NCLEX PRACTICE EXAM (FUNDAMENTALS)
Questions and Answers
1.A nurse is caring for a patient with chronic heart failure who is very ill.
The patient has a "no code" order. The patient goes into ventricular
fibrillation and the nurse defibrillates the patient. The nurse states she was
unaware of the "no code" order. What part of the nursing process did the
nurse fail to perform?
A. Planning
B. Evaluation
C. Assessment
B. Implementation
ANS C. Assessment
2.On the morning laboratory report, the patient's potassium is noted to be
2.5 mEq/L. The nurse does not want to "bother the physician this early."
During the change-of-shift report, the patient develops ventricular
tachycardia and has to be resuscitated. What part of the nursing process
did the nurse fail to perform?
A. Evaluation
B. Implementation
,C. Assessment
D. Planning
ANS B. Implementation
3.A patient in the critical care unit has an order to be transported off the unit
for a diagnostic procedure. The nurse fails to ensure that the patient is prop-
erly monitored during transport, and the patient experiences a cardiac
arrest. Which of the following actions did the nurse fail to adequately
perform?
A. Make the proper nursing diagnosis.
B. Assess and analyze the level of care needed by the patient.
C. Act as a patient advocate to postpone the examination.
D. Communicate findings in a timely manner.
ANS B. Assess and analyze the level of care needed by the patient.
4.The nurse fails to record a set of vital signs on a blood transfusion report,
which is against hospital policy. The patient does not sustain any damage
as a result. Can the nurse be charged with malpractice in this case?
A. No. Documentation is not part of the duty of nurse.
B.Yes. Even though there were no damages, the nurse failed to follow hospita
protocol.
C. No. There were no damages associated with failure to document
,D.Yes. Failure to document always results in negligence.
ANS C. No. There were no damages associated with failure to document
5.A patient with metastatic cancer tells the nurse, "I am tired and do not
want to be put on a breathing machine." The patient's out-of-town son wants
"everything done for my mother" when his mother later develops respiratory
distress. Which ethical principles are involved in this dilemma? (Select all
that apply.)
A. Beneficence
B. Nonmaleficence
C. Autonomy
D. Justice
E. Paternalism
ANS A. Beneficence
B. Nonmaleficence
C. Autonomy
6.The nurse is concerned that the physician is ignoring the wishes of the
pa- tient and family in the care of a patient. The nurse should take these
concerns to (Select all that apply.)
A. The hospital ethics committee
B. The ANA (American Nurses Association)
C. The nursing supervisor
, D. The nursing ethics committee
E. he policy and procedure committee
ANS A. The hospital ethics committee
C. The nursing supervisor
D. The nursing ethics committee
7.The nurse observes a coworker diverting narcotics by administering
normal saline to a patient in pain. By not reporting this observation, the
nurse is in violation of what ethical principle concerning the patients under
the care of the impaired nurse?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Veracity
ANS C. Nonmaleficence
8.The family of a patient who is receiving mechanical ventilation for respira-
tory distress associated with an inoperable brain tumor asks that the patient
be extubated to "allow natural death" to occur. This is an example of what
situation?
A. Withdrawing treatment
B. Rationing care
Questions and Answers
1.A nurse is caring for a patient with chronic heart failure who is very ill.
The patient has a "no code" order. The patient goes into ventricular
fibrillation and the nurse defibrillates the patient. The nurse states she was
unaware of the "no code" order. What part of the nursing process did the
nurse fail to perform?
A. Planning
B. Evaluation
C. Assessment
B. Implementation
ANS C. Assessment
2.On the morning laboratory report, the patient's potassium is noted to be
2.5 mEq/L. The nurse does not want to "bother the physician this early."
During the change-of-shift report, the patient develops ventricular
tachycardia and has to be resuscitated. What part of the nursing process
did the nurse fail to perform?
A. Evaluation
B. Implementation
,C. Assessment
D. Planning
ANS B. Implementation
3.A patient in the critical care unit has an order to be transported off the unit
for a diagnostic procedure. The nurse fails to ensure that the patient is prop-
erly monitored during transport, and the patient experiences a cardiac
arrest. Which of the following actions did the nurse fail to adequately
perform?
A. Make the proper nursing diagnosis.
B. Assess and analyze the level of care needed by the patient.
C. Act as a patient advocate to postpone the examination.
D. Communicate findings in a timely manner.
ANS B. Assess and analyze the level of care needed by the patient.
4.The nurse fails to record a set of vital signs on a blood transfusion report,
which is against hospital policy. The patient does not sustain any damage
as a result. Can the nurse be charged with malpractice in this case?
A. No. Documentation is not part of the duty of nurse.
B.Yes. Even though there were no damages, the nurse failed to follow hospita
protocol.
C. No. There were no damages associated with failure to document
,D.Yes. Failure to document always results in negligence.
ANS C. No. There were no damages associated with failure to document
5.A patient with metastatic cancer tells the nurse, "I am tired and do not
want to be put on a breathing machine." The patient's out-of-town son wants
"everything done for my mother" when his mother later develops respiratory
distress. Which ethical principles are involved in this dilemma? (Select all
that apply.)
A. Beneficence
B. Nonmaleficence
C. Autonomy
D. Justice
E. Paternalism
ANS A. Beneficence
B. Nonmaleficence
C. Autonomy
6.The nurse is concerned that the physician is ignoring the wishes of the
pa- tient and family in the care of a patient. The nurse should take these
concerns to (Select all that apply.)
A. The hospital ethics committee
B. The ANA (American Nurses Association)
C. The nursing supervisor
, D. The nursing ethics committee
E. he policy and procedure committee
ANS A. The hospital ethics committee
C. The nursing supervisor
D. The nursing ethics committee
7.The nurse observes a coworker diverting narcotics by administering
normal saline to a patient in pain. By not reporting this observation, the
nurse is in violation of what ethical principle concerning the patients under
the care of the impaired nurse?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Veracity
ANS C. Nonmaleficence
8.The family of a patient who is receiving mechanical ventilation for respira-
tory distress associated with an inoperable brain tumor asks that the patient
be extubated to "allow natural death" to occur. This is an example of what
situation?
A. Withdrawing treatment
B. Rationing care
