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Nursing Interventions and Standards of Care, Exams of Advanced Education

Virginia Union University (VUU)Advanced Education

Various nursing interventions and standards of care that a registered nurse (rn) would review and discuss with a nursing student or new licensed practical nurse (lpn). It includes topics such as revising a plan of care, performing procedures like blood draws and suctioning, floating to other units, and understanding the purpose of standards of care. Insights into the responsibilities of an rn in supervising and educating nursing students and new nurses to ensure patient safety and adherence to policies and procedures. It highlights the importance of proper documentation, communication, and decision-making in nursing practice.

Typology: Exams

2024/2025

Available from 10/28/2024

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Nursing Leadership and Management
NCLEX Questions
A registered nurse reviews a plan of care developed by a nursing student for a client with depression
and notes a nursing diagnosis of impaired nutrition: less than body requirements. The registered nurse
asks the student to revise the plan if which incorrect intervention is documented?
a) offer small, high-calorie, high protein snacks frequently throughout the day and evening
b) offer high protein, high-calorie fluids frequently throughout the day and evening
c) remain with the client during meals
d) complete the food menu for the client during the depressed period - D
- The client should be asked which foods or drinks she likes, and consultation with a dietitian also may
be done. The client is more likely to eat if the client has selected the foods and is given foods that she
likes. Options A, B, and C are appropriate interventions for the client with depression with this nursing
diagnosis.
A registered nurse reviews a plan of care developed by a nursing student for client with paranoia and
notes a nursing diagnosis of Disturbed thought process. The registered nurse asks the nursing student to
revise the plan if which incorrect intervention is documented?
a) sit with the client and hold the client's hand
b) avoid a warm approach when working with the client
c) use simple and clear language when speaking to the client
d) diffuse angry and hostile verbal attacks with a nondefensive stand - A
- When caring for a paranoid client, the nurse must avoid any physical contact and should not touch the
client. The nurse should ask the client's permission if touch is necessary because touch may be
interpreted as a physical or sexual assault. The nurse would use simple and clear language when
speaking to the client to prevent misinterpretation and to clarify the nurse's intent and actions. A warm
approach is avoided because it can be frightening to a person who needs emotional distance. A matter-
of-fact consistency is nonthreatening. Any anger and hostile verbal attacks need to be diffused with a
nondefensive stand. The anger that a paranoid client expresses is often displaced, and when the staff
becomes defensive, anger of both the client and staff escalates. A nondefensive and nonjudgmental
attitude provides an attitude in which feelings can be explored more easily.
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Nursing Leadership and Management

NCLEX Questions

A registered nurse reviews a plan of care developed by a nursing student for a client with depression and notes a nursing diagnosis of impaired nutrition: less than body requirements. The registered nurse asks the student to revise the plan if which incorrect intervention is documented? a) offer small, high-calorie, high protein snacks frequently throughout the day and evening b) offer high protein, high-calorie fluids frequently throughout the day and evening c) remain with the client during meals d) complete the food menu for the client during the depressed period - D

  • The client should be asked which foods or drinks she likes, and consultation with a dietitian also may be done. The client is more likely to eat if the client has selected the foods and is given foods that she likes. Options A, B, and C are appropriate interventions for the client with depression with this nursing diagnosis. A registered nurse reviews a plan of care developed by a nursing student for client with paranoia and notes a nursing diagnosis of Disturbed thought process. The registered nurse asks the nursing student to revise the plan if which incorrect intervention is documented? a) sit with the client and hold the client's hand b) avoid a warm approach when working with the client c) use simple and clear language when speaking to the client d) diffuse angry and hostile verbal attacks with a nondefensive stand - A
  • When caring for a paranoid client, the nurse must avoid any physical contact and should not touch the client. The nurse should ask the client's permission if touch is necessary because touch may be interpreted as a physical or sexual assault. The nurse would use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurse's intent and actions. A warm approach is avoided because it can be frightening to a person who needs emotional distance. A matter- of-fact consistency is nonthreatening. Any anger and hostile verbal attacks need to be diffused with a nondefensive stand. The anger that a paranoid client expresses is often displaced, and when the staff becomes defensive, anger of both the client and staff escalates. A nondefensive and nonjudgmental attitude provides an attitude in which feelings can be explored more easily.

