Leadership and Management NCLEX
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Question 1 of 5.
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
Correct arrangement
Explanation: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it's preventive.
Question 2 of 5.
The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit.
A. Levofloxacin 750 mg IVPB Q12 hours
B. 0.9% Saline 125 ml/hr
C. Metoclopramide 10 mg IV Push Q8 hours
D. Ketorolac 15 mg IV Push Q8 hours
Explanation: Pneumonia in an elderly client can be particularly severe due to age-related immune system decline and potential for complications like acute respiratory distress syndrome (ARDS) and/or sepsis.
Question 3 of 5.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
A. teaching a client scheduled for discharge how to ambulate with crutches
B. witnessing informed consent for a client needing an emergency laparotomy
C. irrigating a client's ostomy who reports abdominal cramping
D. calculating the intake and output of a client with diabetes insipidus (DI)
Explanation: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
Question 4 of 5.
The nurse recognizes that the most effective way to resolve a conflict is through
A. compromising.
B. accommodating.
C. avoiding.
D. a win-win solution.
Explanation: A win-win solution (D) resolves conflict by addressing all parties' needs, fostering collaboration and long-term resolution. Compromising (A) and accommodating (B) may leave issues unresolved, and avoiding (C) delays resolution.
Question 5 of 5.
A charge nurse is preparing client assignments for the shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?
A. A client with a chest tube requiring frequent oral suctioning.
B. A client receiving continuous IV heparin for a pulmonary embolism (PE).
C. A client 24 hours post-abdominal surgery requiring daily wound care.
D. A client with new-onset seizures awaiting diagnostic tests.
Explanation: A client 24 hours post-abdominal surgery needing wound care (C) is stable and within the LPN scope. Chest tube suctioning (A) and heparin infusion (B) require RN monitoring for complications. New-onset seizures (D) require RN assessment due to instability.
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