Next Generation NCLEX-RN Comprehensive
Post-Test | National Council of State Boards of
Nursing
1. Management of Care
1. A nurse is caring for a client who is scheduled for surgery. The client states, "I
do not want to have this surgery." Which of the following actions should the
nurse take first?
A. Notify the surgeon that the client has refused the procedure.
B. Ask the client why they do not want to have the surgery.
C. Document the client's statement in the medical record.
D. Explain the risks of not having the surgery.
Correct Answer: B. Ask the client why they do not want to have the surgery.
Rationale: The first step in the nursing process is assessment. The nurse must
first assess the client's reason for refusal to understand their concerns and
provide appropriate education or support. Notifying the surgeon (A) or
documenting (C) can occur after the assessment. Explaining risks (D) is part of
education but should be tailored to the client's specific concerns, which are
unknown until an assessment is done.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to delegate?
A. Administering oral pain medication to a stable client.
B. Assessing a client's surgical incision.
C. Ambulating a client who is 1-day post-operative.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: C. Ambulating a client who is 1-day post-operative.
Rationale: Ambulating a stable client is a standard task that can be delegated
to an AP. Administering medication (A), performing assessments (B), and
providing client teaching (D) are all tasks that require the professional judgment
and scope of practice of a registered nurse and cannot be delegated.
,3. A nurse is acting as a client advocate. Which of the following actions best
demonstrates this role?
A. Ensuring the client's bill is accurate.
B. Educating the client about their rights.
C. Providing direct physical care to the client.
D. Coordinating the client's discharge plan.
Correct Answer: B. Educating the client about their rights.
Rationale: Client advocacy involves protecting the client's rights and ensuring
they have the information needed to make informed decisions. Educating a client
about their rights is a core component of this role. While accurate billing (A),
direct care (C), and discharge planning (D) are important nursing responsibilities,
they do not primarily define the advocate role.
4. A nurse is preparing to administer a blood transfusion. Which of the following
actions is the priority?
A. Verify the client has a patent IV line.
B. Obtain the client's vital signs.
C. Ensure informed consent is on the chart.
D. Confirm the client's identity with two identifiers.
Correct Answer: D. Confirm the client's identity with two identifiers.
Rationale: The greatest risk associated with blood transfusion is a hemolytic
reaction due to ABO incompatibility, which can be fatal. The most critical step to
prevent this is verifying the client's identity and the blood product with two
identifiers at the bedside. While a patent IV (A), vital signs (B), and informed
consent (C) are necessary, they are not the priority safety check to prevent a
catastrophic reaction.
5. A nurse manager is reviewing an incident report. Which of the following
situations requires a sentinel event report to The Joint Commission?
A. A client falls but sustains no injury.
B. A client receives the wrong dose of a vitamin.
C. A client commits suicide while hospitalized.
D. A nurse sustains a needlestick injury.
, Correct Answer: C. A client commits suicide while hospitalized.
Rationale: A sentinel event is an unexpected occurrence involving death or
serious physical or psychological injury, or the risk thereof. Suicide of a client
while hospitalized is a clear example of a sentinel event. A fall without injury (A), a
wrong dose of a non-harmful medication (B), and a needlestick injury to staff (D)
are reportable incidents but do not meet the criteria for a sentinel event.
6. A nurse is caring for a client who speaks a different language. Which of the
following actions should the nurse take to ensure effective communication?
A. Use a family member to interpret.
B. Speak loudly and use simple words.
C. Use a facility-approved medical interpreter.
D. Provide written materials in English.
Correct Answer: C. Use a facility-approved medical interpreter.
Rationale: Using a professional medical interpreter is essential to ensure
accurate and confidential communication. Family members (A) may not be
competent to interpret medical terminology and can introduce bias or errors.
Speaking loudly (B) and providing English materials (D) are not effective if the
client does not understand the language.
7. A nurse is preparing to discharge a client who will need home oxygen
therapy. Which of the following referrals should the nurse make first?
A. A social worker to assess financial needs.
B. A home health nurse to provide skilled care.
C. A respiratory therapist to set up equipment.
D. A physical therapist to assess mobility.
Correct Answer: B. A home health nurse to provide skilled care.
