Nclex Questions 100% Solved
The team leader/charge nurse notices at the beginning of the shift that all of the IV ABX for a client are
still in the medication room. Which action should the team leader take first?
1. ask client if client received the meds on previous shift
2. return meds to pharmacy so client does not get billed
3. ask nurse who cared for the client about the medications
4. notify the nurse-manager of the unit - Answer 3.
team leader should attempt to clarify with the involved staff first
Staff from two different dept. are disagreeing over the transfer process b/w there respective dept.
Which is the best process to handle this disagreement?
1. ask director of nursing to establish a policy
2. allow the staff to handle the issue on their own without authoritative interference
3. Arrange managers from the dept. to determine a solution
4. set up a meeting of staff from the departments to identify key issues - Answer 4.
A staff nurse at the nurse's station answers the phone and is told there is a bomb in a client's room.
What action should the nurse take?
1. put call on hold and obtain charge nurse
2. transfer call to security
3. ask caller for details about the bomb placement
4. signal to staff to close the clients door - Answer 3. with potential danger, it is important to determine
as much information as possible
A new graduate nurse is completing the scheduled 4-week orientation to a med-surg unit. Which self-
recognized need should prompt the new graduate nurse to request some additional time or training
before ending orientation?
1. uncomfortable if had to manage a cardiac arrest independently
2. unclear on staffing assignments are made on the unit
,3. frequently unable to establish new IV access on the first attempt
4. unable to manage more than two clients at a time - Answer 4.
Which action can the nurse be legally liable for?
1. administering 2 mg hydromorphone (Dilaudid) when the client is prescribed 1 to 2 mg q 4hrs
2. withholding digoxin (Lanoxin) when the client's apical pulse is 56 bpm
3. withholding mononitrate (Imdur) when client's BP is 80/40
4. Administering cephalosporin when the client has an allergy to penicillin - Answer 4.
(4)There is a cross-sensitivity b/w cephalosporin and penicillin, and the drug should not be given.
(1)When a range is ordered, any dose in the range is acceptable.
(2)Bradycardia is a sign of digoxin toxicity, and the drug should not ordinarily be given if the pulse is less
than 60.
(3)Nitrates cause vasodilation and should not be given when hypotension is present.
The nursing team consists of one RN, one LPN, and one UAP. What is the most appropriate assignment
for the RN to delegate to the LPN?
1. pass the dinner trays
2. empty the Foley cath
3. administer morning PO daily meds
4.suction client who is one day postop after tracheostomy - Answer 3.
The nurse-manager meets with a staff nurse to evaluate performance after a 6-month probationary
period. As part of the evaluation process, the nurse-manager would ask the staff nurse to:
1. accept the nurse-manager's evaluation by signing in agreement
2. contribute a self-evaluation and suggested areas for future growth
3. have peers vouch for his or her performance
4. giver her perception of how the manager is performing - Answer 2.
The nurse-manager implements new processes to decreased the incidence of central IV line infection.
What is the best indicator that the measures have resulted in improved outcomes?
, 1. a survey of the unit's nurses indicates perceived improvement in results
2. a total decrease in the number of central line IV line infections on the unit has been identified
3. retrospective chart audits for infection rate show improvement in clients with central line IV lines
4. comparison of total number of IV ABX used b/w the two time periods has shown a decreased in ABX
use - Answer 3.
The nurse-manager notes an unacceptable rate of falls on the unit. Hourly rounds by nursing staff are
initiated. What is the best method to determine that the change has made a difference?
1. Scores on client satisfaction surveys
2. surveys on staff's perception of the effectiveness
3. comparing fall rates after the rounds are initiated
4. documentation that the rounds are completed as scheduled - Answer 3.
A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client
decides to find a different surgeon to continue treatment. The nurse supports the client's action,
utilizing which ethical principle?
1. beneficence
2. veracity
3. autonomy
4. privacy - Answer 3.
*Autonomy* is the right of individuals to take action for themselves. *Beneficence* is an ethical
principle to do good and applies when the nurse has a duty to help others by doing what is best for
them. *Veracity* refers to truthfullness. *Privacy* is the nondisclosure of information by the health care
team.
A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary
edema. The charge nurse would consider the medication error to constitute negligence b/c the situation
contains which element?
1. purposeful failure to perform a healthcare procedure
2. unintentional failure to perform a healthcare procedure
3. Act of substituting a different med for the one ordered
4. failure to follow a direct order by a physician - Answer 2.