NCLEX RN EXAM PRACTICE QUESTIONS
L/M
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 primary health care provider, and completes an
occurrence report. Which statement should the nurse document on the occurrence
report?
1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found
lying on the floor. 4.The client became restless and tried to get out of bed. - ANS -3. The
client was found lying on the floor
- The occurrence report should contain a factual description of the occurrence, any
injuries experienced by those involved, and the outcome of the situation. The correct
option is the only one that describes the facts as observed by the nurse. Options 1, 2,
and 4 are interpretations of the situation and are not factual information as observed by
the nurse.
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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 primary health care provider, and completes an
occurrence report. Which statement should the nurse document on the occurrence
report?
Test-Taking Strategy(ies):Focus on the subject, documentation of events, and note the
data in the question to select the correct option. Remember to focus on factual
information when documenting, and avoid including interpretations. This will direct you
to the correct option.
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?
1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the
informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the
police to identify the client and locate the family. - ANS -3. Transport the victim to the
operating room for surgery
In general, there are two situations in which informed consent of an adult client is not
needed. One is when an emergency is present and delaying treatment for the purpose of
obtaining informed consent would result in injury or death to the client. The second is
when the client waives the right to give informed consent. Option 1 will delay emergency
treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the
best action because it delays necessary emergency treatment.
Note the strategic word, best. Also note that an emergency is present. Recalling that a
delay in treatment for the purpose of obtaining informed consent could result in injury or
death will direct you to the correct option.
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 the bestaction?
1.Refuse to float to the ICU based on lack of unit orientation. 2.Clarify the ICU client
assignment with the team leader to ensure that it is a safe assignment. 3.Ask the nursing
supervisor to review the hospital policy on floating. 4.Submit a written protest to nursing
administration, and then call the hospital lawyer. - ANS -2.Clarify the ICU client
assignment with the team leader to ensure that it is a safe assignment.
Floating is an acceptable practice used by hospitals to solve understaffing problems.
Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses
can work only in a specified area or the nurse can prove the lack of knowledge for the
performance of assigned tasks. When encountering this situation, the nurse should set
priorities and identify potential areas of harm to the client. That is why clarifying the
client assignment with the team leader to ensure that it is a safe one is the best option.
The nursing supervisor is called if the nurse is expected to perform tasks that he or she
cannot safely perform. Submitting a written protest and calling the hospital lawyer is a
premature action.
Note the strategic word, best. Eliminate option 1 first because of the word refuse. Next,
eliminate options 3 and 4 because they are premature actions.
The nurse who works on the night shift enters the medication room and finds a coworker
with a tourniquet wrapped around the upper arm. The coworker 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?
1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the coworker in the
medication room until help is obtained. - ANS -3. Call the nursing supervisor
Nurse practice acts require reporting impaired nurses. The board of nursing has
jurisdiction over the practice of nursing and may develop plans for treatment and
supervision of the impaired nurse. This occurrence needs to be reported to the nursing
supervisor, who will then report to the board of nursing and other authorities, such as the
police, as required. The nurse may call security if a disturbance occurs, but no
information in the question supports this need, and so this is not the appropriate action.
Option 4 is an inappropriate and unsafe action.
Note the strategic words, most appropriate. Eliminate option 4 first, because this is an
inappropriate and unsafe action. Recall the lines of organizational structure to assist in
directing you to the correct option.
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?
1."I will sign as a witness to your signature." 2."You will need to find a witness on your
own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the
nursing supervisor to seek assistance regarding your request." - ANS -4."I will call the
nursing supervisor to seek assistance regarding your request."
Instructional directives (living wills) are required to be in writing and signed by the client.
The client's signature must be witnessed by specified individuals or notarized. Laws and
guidelines regarding instructional directives vary from state to state, and it is the
responsibility of the nurse to know the laws. Many states prohibit any employee,
including the nurse of a facility where the client is receiving care, from being a witness.
Option 2 is non therapeutic and not a helpful response. The nurse should seek the
assistance of the nursing supervisor.
The nurse has made an error in documentation of the dose administered of an opioid
pain medication in the client's record. The nurse draws 1 mg from the vial and another
registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the
medication, the nurse entered into the medication administration record (MAR) that 2 mg
of hydromorphone was administered instead of the actual dose administered, which was
1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all
that apply.
1.Complete and file an occurrence report. 2.Right-click on the entry and modify it to
reflect the correct information. 3.Document the correct information and end with the
L/M
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 primary health care provider, and completes an
occurrence report. Which statement should the nurse document on the occurrence
report?