Rationale: The home health nurse will perform a comprehensive assessment,
coordinate care, and provide ongoing education and monitoring, which is the
priority for a client with a new and complex medical need like home oxygen. The
nurse can then help coordinate other referrals as needed. While financial needs
(A), equipment setup (C), and mobility (D) are important, the overarching need is
for skilled nursing oversight.
, 8. A nurse is reviewing a client's medical record and notes a "Do Not
Resuscitate" (DNR) order. Which of the following actions should the nurse take?
A. Verify the order with the provider and the client/family.
B. Inform the client's family that the nurse will not provide CPR.
C. Assume the order is valid and proceed with care.
D. Place the DNR order in a prominent location in the chart.
Correct Answer: A. Verify the order with the provider and the client/family.
Rationale: The nurse must ensure the DNR order is valid and reflects the
client's wishes. This involves verifying the order is signed by the provider and that
the client or their legal surrogate decision-maker understands and agrees with it.
Simply informing the family (B) or assuming validity (C) is insufficient. Placing it in
the chart (D) is correct but not the most comprehensive first action.
9. A nurse is caring for a client who is on a ventilator. The nurse notes the low-
pressure alarm is sounding. Which of the following actions should the nurse
take first?
A. Increase the oxygen flow rate.
B. Assess the client's lung sounds.
C. Check for a disconnection in the tubing.
D. Manually ventilate the client with a bag-valve mask.
Correct Answer: C. Check for a disconnection in the tubing.
Rationale: A low-pressure alarm indicates a leak in the system or a
disconnection. The most immediate and common cause is a disconnection. The
nurse's first action should be to quickly trace the tubing from the ventilator to the
client to find the source of the leak. Assessing lung sounds (B) is part of the
assessment, but checking for the most likely cause of the alarm is the priority.
Manually ventilating (D) is a rescue action if the client is unstable, but the first
step is to identify and fix the problem.
10. A nurse is teaching a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
A. "An advance directive is only for older adults."
B. "A living will can be changed at any time."
C. "My family can override my advance directive."
D. "A durable power of attorney for healthcare is the same as a living will."
Post-Test | National Council of State Boards of
Nursing
1. Management of Care
1. A nurse is caring for a client who is scheduled for surgery. The client states, "I
do not want to have this surgery." Which of the following actions should the
nurse take first?
A. Notify the surgeon that the client has refused the procedure.
B. Ask the client why they do not want to have the surgery.
C. Document the client's statement in the medical record.
D. Explain the risks of not having the surgery.
Correct Answer: B. Ask the client why they do not want to have the surgery.
Rationale: The first step in the nursing process is assessment. The nurse must
first assess the client's reason for refusal to understand their concerns and
provide appropriate education or support. Notifying the surgeon (A) or
documenting (C) can occur after the assessment. Explaining risks (D) is part of
education but should be tailored to the client's specific concerns, which are
unknown until an assessment is done.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the
following tasks is appropriate for the nurse to delegate?
A. Administering oral pain medication to a stable client.
B. Assessing a client's surgical incision.
C. Ambulating a client who is 1-day post-operative.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: C. Ambulating a client who is 1-day post-operative.
Rationale: Ambulating a stable client is a standard task that can be delegated
to an AP. Administering medication (A), performing assessments (B), and
providing client teaching (D) are all tasks that require the professional judgment
and scope of practice of a registered nurse and cannot be delegated.
,3. A nurse is acting as a client advocate. Which of the following actions best
demonstrates this role?
A. Ensuring the client's bill is accurate.
B. Educating the client about their rights.
C. Providing direct physical care to the client.
D. Coordinating the client's discharge plan.
Correct Answer: B. Educating the client about their rights.
Rationale: Client advocacy involves protecting the client's rights and ensuring
they have the information needed to make informed decisions. Educating a client
about their rights is a core component of this role. While accurate billing (A),
direct care (C), and discharge planning (D) are important nursing responsibilities,
they do not primarily define the advocate role.
4. A nurse is preparing to administer a blood transfusion. Which of the following
actions is the priority?
A. Verify the client has a patent IV line.
B. Obtain the client's vital signs.
C. Ensure informed consent is on the chart.
D. Confirm the client's identity with two identifiers.
Correct Answer: D. Confirm the client's identity with two identifiers.
