Management of Care

1. The nurse is working at a skilled nursing facility. The nurse enters the client’s room and sees the client attempting to pull himself up from a sitting position on the floor. The nurse inquires with the client as to what happened. The client responds “I fell.” Which of the following should the nurse document in the incident report?
- 1. The nurse should file an incident report stating “Client fell, no injury noted.”
- 2. The nurse should file an incident report stating “Client fell on floor.”
- 3. The nurse should document the event only in the client’s medical record and not in an incident report.
- 4. The nurse should file an incident report stating “Client found on floor. Client stated ‘I fell.’ Assessment completed, no injury noted, physician notified.”
2. The nurse is administering medications to a client on an inpatient psychiatric unit. The client states “I don’t usually take a pink pill” when the nurse gives a cup holding 4 different pills to the client. Which of the following is the MOST appropriate response by the nurse?
- 1. The nurse checks the medication administration record, determines it is correct, and tells the client to take the medication.
- 2. The nurse discounts the client’s concern because he is a psychiatric client and doesn’t know any better.
- 3. The nurse asks the client for a list of medications he routinely takes, and tells the client that she will review and confirm the order with the physician.
- 4. The nurse tells the client that sometimes drugs come in different colors depending on what pharmacy they come from.
3. The nurse is working on a unit that is equipped with electronic medication administration processes. This includes a computer at the bedside that allows for scanning a bar code on the medication order, the medication label, and the client’s identification band. Which of the following is the BEST method for the nurse to practice regularly?
- 1. The nurse should rely solely on the barcoding scanner because it promotes safer medication administration practices.
- 2. The nurse should rely on a combination of nursing judgment and decisionmaking along with the computerized system.
- 3. The nurse should never give a medication that a bar-coding system scans as “incorrect medication.”
- 4. The nurse should override any medication that the machine scans as “incorrect medication” and administer it
4. The nurse is working on a state-of-the-art nursing unit with completely electronic medical records. The rooms are semiprivate, with two clients to a room, and equipped with a computer for each client. Which of the following actions by the nurse is the MOST appropriate?
- 1. After each use of the computer and upon leaving the client room, log off from the computer.
- 2. After each use of the computer and upon leaving the client room, face the computer away from where visitors would be able to see the screen.
- 3. The nurse should not be concerned about the security of the information because there is a single computer for each client and therefore no risk of the information being seen.
- 4. The nurse should pull the curtain to cover the computer screen so that visitors cannot view it.

NCLEX-RN QBank System: Management of Care

NCLEX Practice Questions Part 1