Basics of Nursing Practice (NCLEX-PN
Remediation).
• A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client
who has a history of alcoholism. What need must self-help groups such as AA meet
to be successful?
o Belonging
Rationale
Self-help groups are successful because they support a basic human need for acceptance.
A feeling of comfort and safety and a sense of belonging may be achieved in a
nonjudgmental, supportive, sharing experience with others. AA meets dependency needs
rather than focusing on independence, trust, and growth.
• The registered nurse is explaining basic rules for documentation to a
licensed practical nurse (LPN). Which statements made by the LPN indicate
effective learning? Select all that apply.
o "I will document the details when observed."
o "I will record in the chart using black ink pen."
Rationale
The LPN should document the details when they are observed, but the details should
not be written based on opinions. Black ink pen should be used to record in the chart.
The LPN should not include generalized empty phrases in the details. The LPN
should never leave empty lines in the chart because another person may enter
additional or incorrect information. The LPN should not wait until end of shift to
record important changes that occurred several hours earlier,but record the events
when they occur.
• The nurse resolves a conflict with another nurse by using accommodation. In what
situations is accommodation appropriate for resolving conflict? Select all that
apply.
o When facing trivial issues
o When the other person's solutions appear better
o When harmonious relationships have to be preserved
Rationale
Appropriate reasons for accommodating to resolve conflict include when the issues
are trivial or not important, when the other person's ideas or solutions are better, or
when harmonious relationships have to be preserved. Avoiding defensiveness is not
an appropriate reason to accommodate when resolving conflict. Gathering more
information is not an appropriate reason to accommodate when resolving conflicts,
unless that additional information has shown that the nurse has made a mistake.
,• What does the nurse plan to do before administering preoperative medication to
a client?
o Verifying consent
Rationale
Consent must be acquired when the client is fully oriented and in a clear mental state.
Although important, having the client void can be implemented before surgery even
if the client has received medication. Although important, checking the vital signs can
be implemented before surgery even if the client has received medication. Although
important, removing the client's dentures can be implemented before surgery even if
the client has received medication.
• A nursing student is recalling the order of priority for giving consent to perform an
autopsy in cases where a medical examiner review is not needed. Which person
receives the highest priority for giving consent?
o The client in writing before death
Rationale
If a medical examiner's review is not necessary, the highest priority is given to the
client. The client may provide the consent in writing before death. If the client or the
surviving spouse is unable to give consent for the autopsy, a surviving child may be
requested to give consent. The surviving parent may give consent for an autopsy if the
client, the surviving spouse, and the surviving child are unable to do so. In case the
client has not provided written consent before death, the nurse may obtain consent
from the surviving spouse.
• A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse
manager asks the registered nurse, "Are the equipment and resources available
for the LPN to complete the task?" Which right of delegation is the nurse manager
preserving?
o Right Circumstance
Rationale
Questions such as, "Is the environment conducive to completing the task safely?" and,
"Are the equipment and resources available to complete the task?" ensure the right
circumstance for delegation. Right task is ensured with a question such as, "Is the task
appropriate to the delegate, according to institutional policies and procedures?"
Delegation is taking the right direction if the answer to a question such as, "Do the
delegator and delegatee understand a common work-related language?" is positive.
Right supervision is evaluated with a question such as, "Is the delegator able to
monitor and evaluate the client appropriately?"
• Which organization acts as the guiding force in the development of practical
nurse education?
, o National Association for Practical Nurse Education and Service (NAPNES)
Rationale
Currently, the National Association for Practical Nurse Education and Service is
regarded as the guiding force in the development of practical nursing education.
Though not considered the guiding force in practical nursing education, the other
organizations make contributions to nursing education as well. The National League
for Nursing accredits nursing programs. The Young Women’s Christian Association
established the first school of practical nursing in Brooklyn, New York. The National
Federation of Licensed Practical Nurses is the official membership organization for
licensed practical nurses and licensed vocational nurses.
• Two nurses are planning to help a client with one-sided weakness to move up in
bed. What should the nurses do to conform to proper body mechanics?
o Position the nurses on either side of the bed with their feet apart, gather the pull
sheet close to the client, turn toward the head of the bed, and then move the client.
Rationale
Positioning the nurses on either side of the bed with their feet apart, gathering the pull
sheet close to the client, turning toward the head of the bed, and then moving the
client places both nurses in a stable position in functional alignment, thereby
minimizing stress on muscles, joints, ligaments, and tendons. The client should be
instructed to fold the arms across the chest; this keeps the client's weight toward the
center of the mass being moved and keeps the arms safe during the move up in bed.
The nurses should assist the client in flexing the knees and placing the feet flat on the
bed; this enables the client to push the body upward using a major muscle group. The
client's assistance to the best of his or her ability reduces physical stress on the nurses
as they move the client up in bed. On the count of three, weight should be shifted
from the back to the front leg, not the front to the back leg. This action generates
movement in the direction that the client is being moved.
