NCLEX-RN EXAM 2020 EXAM
The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client
lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care
provider of the incident, and completes an incident report. Which statement should the nurse document on the
incident report?
The client was found lying on the floor.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car.
The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and
is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure,
which is the best action?
Transport the victim to the operating room for surgery.
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the
client and have determined that the client is not injured. After completing the incident report, the nurse should
implement which action next?
Reassess the client.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the
ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU.
The nurse should take which best action?
Clarify with the team leader to make a safe ICU client assignment.
The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet
wrapped around the upper arm. The co- worker is about to insert a needle, attached to a syringe containing a
clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
Call the nursing supervisor.
A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be
bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in
obtaining a witness to the will. Which is the most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your request."
The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the
client's record to correct the error. The nurse should take which actions to correct the error? Select all that
apply.
Document the correct information and end with the nurse's signature and title.
, Draw 1 line through the error, initialing and dating it.
Which identifies accurate nursing documentation notations? Select all that apply.
The client slept through the night.
Abdominal wound dressing is dry and intact without drainage.
The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a
nursing student to identify a situation that represents an example of invasion of client privacy. Which situation,
if identified by the student, indicates an understanding of a violation of this client right?
Observing care provided to the client without the client's permission
Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel
(UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS)
and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who
is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has
violated which legal tort?
Slander
An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical
assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how
the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently
hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate
nursing response?
"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report
and help find a safe place for you to stay."
The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage
prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication
is due to be administered. Which action should the nurse take?
Contact the nursing supervisor.
24) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax)
machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented
photograph. Which is the most appropriate initial nursing action?
Call the nursing supervisor and report the incident.
The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client
lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care
provider of the incident, and completes an incident report. Which statement should the nurse document on the
incident report?
The client was found lying on the floor.
A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car.
The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and
is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure,
which is the best action?
Transport the victim to the operating room for surgery.
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the
client and have determined that the client is not injured. After completing the incident report, the nurse should
implement which action next?
Reassess the client.
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the
ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU.
The nurse should take which best action?
Clarify with the team leader to make a safe ICU client assignment.
The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet
wrapped around the upper arm. The co- worker is about to insert a needle, attached to a syringe containing a
clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
Call the nursing supervisor.
A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be
bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in
obtaining a witness to the will. Which is the most appropriate response to the client?
"I will call the nursing supervisor to seek assistance regarding your request."
The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the
client's record to correct the error. The nurse should take which actions to correct the error? Select all that
apply.
Document the correct information and end with the nurse's signature and title.
, Draw 1 line through the error, initialing and dating it.
Which identifies accurate nursing documentation notations? Select all that apply.
The client slept through the night.
Abdominal wound dressing is dry and intact without drainage.
The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a
nursing student to identify a situation that represents an example of invasion of client privacy. Which situation,
if identified by the student, indicates an understanding of a violation of this client right?
Observing care provided to the client without the client's permission
Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel
(UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS)
and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who
is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has
violated which legal tort?
Slander
An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical
assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how
the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently
hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate
nursing response?
"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report
and help find a safe place for you to stay."
The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage
prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication
is due to be administered. Which action should the nurse take?
Contact the nursing supervisor.
24) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax)
machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented
photograph. Which is the most appropriate initial nursing action?
Call the nursing supervisor and report the incident.
