NCLEX REVIEW AND MANAGEMENT OF
CARE QUESTIONS AND ANSWERS
LATEST VERSION WITH RATIONALE
TESTED AND APPROVED!!!
1. Delegation (LPN - Licensed Practical Nurse) Question: The charge nurse is making
assignment for the health care team. Which of these tasks can be safely delegated to the
licensed practical nurse (LPN)?
1.Teach the initial ostomy care to a client and family members
2.Provide stoma care for a client with a wellfunctioning ostomy
3.Assess the function of a newly created ileostomy
4.Care for a recent complicated double barrel colostomy
Answer: 2
Rationale: LPNs typically function in a stable, predictable environment with established
patients. Providing care for a mature, well-functioning ostomy falls within their scope of
practice . The RN cannot delegate the initial assessment, initial teaching, or care of an
unstable/complicated patient to an LPN.
The RN must perform these higher-level tasks .
2. Quality Improvement
Question: The nurse manager is discussing the goals of total quality management (TQM)
with the health care team. Which statement correctly identifies a key element of TQM?
1.It is a reactionary approach used to investigate the root cause of a problem after it occurs.
2.Top administrators are solely responsible for establishing plans for problem management.
,3.All employees participate in systematically working toward common goals to improve
processes.
4.It is an incident management technique that focuses on employee discipline and retention.
Answer: 3
Rationale: TQM is a proactive, systematic, and continuous approach to improvement that
involves all employees at every level of the organization . The focus is on improving
customer satisfaction. TQM involves all employees, not just top administrators. It is a
proactive, not reactive, approach to solving problems .
3. Staff Management (Impaired Colleague) Question: While giving report to the oncoming
night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge
nurse should:
1.Ignore it, assuming it is mouthwash or a breath mint.
2.Confront the nurse in the hallway in front of the night shift staff.
3.Report this to the nursing supervisor immediately.
4.Send the nurse home for the rest of the shift.
Answer: 3
Rationale: The charge nurse has a legal and ethical duty to protect clients from an unsafe
practitioner. This situation must be reported immediately to the nursing supervisor or
manager, who will follow the proper chain of command and facility policy for investigation
and intervention. The charge nurse does not have the authority to send the nurse home
independently without following protocol.
4. Emergency Consent for Minors
Question: A 13-year-old, found unresponsive in the park, is brought into the emergency
department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity
smell to the breath. There are no family members available to obtain consent for treatment
and an attempt to call them has been unsuccessful. What action should the nurse take?
,1.Obtain consent from the social worker on duty in the emergency department.
2.Begin treatment by inserting two large bore IVs of Normal Saline.
3.Give glucagon IM and wait for the arrival of a parent to consent to further treatment.
4.Withhold treatment until a parent arrives to the emergency department.
Answer: 2
Rationale: In emergencies, if it is impossible to obtain consent from the client or an
authorized person, a health care provider may perform a procedure required to benefit the
client or save a life without liability for failure to obtain consent . In such cases the law
assumes that the client would wish to be treated. The nurse should begin treatment for
diabetic ketoacidosis (DKA). Consent for a minor is not needed in the event of an emergency
.
5. Ethical Practice (Witnessing a Living Will)
Question: A nurse is caring for a client with multiple sclerosis. The client informs the nurse
that a lawyer is coming to prepare a living will and requests the nurse to sign as witness.
Which of the following actions should the nurse take?
1.Agree to sign as a witness to support the client's wishes.
2.Note that the nurse caring for the client cannot be a witness.
3.Refuse and tell the client to ask the lawyer to find a witness.
4.Call the nursing supervisor to come and witness the document.
Answer: 2
Rationale: Employees of the healthcare facility, including the direct care nurse, generally
cannot act as witnesses for a living will due to potential conflicts of interest or facility policy.
The nurse should politely explain this restriction to the client. Some sources note that a
clinical social worker may be a legal witness .
6. Informed Consent & Client Rights
, Question: A client is being prepped for a surgical procedure and the nurse is reviewing the
informed consent with the client. The client asks, "Is there any other way to take care of this
without having surgery?" The nurse has a duty to first:
1.Reassure the client that the surgery is the best treatment option
2.Tell the client if they don't want the surgery, they don't have to have it
3.Notify the surgeon that the client has additional questions about alternatives to surgery
4.Call the surgeon and cancel the surgery until the consent form is signed
Answer: 3
Rationale: The client has a right to a full explanation of the treatment, including risks,
benefits, and alternatives, before signing a consent form . The client is asking for information
the nurse cannot provide (medical alternatives). The nurse acts as a client advocate by
pausing the process and notifying the provider so the client's questions can be answered. The
nurse should never give their own opinion or independently cancel a procedure .
7. Legal Protection & Documentation
Question: A nurse is named in a lawsuit. Which of these factors will offer the best protection
for that nurse in a court of law?
1.Clinical specialty certification by an accredited organization
2.Complete and accurate documentation of assessments and interventions
3.Above-average performance reviews prepared by nurse manager
4.Sworn statement that health care provider orders were followed
Answer: 2
Rationale: The medical record is a legal document. Documentation should include all steps of
the nursing process; it must be complete, accurate, concise and in chronological order . "If it
wasn't documented, it wasn't done." Inaccurate or incomplete documentation will raise red
flags and may indicate the nurse failed to meet the standards of care .
