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