NCLEX Practice Questions
After receiving report at the start of the evening shift, which of the following clients should the
nurse attend to first?
(a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level
of 7.5 mEq/L.
(b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10.
(c) A 55-year-old woman with ovarian cancer waiting to be discharged.
(d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry
of 96% on room air. - ANSCorrect answer: (a) A 34-year-old man undergoing treatment for
non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L.
Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing treatment
for non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b) should be
attended to, but her condition is not as urgent. Patients (c) and (d) do not require immediate
attention.
A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment
with carbamazepine (Tegretol) is being transferred in stable condition from the intensive care
unit to the medical unit. There are 4 beds available. The nurse knows the best choice of
roommates for this client is which of the following?
(a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA).
(b) A 28-year-old woman diagnosed with diarrhea.
(c) A 72-year-old man with fever of unknown origin.
(d) A 68-year-old woman with atrial fibrillation . - ANSCorrect answer: (d) A 68-year-old woman
with atrial fibrillation.
Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues,
including blistering and skin shedding, which can place the client at high risk for infection. Atrial
fibrillation is not an infectious process. All other patients may be an infection risk for an
individual with altered skin integrity.
A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilitation
centre. The nurse case manager is assisting in the process. The nurse knows that the goals of
case management include which of the following? Select all that apply.
(a) Improving the coordination of care
(b) Increasing referrals to local organizations
(c) Reducing the fragmentation of care
, (d) Discharging clients quickly - ANSCorrect answer: (a) Improving the coordination of care; and
(c) Reducing the fragmentation of care
Rationale: Some of the primary goals of case management are to improve the coordination of
care and to reduce fragmentation of care. The other options are not goals of case management.
A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is
being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully
understand the risks and benefits associated with the procedure. Which of the following
describe the nurse's role in obtaining informed consent? Select all that apply.
(a) Explain the risks and benefits associated with the procedure.
(b) Describe alternatives to the procedure.
(c) Witness the client's signature on the consent form.
(d) Advocate for the client by ensuring she is making an informed decision. - ANSCorrect
answer: (c) Witness the client's signature on the consent form; and
(d) Advocate for the client by ensuring she is making an informed decision.
Rationale: Some of the nurse's roles in the informed consent process are to witness the
signature on the consent form, and to advocate for the client by ensuring she has been provided
the necessary information to make an informed decision. It is the physician's duty to provide
information to the client-related risks and benefits, and to provide alternatives.
A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff
member who is not involved in the client's care reading his medical record. The nurse knows
she should FIRST do which of the following?
(a) Nothing. The staff member has a hospital ID badge and is authorized to read the medical
record.
(b) Inform the staff member that without a legitimate need for the information, staff should not be
reading the medical record.
(c) Tell the client his medical records have been read by an unauthorized individual.
(d) Page the physician and ask if it's acceptable for the staff member to access the medical
records. - ANSCorrect answer: (b) Inform the staff member that without a legitimate need for the
information, staff should not be reading the medical record.
Rationale: An individual not involved in the care of the client does not have a legitimate need to
access the medical record. The nurse should protect the client's right to privacy by ensuring only
authorized individuals access medical records.
The nurse is learning how to use the hospital's new electronic medication administration record
(eMAR). The nurse knows this tool has the potential to do which of the following? Select all that
apply.
After receiving report at the start of the evening shift, which of the following clients should the
nurse attend to first?
(a) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a potassium level
of 7.5 mEq/L.
(b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10.
(c) A 55-year-old woman with ovarian cancer waiting to be discharged.
(d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry
of 96% on room air. - ANSCorrect answer: (a) A 34-year-old man undergoing treatment for
non-Hodgkin lymphoma with a potassium level of 7.5 mEq/L.
Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing treatment
for non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b) should be
attended to, but her condition is not as urgent. Patients (c) and (d) do not require immediate
attention.
A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment
with carbamazepine (Tegretol) is being transferred in stable condition from the intensive care
unit to the medical unit. There are 4 beds available. The nurse knows the best choice of
roommates for this client is which of the following?
(a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA).
(b) A 28-year-old woman diagnosed with diarrhea.
(c) A 72-year-old man with fever of unknown origin.
(d) A 68-year-old woman with atrial fibrillation . - ANSCorrect answer: (d) A 68-year-old woman
with atrial fibrillation.
Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues,
including blistering and skin shedding, which can place the client at high risk for infection. Atrial
fibrillation is not an infectious process. All other patients may be an infection risk for an
individual with altered skin integrity.
A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilitation
centre. The nurse case manager is assisting in the process. The nurse knows that the goals of
case management include which of the following? Select all that apply.
(a) Improving the coordination of care
(b) Increasing referrals to local organizations
(c) Reducing the fragmentation of care
, (d) Discharging clients quickly - ANSCorrect answer: (a) Improving the coordination of care; and
(c) Reducing the fragmentation of care
Rationale: Some of the primary goals of case management are to improve the coordination of
care and to reduce fragmentation of care. The other options are not goals of case management.
A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is
being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully
understand the risks and benefits associated with the procedure. Which of the following
describe the nurse's role in obtaining informed consent? Select all that apply.
(a) Explain the risks and benefits associated with the procedure.
(b) Describe alternatives to the procedure.
(c) Witness the client's signature on the consent form.
(d) Advocate for the client by ensuring she is making an informed decision. - ANSCorrect
answer: (c) Witness the client's signature on the consent form; and
(d) Advocate for the client by ensuring she is making an informed decision.
Rationale: Some of the nurse's roles in the informed consent process are to witness the
signature on the consent form, and to advocate for the client by ensuring she has been provided
the necessary information to make an informed decision. It is the physician's duty to provide
information to the client-related risks and benefits, and to provide alternatives.
A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff
member who is not involved in the client's care reading his medical record. The nurse knows
she should FIRST do which of the following?
(a) Nothing. The staff member has a hospital ID badge and is authorized to read the medical
record.
(b) Inform the staff member that without a legitimate need for the information, staff should not be
reading the medical record.
(c) Tell the client his medical records have been read by an unauthorized individual.
(d) Page the physician and ask if it's acceptable for the staff member to access the medical
records. - ANSCorrect answer: (b) Inform the staff member that without a legitimate need for the
information, staff should not be reading the medical record.
Rationale: An individual not involved in the care of the client does not have a legitimate need to
access the medical record. The nurse should protect the client's right to privacy by ensuring only
authorized individuals access medical records.
The nurse is learning how to use the hospital's new electronic medication administration record
(eMAR). The nurse knows this tool has the potential to do which of the following? Select all that
apply.