CARE QUESTIONS AND ANSWERS
LATEST VERSION WITH RATIONALE
TESTED AND APPROVED!!!
1. Delegation (LPN - Licensed Practical Nurse) Question: The charge nurse is making
assignment for the health care team. Which of these tasks can be safely delegated to the
licensed practical nurse (LPN)?
1.Teach the initial ostomy care to a client and family members
2.Provide stoma care for a client with a wellfunctioning ostomy
3.Assess the function of a newly created ileostomy
4.Care for a recent complicated double barrel colostomy
Answer: 2
Rationale: LPNs typically function in a stable, predictable environment with established
patients. Providing care for a mature, well-functioning ostomy falls within their scope of
practice . The RN cannot delegate the initial assessment, initial teaching, or care of an
unstable/complicated patient to an LPN.
The RN must perform these higher-level tasks .
2. Quality Improvement
Question: The nurse manager is discussing the goals of total quality management (TQM)
with the health care team. Which statement correctly identifies a key element of TQM?
1.It is a reactionary approach used to investigate the root cause of a problem after it occurs.
2.Top administrators are solely responsible for establishing plans for problem management.
,3.All employees participate in systematically working toward common goals to improve
processes.
4.It is an incident management technique that focuses on employee discipline and retention.
Answer: 3
Rationale: TQM is a proactive, systematic, and continuous approach to improvement that
involves all employees at every level of the organization . The focus is on improving
customer satisfaction. TQM involves all employees, not just top administrators. It is a
proactive, not reactive, approach to solving problems .
3. Staff Management (Impaired Colleague) Question: While giving report to the oncoming
night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge
nurse should:
1.Ignore it, assuming it is mouthwash or a breath mint.
2.Confront the nurse in the hallway in front of the night shift staff.
3.Report this to the nursing supervisor immediately.
4.Send the nurse home for the rest of the shift.
Answer: 3
Rationale: The charge nurse has a legal and ethical duty to protect clients from an unsafe
practitioner. This situation must be reported immediately to the nursing supervisor or
manager, who will follow the proper chain of command and facility policy for investigation
and intervention. The charge nurse does not have the authority to send the nurse home
independently without following protocol.
4. Emergency Consent for Minors
Question: A 13-year-old, found unresponsive in the park, is brought into the emergency
department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity
smell to the breath. There are no family members available to obtain consent for treatment
and an attempt to call them has been unsuccessful. What action should the nurse take?
,1.Obtain consent from the social worker on duty in the emergency department.
2.Begin treatment by inserting two large bore IVs of Normal Saline.
3.Give glucagon IM and wait for the arrival of a parent to consent to further treatment.
4.Withhold treatment until a parent arrives to the emergency department.
Answer: 2
Rationale: In emergencies, if it is impossible to obtain consent from the client or an
authorized person, a health care provider may perform a procedure required to benefit the
client or save a life without liability for failure to obtain consent . In such cases the law
assumes that the client would wish to be treated. The nurse should begin treatment for
diabetic ketoacidosis (DKA). Consent for a minor is not needed in the event of an emergency
.
5. Ethical Practice (Witnessing a Living Will)
Question: A nurse is caring for a client with multiple sclerosis. The client informs the nurse
that a lawyer is coming to prepare a living will and requests the nurse to sign as witness.
Which of the following actions should the nurse take?
1.Agree to sign as a witness to support the client's wishes.
2.Note that the nurse caring for the client cannot be a witness.
3.Refuse and tell the client to ask the lawyer to find a witness.
4.Call the nursing supervisor to come and witness the document.
Answer: 2
Rationale: Employees of the healthcare facility, including the direct care nurse, generally
cannot act as witnesses for a living will due to potential conflicts of interest or facility policy.
The nurse should politely explain this restriction to the client. Some sources note that a
clinical social worker may be a legal witness .
6. Informed Consent & Client Rights
, Question: A client is being prepped for a surgical procedure and the nurse is reviewing the
informed consent with the client. The client asks, "Is there any other way to take care of this
without having surgery?" The nurse has a duty to first:
1.Reassure the client that the surgery is the best treatment option
2.Tell the client if they don't want the surgery, they don't have to have it
3.Notify the surgeon that the client has additional questions about alternatives to surgery
4.Call the surgeon and cancel the surgery until the consent form is signed
Answer: 3
Rationale: The client has a right to a full explanation of the treatment, including risks,
benefits, and alternatives, before signing a consent form . The client is asking for information
the nurse cannot provide (medical alternatives). The nurse acts as a client advocate by
pausing the process and notifying the provider so the client's questions can be answered. The
nurse should never give their own opinion or independently cancel a procedure .
7. Legal Protection & Documentation
Question: A nurse is named in a lawsuit. Which of these factors will offer the best protection
for that nurse in a court of law?
1.Clinical specialty certification by an accredited organization
2.Complete and accurate documentation of assessments and interventions
3.Above-average performance reviews prepared by nurse manager
4.Sworn statement that health care provider orders were followed
Answer: 2
Rationale: The medical record is a legal document. Documentation should include all steps of
the nursing process; it must be complete, accurate, concise and in chronological order . "If it
wasn't documented, it wasn't done." Inaccurate or incomplete documentation will raise red
flags and may indicate the nurse failed to meet the standards of care .
