Saunders NCLEX-RN Test Bank
Saunders NCLEX-RN Test Bank 5 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
The nurse manager has implemented a change in the method of the nursing delivery system
from functional to team nursing. An assistive personnel (AP) is resistant to the change and is
not taking an active part in facilitating the process of change. Which is the best approach in
dealing with the AP?
1. Ignore the resistance.
2. Exert coercion on the AP.
3. Provide a positive reward system for the AP.
4. Confront the AP to encourage verbalization of feelings regarding the change. –
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Correct Answer :Answer: 4
Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face
meetings to confront the issue at hand will allow verbalization of feelings, identification of
problems and issues, and development of strategies to solve the problem. Option 1 will not
address the problem. Option 2 may produce additional resistance. Option 3 may provide a
temporary solution to the resistance but will not address the concern specifically.
The registered nurse is planning the client assignments for the day. Which is the most
appropriate assignment for an assistive personnel (AP)?
1. A client requiring a colostomy irrigation
2. A client receiving continuous tube feedings
3. A client who requires urine specimen collections
4. A client with difculty swallowing food and fluids - Correct Answer :Answer: 3
Rationale: The nurse must determine the most appropriate assignment based on the skills of
the staff member and the needs of the client. In this case, the most appropriate assignment
for the AP would be to care for the client who requires urine specimen collections. The AP is
skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs
because these are invasive procedures. The client with difficulty swallowing food and fluids is
at risk for aspiration.
The nurse employed in a long-term care facility is planning assignments for the clients on a
nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and
three assistive personnel (APs) on a nursing team. Which client would the nurse most
appropriately assign to the licensed practical nurse?
1. A client who requires a bed bath
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
2. An older client requiring frequent ambulation
3. A client who requires hourly measurement of vital signs
4. A client requiring abdominal wound irrigations and dressing changes every 3 hours - Correct
Answer :Answer: 4
Rationale: When delegating nursing assignments, the nurse needs to consider the skills and
educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation,
and taking vital signs can be assigned most appropriately to an AP. The licensed practical
nurse is skilled in wound irrigations and dressing changes and most appropriately would be
assigned to the client who needs this care.
The charge nurse is planning the assignment for the day. Which factors would the nurse
remain mindful of when delegating tasks? Select all that apply.
1. The acuity level of the clients
2. Specic requests from the staff
3. The clustering of the rooms on the unit
4. The number of anticipated client discharges
4. Client needs and workers' needs and abilitie - Correct Answer :Answer: 1, 5
Rationale: There are guidelines that the nurse would use when delegating tasks. These
include the following: ensure client safety; be aware of individual variations in work abilities;
determine which tasks can be delegated and to whom; match the task to the delegatee on
the basis of the nurse practice act and appropriate position descriptions; provide directions
that are clear, concise, accurate, and complete; validate the delegatee's understanding of the
directions; communicate a feeling of confidence to the delegatee and provide feedback
promptly after the task is performed; and maintain continuity of care as much as possible
when assigning client care. Staff requests, convenience (as in clustering of client rooms), and
anticipated changes in unit census are not specific guidelines to use when delegating tasks,
but may be considered when making assignments.
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The nurse manager is discussing with the staff the facility's protocol in the event of a tornado.
Which instructions would the nurse manager include in the discussion? Select all that apply.
1. Open doors to client rooms.
2. Move beds away from windows.
3. Close window shades and curtains.
4. Place blankets over clients who are confined to bed.
5. Relocate ambulatory clients from the hallways back into their rooms. - Correct Answer
:Answer: 2, 3, 4
Rationale: In this weather event, the appropriate nursing actions focus on protecting clients
from flying debris or glass. The nurse would close doors to each client's room and move beds
away from windows, and close window shades and curtains to protect clients, visitors, and
staff from shattering glass and flying debris. Blankets need to be placed over clients confined
to bed. Ambulatory clients need to be moved into the hallways from their rooms, away from
windows.
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the
client is dyspneic, and crackles are audible on auscultation. What additional manifestations
would the nurse expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and
increased respirations
4. Weakness and decreased central venous pressure (CVP) - Correct Answer :Answer: 3
Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs
when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings
associated with fluid volume excess include cough, dyspnea, crackles, tachypnea,
tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema,
neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry
A+ TEST BANK 4
Saunders NCLEX-RN Test Bank 5 Questions
And Answers(100% CORRECT ANSWERS)
WITH RATIONALES/ GUARANTEED PASS
GRADED A+
The nurse manager has implemented a change in the method of the nursing delivery system
from functional to team nursing. An assistive personnel (AP) is resistant to the change and is
not taking an active part in facilitating the process of change. Which is the best approach in
dealing with the AP?