• The nurse introduces himself or herself to the client while measuring the
client’s body temperature. What is the reason for this introduction?
o To decrease the client’s anxiety
Rationale
When the nurse introduces herself or himself to the client, this action decreases
anxiety in the client. Explaining the procedure to the client will help to gain the
client’s cooperation. Identifying a client by his or her identification band will help to
ensure the correct client is receiving the correct procedure. Assembling the
thermometer, providing soft disposable tissues, having a lubricant pen and note pad,
having disposable gloves, and having a plastic sleeve will promote an efficiently
completed procedure.
, • In what position should the nurse place a client recovering from general anesthesia?
o Side-lying
Rationale
Turning the client to the side promotes drainage of secretions and prevents aspiration,
especially when the gag reflex is not intact. This position also brings the tongue
forward, preventing it from occluding the airway when it is in the relaxed state. The
risk for aspiration is increased when the supine position is assumed by a semi-alert
client. High Fowler position may cause the neck to flex in a client who is not alert,
interfering with respirations. Trendelenburg position is not used for a postoperative
client, because it interferes with breathing.
• A client who has reached the stage of acceptance in the grieving process appears
peaceful, but demonstrates a lack of involvement with the environment. How
should the nurse address this behavior?
o Accept the behavior the client is exhibiting
Rationale
Detachment is a coping mechanism that the client needs, especially when faced with
the inevitability of death; the nurse should accept this behavior. Ignoring the behavior
does not convey a willingness to listen and denies the client's feelings. The client is in
acceptance. It is unnecessary to point out the reality of the situation. It is
counterproductive to encourage the client to become involved with the environment.
• A client is being admitted to a medical unit with a diagnosis of pulmonary
tuberculosis. Which type of room should the nurse assign the client?
o Negative airflow room
Rationale
Tuberculosis is an airborne contagious disease that is best contained in a negative
airflow room. Negative airflow rooms are always private. A private room,
semiprivate room, and a room with windows that can be opened are not appropriate
for the standard of care for a client diagnosed with tuberculosis. Additionally,
opening windows would present a possible safety hazard in a client's room.
• The client is about to leave the hospital, with home health nursing. Where
should the nurse document the physiologic status of the client?
o Discharge and transfer forms
Rationale
The nurse should document the physiologic status of the client in discharge and
transfer forms. The nurse documents the client’s laboratory and radiology results in
flow sheets. The nurse documents the functional status of the client in progress
notes.
Remediation).
• A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client
who has a history of alcoholism. What need must self-help groups such as AA meet
to be successful?
o Belonging
Rationale
Self-help groups are successful because they support a basic human need for acceptance.
A feeling of comfort and safety and a sense of belonging may be achieved in a
nonjudgmental, supportive, sharing experience with others. AA meets dependency needs
rather than focusing on independence, trust, and growth.
• The registered nurse is explaining basic rules for documentation to a
licensed practical nurse (LPN). Which statements made by the LPN indicate
effective learning? Select all that apply.
o "I will document the details when observed."
o "I will record in the chart using black ink pen."
Rationale
The LPN should document the details when they are observed, but the details should
not be written based on opinions. Black ink pen should be used to record in the chart.
The LPN should not include generalized empty phrases in the details. The LPN
should never leave empty lines in the chart because another person may enter
additional or incorrect information. The LPN should not wait until end of shift to
record important changes that occurred several hours earlier,but record the events
when they occur.
• The nurse resolves a conflict with another nurse by using accommodation. In what
situations is accommodation appropriate for resolving conflict? Select all that
apply.
o When facing trivial issues
o When the other person's solutions appear better
o When harmonious relationships have to be preserved
Rationale
Appropriate reasons for accommodating to resolve conflict include when the issues
are trivial or not important, when the other person's ideas or solutions are better, or
when harmonious relationships have to be preserved. Avoiding defensiveness is not
an appropriate reason to accommodate when resolving conflict. Gathering more
information is not an appropriate reason to accommodate when resolving conflicts,
unless that additional information has shown that the nurse has made a mistake.
,• What does the nurse plan to do before administering preoperative medication to
a client?
o Verifying consent
Rationale
Consent must be acquired when the client is fully oriented and in a clear mental state.
Although important, having the client void can be implemented before surgery even
if the client has received medication. Although important, checking the vital signs can
be implemented before surgery even if the client has received medication. Although
important, removing the client's dentures can be implemented before surgery even if
the client has received medication.
• A nursing student is recalling the order of priority for giving consent to perform an
autopsy in cases where a medical examiner review is not needed. Which person
receives the highest priority for giving consent?
o The client in writing before death
Rationale
If a medical examiner's review is not necessary, the highest priority is given to the
client. The client may provide the consent in writing before death. If the client or the
surviving spouse is unable to give consent for the autopsy, a surviving child may be
requested to give consent. The surviving parent may give consent for an autopsy if the
client, the surviving spouse, and the surviving child are unable to do so. In case the
client has not provided written consent before death, the nurse may obtain consent
from the surviving spouse.
