NCLEX LEADERSHIP MANAGEMENT PROCTORED EXAM
NCLEX LEADERSHIP MANAGEMENT PROCTORED EXAM
A nurse is caring for four laboring clients. Each of the
clients is requesting an epidural. Which of the
following clients should
...
NCLEX LEADERSHIP MANAGEMENT PROCTORED EXAM
NCLEX LEADERSHIP MANAGEMENT PROCTORED EXAM
A nurse is caring for four laboring clients. Each of the
clients is requesting an epidural. Which of the
following clients should receive her epidural frst?
Select one:
a. Mulitipara with contractions occurring every 3
minutes, lasting 45 seconds. The cervical os is dilated
5 cms.
b. Primipara with contractions occurring every 10-15
minutes, lasting 15 seconds. The cervical os is dilated
3 cms.
c. Primipara with contractions occurring every 2
minutes, lasting 90 seconds. The cervical os is dilated
10 cms.
d. Mulitipara with contractions occurring every 2
minutes, lasting 130 seconds. The cervical os is
dilated 8 cms.
a. Mulitipara with contractions
occurring every 3 minutes,
lasting 45 seconds. The
cervical os is dilated 5 cms.
An epidural is indicated in the
active phase of labor. Active
labor is defned as: cervical
dilation of 4-7 cms,
contractions occurring every
3-5 minutes and lasting 30-60
seconds.
transition phase of labor and
is approaching second stage:
cervical dilation of 8-10 cms,
contractions every 2-3
minutes and lasting 45-90
seconds. Many clients in this
phase of labor become
exhausted. An epidural during
this phase could prolong
delivery as the epidural may
interfere with the client's
ability to push.
A nurse is preparing a client who speaks limited
English for surgery. Which of the following is the most
appropriate nursing action in obtaining informed
a. Seek the assistance of a
nurse on the floor who is
fluent in the client's
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shared via CourseHero.comconsent from this client?
Select one:
a. Seek the assistance of a nurse on the floor who is
fluent in the client's language.
b. The nurse should explain the procedures using
pictures and hand gestures.
c. Have the nurse respond to the client's concerns so
the provider can prepare for surgery.
d. Do nothing as this is the provider's primary
concern.
language.
The nurse is responsible for
ensuring that the client
understands the information
provided regarding the
procedure.
A nurse is caring for a client recently diagnosed
Hepatitis C. He asks the nurse to promise him his wife
will fnd not out about his diagnosis. What is the best
response by the nurse?
Select one:
a. "I can't promise you because your provider may
inform her anyway."
b. "Your wife has the right to know about your
condition because she may be at increased risk."
c. "I'll place a note in your chart concerning your
request for your wife not to be informed."
d. "Your medical information is considered confdential
to be shared only if you agree."
d. "Your medical information i
considered confdential to be
shared only if you agree."
The client must give consent
for health care information,
including laboratory results,
diagnosis, and prognosis, to
be shared with anyone that is
not involved in the client's
care. This includes sharing the
information with family
members.
Even though the wife may be
at an increased risk for
Hepatitis C, she cannot be
informed without the client's
consent.
A nurse is using silence to communicate with a client.
Which of the following describes a therapeutic
purpose of silence?
Select one:
a. Conveys the nurse's understanding of the client
and assists with clarifcation.
b. Encourages the client to discuss central issues and
keeps communication goal-oriented.
c. Allows the client time to gain insights and slows the
pace of the interaction.
d. Communicates the nurse's interest and concern for
the well-being of the client.
c. Allows the client time to
gain insights and slows the
pace of the interaction.
Silence gives the client time
to think and gain insights,
slows the pace of the
interaction, and encourages
the client to initiate
conversation, while conveying
the nurse's support,
understanding, and
acceptance.
A client is admitted to the hospital for suspected
infective endocarditis. The client is reporting chills,
c. Obtain the blood cultures
from three sites
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shared via CourseHero.comfatigue, myalgia and dyspnea upon exertion. When
assessing the client the nurse notes a heart murmur
and a temperature of 102.3 F (38.2 C). Which of the
following orders should the nurse implement frst?
Select one:
a. Order the EKG
b. Administer acetaminophen 325 mg by mouth
c. Obtain the blood cultures from three sites
d. Administer IV Penicillin G, 2 million units
Obtaining blood cultures is the
priority intervention. Cultures
must be drawn prior to
initiation of antibiotics so
sensitivity results are not
influenced. Obtaining
specimens from three sites
increases the reliability of the
results. Clients at risk for
endocarditis should be treated
with prophylactic antibiotics
prior to dental procedures;
respiratory and GI diagnostic
procedures; GU and Cardiac
surgeries.
Administering an antipyretic
medication should follow the
administration of antibiotics.
Temperatures may be as high
as 102-104 degrees F. in
clients with infective
endocarditis. Antipyretics are
a priority for this client, but it
is a lower priority than blood
cultures and antibiotic
administration. Clients at risk
for endocarditis should be
treated with prophylactic
antibiotics prior to dental
procedures; respiratory and G
diagnostic procedures; GU
and Cardiac surgeries.
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