A registered nurse is discussing the characteristics of anorexia nervosa with a nursing student. The registered nurse determines that the nursing student needs to further research this disorder if the student states that which of the following is a characteristic of anorexia nervosa? a) personal relationships tend to become more superficial and distant b) social contacts are avoided because of the fear of being invited to eat and being discovered c) the client is being preoccupied with food and meal planning, especially for others d) the client will usually keep her weight near normal - D

  • As anorexia nervosa develops, personal relationships tend to become more superficial and distant. Social contacts are avoided because of the fear of being invited to eat and being discovered. The client is preoccupied with food and meal planning (especially for others), personal caloric intake throughout the day, and methods to avoid eating. Anorexic persons are likely to become very emaciated and will not maintain their near-normal body weight. An experienced emergency department nurse observes a new nurse employed in the emergency department obtain the equipment needed to draw a blood sample for a blood alcohol level on a client. The experienced emergency department nurse intervenes if the new nurse plans to use which item? a) tourniquet b) alcohol swabs c) a blood-draw needle d) a blood tube - B
  • Isopropyl alcohol or any antiseptic solution containing alcohol must not be used as a skin preparation before a blood alcohol specimen is drawn. These agents may falsely elevate the blood alcohol level and render the test invalid. Option A, C and D identify items needed to obtain the blood specimen. A nurse administers digoxin (Lanoxin) 0.25 mg instead of the prescribed order of 0.125 mg. The nurse discovers the error while charting the medication. The nurse completes an incident report and notifies the physician of the incident. The nurse takes which additional action? a) gives the client a copy of the incident report b) makes a copy of the incident report and sends it to the physician's office
  • Because wound irrigation is a sterile procedure and a risk for infection exists with an open wound, it is most appropriate to ask the nursing assistant to obtain a telephone number from the physician so that the call can be returned. It is not appropriate to ask a physician to wait while a procedure is being completed. It is best to return the call. Option D is not a responsibility of the nursing assistant. A case manager is reviewing the records of the clients in the nursing unit. Which of the following documentation, if noted in a client's record, would the nurse indicate as a positive variance? a) a client in skeletal traction has a temperature of 98.6F and the pin sites are clean and dry b) a postoperative client is performing coughing and deep-breathing exercises every hour c) a client with congestive heart failure has clear breath sounds d) a client with pneumonia is discharged to home 1 day earlier than expected - D
  • Variances are actual deviations or detours from the critical path. Variances are either positive or negative and avoidable or unavoidable, and may be caused by a variety of things. A positive variance occurs when the client has achieved maximum benefits and is discharged earlier than anticipated on her critical path. Option 4 is the only option that specifically identifies a positive variance. Options A, B, and C demonstrate progression on a critical path, but they are not specifically associated with the definition of a positive variance. A nurse is a member of a community task force on violence. The task force recognizes that it has insufficient data to make decisions about specific interventions. Using the nursing process, the first activity that the nurse would suggest to the task force is to: a) call other communities similar in size to determine what they do b) develop a general educational program related to violence c) conduct a community survey to assess community perceptions regarding violence d) develop a pamphlet on violence to be distributed to the community - C
  • An assessment activity is always the first step in the nursing process. Option C addresses assessment of community perceptions. Option A is a part of analysis from a variety of assessment data, but is not specific to the subject of the question. Options B and D are implementation measures. A community health nurse has been assigned to be the leader of a task force to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the

members express concern that more information is needed to determine appropriate measures for the target teenagers. The nurse would direct the group effectively by suggesting which of the following? a) preparing a survey that can be distributed to community members to determine their understanding of the drug abuse problem b) initiating a drug abuse program in all of the schools c) seeking out the teenage drug abusers and referring them to drug abuse centers d) preparing posters that can be distributed to the schools - A

  • Option A is the only option that addresses the subject of the question and will identify the additional information required by the task force. Options B, C, and D do not provide the additional information required in order for the task force to proceed with the necessary task of the group.
  1. A registered nurse is discussing treatment for a client who is hospitalized with acute systemic lupus erythematosus (SLE) with a nursing student assigned to the client. The registered nurse realized that the nursing student needs to research information about the disease if the student states that which of the following is a clinical manifestation of SLE? a) fever b) bradycardia c) butterfly rash on the face d) muscular aches and pains - B
  • Manifestations of acute SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, convulsions, psychosis, and coma. A nurse administers a fatal dose if a cardiac medication to a client. During the subsequent investigation, it was determined that the nurse did not check the client's vital signs before administering the medication. This failure to complete an appropriate assessment is addressed under which function on the Nurse Practice Act? a) defining the specific educational requirements for licensure b) describing the scope of practice of licensed and unlicensed care providers c) recommending disciplinary action for nurses who violate the law

A nurse is performing an admission assessment on a client admitted to the hospital with a diagnosis of fever of unknown origin. The nurse performs interventions based on the nurse practice act when the nurse: a) enters the information on the client's record b) writes the information on a worksheet c) informs the supervisor of the client's vital signs d) tells another nurse that the client has a high fever - A

