Exam (elaborations)

NCLEX Management of Care Questions and Correct Answers the Latest Update and Recommended Version

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NCLEX

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NCLEX

Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two ...

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nclex management of care questions and correct an

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NCLEX Management of Care Questions
and Correct Answers the Latest Update
and Recommended Version
Which finding would indicate to the nurse that a client is at nutritional risk and should receive

a dietary consult?

1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery.

2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN).

3. Two year old taking only clear liquids since admission 24 hours ago.

4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.

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• 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery.
•
• (1. Correct: This child has been receiving only clear liquids for more than 3 days and
would be a nutritional risk. Proper nutrients are required for healing after surgery, and
only liquids would not be adequate.
•
• 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a
nutritional evaluation receiving supplementation for nutritional needs. After reviewing
the nutritional evaluation, the TPN will be formulated accordingly.
•
• 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on
liquids for more than 3 days, then would be at nutritional risk. After 3 days the
nutritional status of the child should be evaluated due to the food restrictions of a clear
liquid diet.
•
• 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is
tolerated, then the strength will be advanced; therefore, this client is not at risk.)

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain

level on a scale of 0-10. What strategies could the nurse manager initiate to improve

performance?

Select all that apply.

1. Provides "just in time" posters outlining the importance of pain assessment.

2. Conducts brief in-services for each shift.

3. Counsels nurses when pain level scale is not utilized.

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4. Ensures that a complete and clear performance standard exists.

5. Assesses nurses' reasons for not using pain level scale.

6. Disciplines offenses through unpaid time off.

• 1. Provides "just in time" posters outlining the importance of pain assessment.
•
• 2. Conducts brief in-services for each shift.
•
• 3. Counsels nurses when pain level scale is not utilized.
•
• 4. Ensures that a complete and clear performance standard exists.
•
• 5. Assesses nurses' reasons for not using pain level scale.
•
• (1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and
performed the skill before, but have not practiced the skill on a regular basis, a
different type of education is required. This may take the form of "just in time" tools
such as posters or guidelines outlining the critical steps in performing the skill. Brief in-
services, videos, or DVDs available on the unit may also be effective in providing on
the spot refreshers. Counseling the nurses when pain level scale is not utilized may
improve understanding and performance. Ensuring that performance standards exist,
are clear and complete, and that they are readily available to staff is essential. The
first step in correcting a performance gap is to understand what the difference is
between the behavior being exhibited and what the expectations are. Always assess
why staff are doing or not doing what is needed for clients. There may be a lack of
knowledge or there may be a sense of non-importance.
•
• 6. Incorrect: Quality improvement looks at improving processes and does not use
intimidation and punishment to improve quality care.)

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A new nurse is documenting in a client's electronic record. Which documentation would the

charge nurse evaluate as appropriate documentation by the new nurse?

Select all that apply.

1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services.

2. Appears to be having abdominal discomfort.

3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon.

4. Pre op Diazepam 10.0 mg given po.

5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

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Exam (elaborations)

NCLEX Management of Care Questions and Correct Answers the Latest Update and Recommended Version

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