• A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse
manager asks the registered nurse, "Are the equipment and resources available
for the LPN to complete the task?" Which right of delegation is the nurse manager
preserving?
o Right Circumstance
Rationale
Questions such as, "Is the environment conducive to completing the task safely?" and,
"Are the equipment and resources available to complete the task?" ensure the right
circumstance for delegation. Right task is ensured with a question such as, "Is the task
appropriate to the delegate, according to institutional policies and procedures?"
Delegation is taking the right direction if the answer to a question such as, "Do the
delegator and delegatee understand a common work-related language?" is positive.
Right supervision is evaluated with a question such as, "Is the delegator able to
monitor and evaluate the client appropriately?"
• Which organization acts as the guiding force in the development of practical
nurse education?
, o National Association for Practical Nurse Education and Service (NAPNES)
Rationale
Currently, the National Association for Practical Nurse Education and Service is
regarded as the guiding force in the development of practical nursing education.
Though not considered the guiding force in practical nursing education, the other
organizations make contributions to nursing education as well. The National League
for Nursing accredits nursing programs. The Young Women’s Christian Association
established the first school of practical nursing in Brooklyn, New York. The National
Federation of Licensed Practical Nurses is the official membership organization for
licensed practical nurses and licensed vocational nurses.
• Two nurses are planning to help a client with one-sided weakness to move up in
bed. What should the nurses do to conform to proper body mechanics?
o Position the nurses on either side of the bed with their feet apart, gather the pull
sheet close to the client, turn toward the head of the bed, and then move the client.
Rationale
Positioning the nurses on either side of the bed with their feet apart, gathering the pull
sheet close to the client, turning toward the head of the bed, and then moving the
client places both nurses in a stable position in functional alignment, thereby
minimizing stress on muscles, joints, ligaments, and tendons. The client should be
instructed to fold the arms across the chest; this keeps the client's weight toward the
center of the mass being moved and keeps the arms safe during the move up in bed.
The nurses should assist the client in flexing the knees and placing the feet flat on the
bed; this enables the client to push the body upward using a major muscle group. The
client's assistance to the best of his or her ability reduces physical stress on the nurses
as they move the client up in bed. On the count of three, weight should be shifted
from the back to the front leg, not the front to the back leg. This action generates
movement in the direction that the client is being moved.
• The nurse introduces himself or herself to the client while measuring the
client’s body temperature. What is the reason for this introduction?
o To decrease the client’s anxiety
Rationale
When the nurse introduces herself or himself to the client, this action decreases
anxiety in the client. Explaining the procedure to the client will help to gain the
client’s cooperation. Identifying a client by his or her identification band will help to
ensure the correct client is receiving the correct procedure. Assembling the
thermometer, providing soft disposable tissues, having a lubricant pen and note pad,
having disposable gloves, and having a plastic sleeve will promote an efficiently
completed procedure.
, • In what position should the nurse place a client recovering from general anesthesia?
o Side-lying
Rationale
Turning the client to the side promotes drainage of secretions and prevents aspiration,
especially when the gag reflex is not intact. This position also brings the tongue
forward, preventing it from occluding the airway when it is in the relaxed state. The
risk for aspiration is increased when the supine position is assumed by a semi-alert
client. High Fowler position may cause the neck to flex in a client who is not alert,
interfering with respirations. Trendelenburg position is not used for a postoperative
client, because it interferes with breathing.
• A client who has reached the stage of acceptance in the grieving process appears
peaceful, but demonstrates a lack of involvement with the environment. How
should the nurse address this behavior?
o Accept the behavior the client is exhibiting
Rationale
Detachment is a coping mechanism that the client needs, especially when faced with
the inevitability of death; the nurse should accept this behavior. Ignoring the behavior
does not convey a willingness to listen and denies the client's feelings. The client is in
acceptance. It is unnecessary to point out the reality of the situation. It is
counterproductive to encourage the client to become involved with the environment.
• A client is being admitted to a medical unit with a diagnosis of pulmonary
tuberculosis. Which type of room should the nurse assign the client?
o Negative airflow room
Rationale
Tuberculosis is an airborne contagious disease that is best contained in a negative
airflow room. Negative airflow rooms are always private. A private room,
semiprivate room, and a room with windows that can be opened are not appropriate
for the standard of care for a client diagnosed with tuberculosis. Additionally,
opening windows would present a possible safety hazard in a client's room.
• The client is about to leave the hospital, with home health nursing. Where
should the nurse document the physiologic status of the client?
o Discharge and transfer forms
Rationale
The nurse should document the physiologic status of the client in discharge and
transfer forms. The nurse documents the client’s laboratory and radiology results in
flow sheets. The nurse documents the functional status of the client in progress
notes.