  • Recording assessment data reflects the requirement of the nurse practice act to maintain adequate records. Verbal information and notes on worksheets are not part of the client's permanent record. A nurse educator at the local community hospital is conducting an orientation session for nurses that are newly employed at the hospital. The nurse educator informs the new nurses that the policy of the hospital requires that nurses "float" to other nursing departments when client census is high on other units. The nurse educator advises the new nurses that if this situation arises and if the nurse is unfamiliar with the unit in which the nurse must "float" to: a) refuse to float b) call the nurse educator c) report to the unit and identify tasks that can be safely performed d) call the nursing supervisor - C
  • Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally a nurse cannot refuse to float unless union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, nurses should report to the unit and identify tasks that can be safely performed. The nursing supervisor and the nurse educator may need to become involved in the situation at some point if the nurse requires assistance or education regarding a new skill, but the action that the nurse must take is identified in option C. A staff nurse makes negative comments about a unit manager's leadership style, and the unit manager overhears the staff nurse. Which action by the unit manager would be appropriate? a) tell the staff nurse to stop making the comments b) propose a tentative solution regarding the comments, and discuss it with the staff nurse

c) encourage the staff nurse to discuss the comments d) persuade the staff nurse to stop being so critical - C

  • Encouraging the staff nurse to discuss the comments will assist in identifying the concerns in a democratic way. Options A and D are autocratic. Option B does not provide the opportunity for the staff nurse to directly share concerns. A registered nurse is reviewing a plan of care developed by a nursing student for a client scheduled for keratoplasty. The registered nurse tells the nursing student that which intervention written in the plan needs to be deleted because it is incorrect? a) obtain a specimen for culture and sensitivity of the eye with a conjunctival swab b) instill antibiotic ophthalmic medication as prescribed c) cut the client's eyelashes d) administer medications that will dilate the pupil - D
  • Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor (live or cadaver). Preoperative preparation of the recipient's eye may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting the eyelashes. Some ophthalmologists order a medication such as 2% pilocarpine to constrict the pupil (not dilate the pupil) before surgery. A registered nurse is discussing the clinical manifestations of Meniere's disease with a nursing student. The registered nurse determines that the nursing student needs to further research this disorder if the student states that which of the following is a manifestation of Meniere's disease? a) tinnitus b) sensorineural hearing loss on the involved side c) conductive hearing loss on the involved side d) vertigo accompanied by nausea and vomiting - C
  • The three characteristic symptoms of Ménière's disease are tinnitus, sensorineural hearing loss on the involved side, and severe vertigo accompanied by nausea and vomiting. Option C is not associated with Ménière's disease.

d) include providing care based on specialty guidelines for the client's condition - C

  • The purpose of standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, across the country. Standards of care include providing competent levels of care based on current practice. Options A, B, and D do not specifically describe standards of care. Option A is specific to technology. Option B addresses medical research. Option D addresses specialty guidelines. A registered nurse (RN) is observing a new licensed practical nurse (LPN) suctioning a client who has a diagnosis of acquired immunodeficiency syndrome (AIDS). The RN would determine that the LPN was performing the procedure safely if the RN observed that the LPN was wearing which of the following protective devices? a) gloves, mask, and protective eyewear b) gloves, gown, and mask c) gown, mask, and protective eyewear d) gloves, gown, and protective eyewear - A
  • The RN is responsible for supervising procedures performed by a new LPN to ensure that client safety is maintained and that policies and procedural guidelines are adhered to. Standard precautions include use of gloves whenever there is actual or potential contact with blood or body fluids. During suctioning the nurse wears gloves, a mask, and protective eyewear or a face shield. Impervious gowns are worn in those instances when it is anticipated that there will be contact with a large amount of body fluid or blood. A registered nurse (RN) is observing a nursing assistant ambulating a client with right-sided weakness. The RN would determine that the nursing assistant was performing the procedure safely if the nurse observed the nursing assistant: a) standing behind the client b) standing in front of the client c) standing on the left side of the client d) standing on the right side of the client - D
  • When walking with clients, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the client's back. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at the feet. Options A,B, and C are incorrect.

A registered nurse (RN) is observing a new licensed practical nurse (LPN) administer a deep intramuscular injection in the dorsogluteal site of a client. The RN determines that the LPN is performing the procedure correctly if the LPN: a) administers the injection 2 inches below the acromial process b) administers the injection in the thigh c) positions the client in a prone toe-in position d) positions the client in a Sims' position - C

  • The RN is responsible for supervising certain procedures performed by an LPN to ensure that client safety is maintained. The dorsogluteal site or gluteus medius muscle is the desired site for deep intramuscular injections. A prone toe-in position will promote internal rotation of the hips, which will relax the muscle and make the injection less painful. Option D is incorrect and will not relax the muscle. Option A describes the administration of an injection into the deltoid muscle. Option B describes an injection into the vastus lateralis or rectus femoris muscle.