which situation is an example of the use of evidence based practice in the delivery of client care
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Nursing Elites

NCLEX-PN

NCLEX PN Test Bank

1. Which situation is an example of the use of evidence-based practice in the delivery of client care?

Correct answer: C

Rationale: Evidence-based practice is an approach that integrates client preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring sterile solution into a plastic-lined waste receptacle before using it for wound cleansing reflects evidence-based practice by preventing the entrance of harmful bacteria into the wound. Option A is incorrect because encouraging a stroke client to consume thickened liquids and soft foods is appropriate, not thin liquids and foods that pose a choking risk. Option B is incorrect as picking up a radiation implant with long-handled forceps to minimize radiation exposure is a safety measure, not evidence-based practice. Option D is incorrect because blowing on a fingerstick site after cleaning can recontaminate the site, which goes against best practices in infection control.

2. What is the appropriate intervention for a client who is restrained?

Correct answer: C

Rationale: The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.

3. Priorities designated as intermediate by the nurse are:

Correct answer: A

Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client's immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.

4. In a centralized decision-making process within an organization, where is the authority to make decisions vested?

Correct answer: B

Rationale: In a centralized decision-making process within an organization, the authority to make decisions is concentrated in a few individuals, such as the board of directors. This means that key decision-making power is held by a select group at the top of the organizational hierarchy. Choices A, C, and D are incorrect because in a centralized structure, decision-making authority is not distributed among every employee, does not filter down to individual employees, and is not shared among all nursing employees, pharmacists, or hospital health care providers. Centralized decision-making implies a more top-down approach.

5. Which of the following statements describes the purpose of client restraint?

Correct answer: B

Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.

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