery and the implications of their decision. By assessing the client's knowledge level, the nurse can ensure that the client is fully informed and capable of making an informed decision about their healthcare. Witnessing the signature and explaining the risks and routine nature of obtaining the signature are also important steps, but evaluating the client's knowledge level takes precedence in ensuring informed consent.

16. The physician prescribes "NPO after midnight" for a hospitalized client who is schedule for diagnostic test. The morning of the test the client eats breakfast. The test cancelled and the client must stay an extra day. The client is very disturbed and insists on not paying for additional day because of the error. Ion situation such as this:

The client is responsible for the hospital bill and must pay

A full explanation of test or treatments is the right of the client

The order should have been written more clearly by the physician

This go wrong, and hospital personnel are not responsible unless there is gross negligence

The correct answer is that a full explanation of the test or treatments is the right of the client. In this situation, the client has the right to be fully informed about the test or treatment they are undergoing. The fact that the client ate breakfast on the morning of the test suggests that they may not have been adequately informed about the NPO (nothing by mouth) order. This lack of understanding could have led to the test being cancelled and the client having to stay an extra day. Therefore, the client has a valid argument for not wanting to pay for the additional day.

Explanation

The correct answer is that a full explanation of the test or treatments is the right of the client. In this situation, the client has the right to be fully informed about the test or treatment they are undergoing. The fact that the client ate breakfast on the morning of the test suggests that they may not have been adequately informed about the NPO (nothing by mouth) order. This lack of understanding could have led to the test being cancelled and the client having to stay an extra day. Therefore, the client has a valid argument for not wanting to pay for the additional day.

17. When teaching about child abuse, the nurse tells a parent group that best legal definition of assault is:

Threats to do bodily harm to the person of another person

The application of force to another person without lawful justification

A legal wrong committed against the property of another

A legal wrong committed against the public and punished by law through the state and courts

The correct answer is "Threats to do bodily harm to the person of another person." This is the best legal definition of assault because it refers to the act of threatening to cause physical harm to another person. Assault does not necessarily involve physical contact, but the act of making threats or creating fear of bodily harm is considered assault under the law.

Explanation

The correct answer is "Threats to do bodily harm to the person of another person." This is the best legal definition of assault because it refers to the act of threatening to cause physical harm to another person. Assault does not necessarily involve physical contact, but the act of making threats or creating fear of bodily harm is considered assault under the law.

18. When assessing as client with an acute anxiety reactyion,. The most significant legal facto0r for the nurse to explore is the client's:

Physician status

Available support systems

Past behavior under stress

Perception of the current situation

In assessing a client with an acute anxiety reaction, the nurse needs to explore the client's perception of the current situation. This is important because the client's perception will influence their level of anxiety and how they are experiencing and interpreting the events around them. Understanding their perception will help the nurse determine appropriate interventions and support for the client.

Explanation

In assessing a client with an acute anxiety reaction, the nurse needs to explore the client's perception of the current situation. This is important because the client's perception will influence their level of anxiety and how they are experiencing and interpreting the events around them. Understanding their perception will help the nurse determine appropriate interventions and support for the client.

19. A 15-year-old is taken to the emergency room of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks if the adolescent has been immunized against tetanus. The reply is affirmative. Penicillin is administered, and the adolescent is sent home with instructions to return if there is any change in the wound area. A few days later, the adolescent is admitted to the hospital with a diagnosis of tetanus. Legally:

Hospital protocol should govern treatment in emergency care

The nurse’s judgment was adequate in view of client’s symptoms

Assessment by the nurse was incomplete and the treatment was inadequate

The possibility of tetanus could not have been foreseen, because the adolescent had been immunized

The correct answer is "Assessment by the nurse was incomplete and the treatment was inadequate." This is because even though the adolescent had been immunized against tetanus, it is still possible for them to contract the disease. The nurse should have conducted a more thorough assessment to ensure that all necessary precautions were taken, such as administering a tetanus booster shot. Additionally, the treatment of simply cleansing the wound and applying a sterile dressing may not have been sufficient to prevent tetanus infection.

Explanation

The correct answer is "Assessment by the nurse was incomplete and the treatment was inadequate." This is because even though the adolescent had been immunized against tetanus, it is still possible for them to contract the disease. The nurse should have conducted a more thorough assessment to ensure that all necessary precautions were taken, such as administering a tetanus booster shot. Additionally, the treatment of simply cleansing the wound and applying a sterile dressing may not have been sufficient to prevent tetanus infection.