1. Ignore the resistance.
2. Exert coercion on the AP.
3. Provide a positive reward system for the AP.
4. Confront the AP to encourage verbalization of feelings regarding the change. –
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Correct Answer :Answer: 4
Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face
meetings to confront the issue at hand will allow verbalization of feelings, identification of
problems and issues, and development of strategies to solve the problem. Option 1 will not
address the problem. Option 2 may produce additional resistance. Option 3 may provide a
temporary solution to the resistance but will not address the concern specifically.
The registered nurse is planning the client assignments for the day. Which is the most
appropriate assignment for an assistive personnel (AP)?
1. A client requiring a colostomy irrigation
2. A client receiving continuous tube feedings
3. A client who requires urine specimen collections
4. A client with difculty swallowing food and fluids - Correct Answer :Answer: 3
Rationale: The nurse must determine the most appropriate assignment based on the skills of
the staff member and the needs of the client. In this case, the most appropriate assignment
for the AP would be to care for the client who requires urine specimen collections. The AP is
skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs
because these are invasive procedures. The client with difficulty swallowing food and fluids is
at risk for aspiration.
The nurse employed in a long-term care facility is planning assignments for the clients on a
nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and
three assistive personnel (APs) on a nursing team. Which client would the nurse most
appropriately assign to the licensed practical nurse?
1. A client who requires a bed bath
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
2. An older client requiring frequent ambulation
3. A client who requires hourly measurement of vital signs
4. A client requiring abdominal wound irrigations and dressing changes every 3 hours - Correct
Answer :Answer: 4
Rationale: When delegating nursing assignments, the nurse needs to consider the skills and
educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation,
and taking vital signs can be assigned most appropriately to an AP. The licensed practical
nurse is skilled in wound irrigations and dressing changes and most appropriately would be
assigned to the client who needs this care.
The charge nurse is planning the assignment for the day. Which factors would the nurse
remain mindful of when delegating tasks? Select all that apply.
1. The acuity level of the clients
2. Specic requests from the staff
3. The clustering of the rooms on the unit
4. The number of anticipated client discharges
4. Client needs and workers' needs and abilitie - Correct Answer :Answer: 1, 5
Rationale: There are guidelines that the nurse would use when delegating tasks. These
include the following: ensure client safety; be aware of individual variations in work abilities;
determine which tasks can be delegated and to whom; match the task to the delegatee on
the basis of the nurse practice act and appropriate position descriptions; provide directions
that are clear, concise, accurate, and complete; validate the delegatee's understanding of the
directions; communicate a feeling of confidence to the delegatee and provide feedback
promptly after the task is performed; and maintain continuity of care as much as possible
when assigning client care. Staff requests, convenience (as in clustering of client rooms), and
anticipated changes in unit census are not specific guidelines to use when delegating tasks,
but may be considered when making assignments.
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
The nurse manager is discussing with the staff the facility's protocol in the event of a tornado.
Which instructions would the nurse manager include in the discussion? Select all that apply.
1. Open doors to client rooms.
2. Move beds away from windows.
3. Close window shades and curtains.
4. Place blankets over clients who are confined to bed.
5. Relocate ambulatory clients from the hallways back into their rooms. - Correct Answer
:Answer: 2, 3, 4
Rationale: In this weather event, the appropriate nursing actions focus on protecting clients
from flying debris or glass. The nurse would close doors to each client's room and move beds
away from windows, and close window shades and curtains to protect clients, visitors, and
staff from shattering glass and flying debris. Blankets need to be placed over clients confined
to bed. Ambulatory clients need to be moved into the hallways from their rooms, away from
windows.
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the
client is dyspneic, and crackles are audible on auscultation. What additional manifestations
would the nurse expect to note in this client if excess fluid volume is present?
1. Weight loss and dry skin
2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and
increased respirations
4. Weakness and decreased central venous pressure (CVP) - Correct Answer :Answer: 3
Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs
when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings
associated with fluid volume excess include cough, dyspnea, crackles, tachypnea,
tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema,
neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry
A+ TEST BANK 4
