Nursing Management Styles (NCLEX 66-70)

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66. A physician wrote an order for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. When checking the client, which observation would indicate that the nursing assistant performed unsafe care?

a) a safety (hitch) knot was used to secure the restraints
b) restraints were released every 2 hours
c) restraints were applied snugly and tightly
d) the call light was placed within reach of the client's hand

67. A registered nurse assigns a new nursing graduate to care for a client with a diagnosis of active tuberculosis, and the registered nurse explains the use of a particulate respirator to the graduate. Which observation indicates that the new nursing graduate understands how the particulate respirator operates?

a) the nosepiece is readjusted if air is detected escaping around the nose
b) another particulate respirator is obtained if air is escaping around the nose
c) the new nursing graduate states that a fit check is not needed
d) the new nursing graduate states that a fit check is necessary only when putting on the respirator for the first time

68. A registered nurse has instructed a new nursing graduate about the procedure for weaning a client from a ventilator by using a T-piece. The registered nurse determines that the new nursing graduate nurse states which of the following to be part of the procedure?

a) removing the client from the mechanical ventilator for a short period
b) connecting the T-piece to the client's artificial airway
c) providing supplemental oxygen through the T-piece at an Flo2 that is 10% higher than the ventilator setting
d) gradually decreasing the respiratory rate on the ventilator until the client takes over all of the work of breathing

69. A registered nurse is mentoring a new nurse hired to work in the nursing unit. The registered nurse determines that the new nurse is competent to provide safe effective care for a client on a ventilator when the registered nurse notes that the new nurse:

a) has the ventilator routinely assessed by the respiratory therapist
b) realizes that the ventilator readings provide information without human error
c) teaches family members how to reset controls during their visits if necessary
d) establishes a rest pattern before morning care

70. A nursing student develops a plan of care for a client who will be returning from the operating room after a mastoidectomy. The registered nurse reviews the plan of care and instructs the student to revise the plan if which intervention is listed?

a) assess client for pain, dizziness, or nausea
b) keep the head of the bed elevated to 30 degrees
c) instruct the client to lie on the affected side
d) assess for signs of injury to cranial nerve VII





Nursing Management Styles
Answers and Rationale

66) C
- Restraints should never be applied tightly because they could impair the circulation. A safety (hitch) knot may be used on the restraint because it can easily be released in an emergency. Restraints must be released at least every 2 hours (or per agency policy) to inspect the skin for abnormalities and to provide range-of-motion exercises. The call light must always be at the client's reach in case the client needs assistance.

67) A
- Personal protective equipment, called particulate respirators, is required for all health care workers entering a tuberculosis isolation room. When fitted and used properly, these respirators filter droplet nuclei. It is important that no air escapes around the nose while wearing the respirator. The strap needs to be adjusted if air is escaping. It is important to exhale forcefully while placing both hands over the apparatus. It is necessary to perform a fit check each time the nurse uses the mask.

68) D
- The T-piece or Briggs device requires that the client is removed from the mechanical ventilation for a short time, usually beginning with a 5-minute period. The ventilator is disconnected and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FIo2 that is 10% higher than the ventilator setting. Option 4 describes the process of weaning via synchronized intermittent mandatory ventilation.

69) A
- Ventilators need to be assessed routinely by the respiratory therapist. Ventilators are machines, and machines can fail. Therefore, option B is not a reasonable option. Family members should not reset ventilator controls. Although option D is considered good nursing practice for the comfort of the client, it is not the priority option.

70) C
- Following mastoidectomy, the nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse should assess for signs of facial nerve injury to cranial nerve VII and assess the client for pain, dizziness, or nausea. The head of the bed should be elevated at least 30 degrees, and the client is instructed to lie on the unaffected side. The client would probably have sutures and an outer ear packing and a bulky dressing, which is removed on approximately the sixth postoperative day.



After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Nursing Management Styles (1-5)


Or proceed to the next set of questions:

Nursing Management Styles (71-75)