20. Nurse are protected from all legal action when they:

Offer health teaching regarding family planning

Offer first aid at the scene of an automobile-bus accident

Administer CPR measures on an unconscious child pulled from a swimming pool

Report incidents of suspected child abuse of the appropriate authorities identified in legislation and policies

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Explanation

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21. The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The nurse involved in this situation should:

Phone the physician for a special administrative order to give the blood under these circumstance

Have the spouse sign a treatment refusal form and notify the physician so that a court order can be obtained

Gently explain to the spouse why the transfusion is necessary, emphasizing the implication of not having the transfusion

Institute the blood transfusion anyway, because the physician ordered it and client’s survival depends on volume replacement

The correct answer is to have the spouse sign a treatment refusal form and notify the physician so that a court order can be obtained. This is the most ethical and legal course of action in this situation. By respecting the spouse's wishes and obtaining a court order, the nurse ensures that the client's autonomy is respected while also following legal protocols. It is important to involve the physician and the legal system to ensure that the best interests of the client are upheld.

Explanation

The correct answer is to have the spouse sign a treatment refusal form and notify the physician so that a court order can be obtained. This is the most ethical and legal course of action in this situation. By respecting the spouse's wishes and obtaining a court order, the nurse ensures that the client's autonomy is respected while also following legal protocols. It is important to involve the physician and the legal system to ensure that the best interests of the client are upheld.

22. A client is voluntarily admitted to the psychiatric unit. Later the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. When preparing the client for an appendectomy the nurse should:

Have two nurses witness the operative consent as the client signs it

Have surgeon and the psychiatrist sign for the surgery, because it is emergency procedure

Ask the client sign the preoperative consent form after being informed of the procedure and required care

The correct answer is to ask the client to sign the preoperative consent form after being informed of the procedure and required care. This is because when a client is voluntarily admitted to the psychiatric unit, they still have the right to make decisions about their own medical treatment. In this case, the client should be fully informed about the appendectomy procedure and the required care before giving their consent by signing the form.

Explanation

The correct answer is to ask the client to sign the preoperative consent form after being informed of the procedure and required care. This is because when a client is voluntarily admitted to the psychiatric unit, they still have the right to make decisions about their own medical treatment. In this case, the client should be fully informed about the appendectomy procedure and the required care before giving their consent by signing the form.

23. The family of an elderly, aphasic client complains that the nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. This is example of:

A catheter inserted for the client’s benefit

A treatment that does not need a separate consent form

Treatment without consent of the client, which is an invasion of rights

Inability to obtain consent for treatment because the client was aphasic

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Explanation

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24. A female client is hospitalized because of a severe depression. While at home she refused to eat, stayed in bed most of the time, and did not talk with family members. Finally, unable to cope with the problem, her husband took her to the hospital. Here symptoms persist, and she will not leave her room. The nurse caring for her attempts to talk to her, asking question but receiving no answers. Finally, in exasperation, the nurse tells the client that if she does not respond she will be left alone. The nurse:

Recognize that the client has the right to make the decision

Attempts to use reward and punishment to motivate the client

Is really assaulting the client and should have refrained from this

Should get her involved in group therapy rather than attempting one-to-one therapy

The nurse's threat to leave the client alone if she does not respond is a form of assault. It is not an appropriate or therapeutic approach to dealing with a patient who is experiencing severe depression. The nurse should have refrained from making such a threat and instead should have continued to provide supportive care and attempt to engage the client in a more empathetic and understanding manner.

Explanation

The nurse's threat to leave the client alone if she does not respond is a form of assault. It is not an appropriate or therapeutic approach to dealing with a patient who is experiencing severe depression. The nurse should have refrained from making such a threat and instead should have continued to provide supportive care and attempt to engage the client in a more empathetic and understanding manner.

25. Twenty-four hours after a cesarean delivery a client elects to sign herself and her baby out of the hospital because of difficult at home with her 2-year-old son. Staff members have been unable to contact her physician. The client arrives at the nursery dressed and ready to leave and ask that her infant be given to her to dress and take home. Appropriate nursing action would be:

The appropriate nursing action would be to give the baby to the client to take home, while ensuring that she receives information regarding care and feeding of a 2-day-old infant and any potential problems which may develop. This is because the client has elected to sign herself and her baby out of the hospital, and the staff members have been unable to contact her physician. While it is important to follow hospital policy and wait for orders from the physician, the client's decision to leave with her baby should be respected, as long as she is provided with the necessary information and support for caring for her infant.

Explanation

The appropriate nursing action would be to give the baby to the client to take home, while ensuring that she receives information regarding care and feeding of a 2-day-old infant and any potential problems which may develop. This is because the client has elected to sign herself and her baby out of the hospital, and the staff members have been unable to contact her physician. While it is important to follow hospital policy and wait for orders from the physician, the client's decision to leave with her baby should be respected, as long as she is provided with the necessary information and support for caring for her infant.