1.The client fell out of bed. 2.The client climbed over the side rails. 3.The client was found
lying on the floor. 4.The client became restless and tried to get out of bed. - ANS -3. The
client was found lying on the floor
- The occurrence report should contain a factual description of the occurrence, any
injuries experienced by those involved, and the outcome of the situation. The correct
option is the only one that describes the facts as observed by the nurse. Options 1, 2,
and 4 are interpretations of the situation and are not factual information as observed by
the nurse.
HomeHelpCalculator
Study Mode
Question 1 of 186
ID: 0016 | 6.xml #16
PreviousGoNext
StopBookmark
Rationale Strategy Reference Labs
Submit
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 primary health care provider, and completes an
occurrence report. Which statement should the nurse document on the occurrence
report?
Test-Taking Strategy(ies):Focus on the subject, documentation of events, and note the
data in the question to select the correct option. Remember to focus on factual
information when documenting, and avoid including interpretations. This will direct you
to the correct option.
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?
1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the
informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the
police to identify the client and locate the family. - ANS -3. Transport the victim to the
operating room for surgery
In general, there are two situations in which informed consent of an adult client is not
needed. One is when an emergency is present and delaying treatment for the purpose of
obtaining informed consent would result in injury or death to the client. The second is
when the client waives the right to give informed consent. Option 1 will delay emergency
treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the
best action because it delays necessary emergency treatment.
Note the strategic word, best. Also note that an emergency is present. Recalling that a
delay in treatment for the purpose of obtaining informed consent could result in injury or
death will direct you to the correct option.
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 the bestaction?
1.Refuse to float to the ICU based on lack of unit orientation. 2.Clarify the ICU client
assignment with the team leader to ensure that it is a safe assignment. 3.Ask the nursing
supervisor to review the hospital policy on floating. 4.Submit a written protest to nursing
administration, and then call the hospital lawyer. - ANS -2.Clarify the ICU client
assignment with the team leader to ensure that it is a safe assignment.
Floating is an acceptable practice used by hospitals to solve understaffing problems.
Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses
can work only in a specified area or the nurse can prove the lack of knowledge for the
performance of assigned tasks. When encountering this situation, the nurse should set
priorities and identify potential areas of harm to the client. That is why clarifying the
client assignment with the team leader to ensure that it is a safe one is the best option.
The nursing supervisor is called if the nurse is expected to perform tasks that he or she
cannot safely perform. Submitting a written protest and calling the hospital lawyer is a
premature action.
Note the strategic word, best. Eliminate option 1 first because of the word refuse. Next,
eliminate options 3 and 4 because they are premature actions.
The nurse who works on the night shift enters the medication room and finds a coworker
with a tourniquet wrapped around the upper arm. The coworker 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?
1.Call security. 2.Call the police. 3.Call the nursing supervisor. 4.Lock the coworker in the
medication room until help is obtained. - ANS -3. Call the nursing supervisor
Nurse practice acts require reporting impaired nurses. The board of nursing has
jurisdiction over the practice of nursing and may develop plans for treatment and
supervision of the impaired nurse. This occurrence needs to be reported to the nursing
supervisor, who will then report to the board of nursing and other authorities, such as the
police, as required. The nurse may call security if a disturbance occurs, but no
information in the question supports this need, and so this is not the appropriate action.
Option 4 is an inappropriate and unsafe action.
Note the strategic words, most appropriate. Eliminate option 4 first, because this is an
inappropriate and unsafe action. Recall the lines of organizational structure to assist in
directing you to the correct option.
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?
1."I will sign as a witness to your signature." 2."You will need to find a witness on your
own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the
nursing supervisor to seek assistance regarding your request." - ANS -4."I will call the
nursing supervisor to seek assistance regarding your request."
Instructional directives (living wills) are required to be in writing and signed by the client.
The client's signature must be witnessed by specified individuals or notarized. Laws and
guidelines regarding instructional directives vary from state to state, and it is the
responsibility of the nurse to know the laws. Many states prohibit any employee,
including the nurse of a facility where the client is receiving care, from being a witness.
Option 2 is non therapeutic and not a helpful response. The nurse should seek the
assistance of the nursing supervisor.
The nurse has made an error in documentation of the dose administered of an opioid
pain medication in the client's record. The nurse draws 1 mg from the vial and another
registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the
medication, the nurse entered into the medication administration record (MAR) that 2 mg
of hydromorphone was administered instead of the actual dose administered, which was
1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all
that apply.
1.Complete and file an occurrence report. 2.Right-click on the entry and modify it to
reflect the correct information. 3.Document the correct information and end with the
