LATEST 2025 VERSION VERIFIED RATIONALE
GRADED A+
The nurse uses the Internet to receive electrocardiogram results from a client living in a nursing home.
The nurse knows this type of information technology is best described as which of the following?
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.
The nurse is caring for a client newly diagnosed with diabetes, and performs the following tasks. Place
the tasks the nurse would perform in the appropriate order. All options must be used.
The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices concern
about her ability to manage when she gets home. Which of the following statements best illustrates
quality care delivery by the nurse? Select all that apply.
Rationale: This question addresses content related to delegation in the subcategory Management of
Care in the Client Needs category of Safe and Effective Care Environment. Work that is delegated to
others must be done consistent with the individual's level of expertise and licensure or lack of licensure.
In this situation, the most appropriate assignment for the nursing assistant is to care for the client who
requires stool specimen collections. Colostomy irrigations and tube feedings are not performed by
unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration.
Remember, the health care provider needs to be competent and skilled to perform the assigned task or
activity.
Rationale: Telehealth uses transmissions via telecommunications technology to transmit health
information remotely. Encryption refers to the conversion of information to code during transmission to
keep the information secure. Telecommunications refers to the electronic transmission of data over
phone-based lines. Nursing informatics refers to a specialty of nursing that integrates nursing and
computer science
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.
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.
Rationale: Nursing process - assessment, diagnosis, establishing outcomes/planning, and evaluation.
Rationale: LPN/LVNs assist with implementation of care; performs procedures; differentiates normal
from abnormal; cares for stable patients with predictable conditions; has knowledge of asepsis and
dressing changes; administers medications. Patient (a) is stable with an expected outcome. Patients (b)
and (c) require assessment and nursing judgement; and Patient (d) involves a standard unchanging
procedure that can be assigned to the nursing assistant.
, NCLEX PRACTICE QUESTIONS AND ANSWERS
LATEST 2025 VERSION VERIFIED RATIONALE
GRADED A+
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.
Rationale: eMARs have the potential to reduce medication administration errors and to improve access
to client information at the point of care. It is always the nurse's responsibility to document medication
administration and to verify doses of drugs being administered.
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.
Rationale: A referral to home health care provides the client with opportunities for support and
assistance during this transition; and a referral to support groups provides the client with opportunities
for support and assistance during this transition. The other options are not appropriate for a new mother
expressing concerns about her ability to cope.
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.
After receiving report at the start of the evening shift, which of the following clients should the nurse
attend to first?
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 registered nurse is planning the client assignments for the day. Which of the following is the most
appropriate assignment for the nursing assistant?
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 nursing team consists of an RN, an LPN/ LVN, and a nursing assistant. The nurse should assign which of
the following patients to the LPN/LVN?
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 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