Rationale: The greatest risk associated with blood transfusion is a hemolytic
reaction due to ABO incompatibility, which can be fatal. The most critical step to
prevent this is verifying the client's identity and the blood product with two
identifiers at the bedside. While a patent IV (A), vital signs (B), and informed
consent (C) are necessary, they are not the priority safety check to prevent a
catastrophic reaction.
5. A nurse manager is reviewing an incident report. Which of the following
situations requires a sentinel event report to The Joint Commission?
A. A client falls but sustains no injury.
B. A client receives the wrong dose of a vitamin.
C. A client commits suicide while hospitalized.
D. A nurse sustains a needlestick injury.
, Correct Answer: C. A client commits suicide while hospitalized.
Rationale: A sentinel event is an unexpected occurrence involving death or
serious physical or psychological injury, or the risk thereof. Suicide of a client
while hospitalized is a clear example of a sentinel event. A fall without injury (A), a
wrong dose of a non-harmful medication (B), and a needlestick injury to staff (D)
are reportable incidents but do not meet the criteria for a sentinel event.
6. A nurse is caring for a client who speaks a different language. Which of the
following actions should the nurse take to ensure effective communication?
A. Use a family member to interpret.
B. Speak loudly and use simple words.
C. Use a facility-approved medical interpreter.
D. Provide written materials in English.
Correct Answer: C. Use a facility-approved medical interpreter.
Rationale: Using a professional medical interpreter is essential to ensure
accurate and confidential communication. Family members (A) may not be
competent to interpret medical terminology and can introduce bias or errors.
Speaking loudly (B) and providing English materials (D) are not effective if the
client does not understand the language.
7. A nurse is preparing to discharge a client who will need home oxygen
therapy. Which of the following referrals should the nurse make first?
A. A social worker to assess financial needs.
B. A home health nurse to provide skilled care.
C. A respiratory therapist to set up equipment.
D. A physical therapist to assess mobility.
Correct Answer: B. A home health nurse to provide skilled care.
Rationale: The home health nurse will perform a comprehensive assessment,
coordinate care, and provide ongoing education and monitoring, which is the
priority for a client with a new and complex medical need like home oxygen. The
nurse can then help coordinate other referrals as needed. While financial needs
(A), equipment setup (C), and mobility (D) are important, the overarching need is
for skilled nursing oversight.
, 8. A nurse is reviewing a client's medical record and notes a "Do Not
Resuscitate" (DNR) order. Which of the following actions should the nurse take?
A. Verify the order with the provider and the client/family.
B. Inform the client's family that the nurse will not provide CPR.
C. Assume the order is valid and proceed with care.
D. Place the DNR order in a prominent location in the chart.
Correct Answer: A. Verify the order with the provider and the client/family.
Rationale: The nurse must ensure the DNR order is valid and reflects the
client's wishes. This involves verifying the order is signed by the provider and that
the client or their legal surrogate decision-maker understands and agrees with it.
Simply informing the family (B) or assuming validity (C) is insufficient. Placing it in
the chart (D) is correct but not the most comprehensive first action.
9. A nurse is caring for a client who is on a ventilator. The nurse notes the low-
pressure alarm is sounding. Which of the following actions should the nurse
take first?
A. Increase the oxygen flow rate.
B. Assess the client's lung sounds.
C. Check for a disconnection in the tubing.
D. Manually ventilate the client with a bag-valve mask.
Correct Answer: C. Check for a disconnection in the tubing.
Rationale: A low-pressure alarm indicates a leak in the system or a
disconnection. The most immediate and common cause is a disconnection. The
nurse's first action should be to quickly trace the tubing from the ventilator to the
client to find the source of the leak. Assessing lung sounds (B) is part of the
assessment, but checking for the most likely cause of the alarm is the priority.
Manually ventilating (D) is a rescue action if the client is unstable, but the first
step is to identify and fix the problem.
10. A nurse is teaching a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
A. "An advance directive is only for older adults."
B. "A living will can be changed at any time."
C. "My family can override my advance directive."
D. "A durable power of attorney for healthcare is the same as a living will."
