NUR 114 EXAM 5 (PDF) |
2026 NCLEX Questions |
NURSING FUNDAMENTALS
1. A nurse is explaining a patient's lab results to the physician. The nurse accurately
states, "The patient's potassium level is 5.0 mEq/L, which is critically low." This is an
example of the "Telling" method. What is the rationale?
A. It demonstrates respect.
B. It involves a back-and-forth dialogue.
C. It involves guiding the patient to express their feelings first.
D. It provides factual, direct information to the patient and/or provider.
Correct Answer: D
Rationale:The "Telling" method is used to provide factual, direct, specific information.
It is the best method for reporting data to other healthcare providers, as accuracy and
clarity prevent fatal medication errors.
2. Which teaching strategy uses visual aids?
A. Telling
,B. Returning demonstration
C. Modified Telling
D. Standard Telling
Correct Answer: B
Rationale:Returning demonstration is used to teach psychomotor skills. The nurse
demonstrates the skill once, then asks the patient to return the demonstration.
3. A nurse notices a patient's clinical status has improved significantly, but there is no
documented evidence of improvement. What is the best action?
A. Chart the improvement immediately to reflect the new status.
B. Assess the patient again to be absolutely sure the status has improved.
C. Document the previous data as accurate and plan to update it later.
D. Wait a few hours to ensure the improvement is sustained.
Correct Answer: C
Rationale:Legally and ethically, you may only document the data exactly as it exists at
the exact time of assessment. Charting retrospective data as "current data" is falsifying
the medical record.
4. When entering a patient's room to perform a focused respiratory assessment, the
nurse notices the patient is exhibiting use of accessory muscles. The nurse decides to
measure the patient immediately, interrupting the assessment to ensure a patent
airway. This is an example of:
A. Risk identification.
B. Problem identification.
C. Planning.
D. Evaluation.
,Correct Answer: D
Rationale:Evaluation involves comparing the patient's response to the planned
interventions. Realizing the patient is in acute respiratory distress and immediately
prioritizing the airway is an acute evaluation decision.
5. A student nurse administers a medication late. How should the student document the
time in the Medication Administration Record (MAR)?
A. Document the time the medication was *supposed* to be given.
B. Document the time the medication was *actually* given.
C. Document the time the pill was ingested.
D. Document the time the order was placed.
Correct Answer: B
Rationale:MARs must reflect the exact time the medication was given, not the
scheduled time.
6. Which nursing action is considered a risk to patient safety when preparing an
injection?
A. Identifying the patient using two identifiers.
B. Swabbing the vial's rubber stopper.
C. Drawing the correct dose.
D. Checking the medication label three times.
Correct Answer: B
Rationale:Swabbing the rubber stopper is an unaccepted action in most facilities
because it can introduce rubber particles into the medication. It is a direct, negligent
action that creates risk.
, 7. During the Planning phase of the nursing process, the nurse sets a goal: "Patient will
maintain a patent airway." This goal is considered a(n):
A. Short-term goal.
B. Long-term goal.
C. Problem statement.
D. Nursing diagnosis.
Correct Answer: A
Rationale:Short-term goals are measurable outcomes achievable in hours to days. A
long-term goal takes weeks to months to achieve.
8. A patient asks the nurse to explain what "living will" is. Which response accurately
explains this legal document?
A. It is a form that allows patients to refuse treatment, but only if they sign a form.
B. A: 'living will' is unique, and patients can add provisions to the template.
C. It guarantees no life-sustaining treatment can be overridden.
D. It must be signed by two physicians.
Correct Answer: B
Rationale:Advanced Directives (Living Wills) can be used flexibly to address specific
preferences (like refusing dialysis or artificial nutrition) provided the legal requirements
for validity are met.
9. When teaching a patient how to use an incentive spirometer, the nurse says, "Breat in
slowly, hold your breath for 5 seconds, and if you do not answer my questions, the laws
require the most rigorous standard of care." This is an example of:
A. Telling.
B. Standard Telling.
2026 NCLEX Questions |
NURSING FUNDAMENTALS
1. A nurse is explaining a patient's lab results to the physician. The nurse accurately
states, "The patient's potassium level is 5.0 mEq/L, which is critically low." This is an
example of the "Telling" method. What is the rationale?
A. It demonstrates respect.
B. It involves a back-and-forth dialogue.
C. It involves guiding the patient to express their feelings first.
D. It provides factual, direct information to the patient and/or provider.
Correct Answer: D
Rationale:The "Telling" method is used to provide factual, direct, specific information.
It is the best method for reporting data to other healthcare providers, as accuracy and
clarity prevent fatal medication errors.
2. Which teaching strategy uses visual aids?
A. Telling
,B. Returning demonstration
C. Modified Telling
D. Standard Telling
Correct Answer: B
Rationale:Returning demonstration is used to teach psychomotor skills. The nurse
demonstrates the skill once, then asks the patient to return the demonstration.
3. A nurse notices a patient's clinical status has improved significantly, but there is no
documented evidence of improvement. What is the best action?
A. Chart the improvement immediately to reflect the new status.
B. Assess the patient again to be absolutely sure the status has improved.
C. Document the previous data as accurate and plan to update it later.
D. Wait a few hours to ensure the improvement is sustained.
Correct Answer: C
Rationale:Legally and ethically, you may only document the data exactly as it exists at
the exact time of assessment. Charting retrospective data as "current data" is falsifying
the medical record.
4. When entering a patient's room to perform a focused respiratory assessment, the
nurse notices the patient is exhibiting use of accessory muscles. The nurse decides to
measure the patient immediately, interrupting the assessment to ensure a patent
airway. This is an example of:
A. Risk identification.
B. Problem identification.
C. Planning.
D. Evaluation.
,Correct Answer: D
Rationale:Evaluation involves comparing the patient's response to the planned
interventions. Realizing the patient is in acute respiratory distress and immediately
prioritizing the airway is an acute evaluation decision.
5. A student nurse administers a medication late. How should the student document the
time in the Medication Administration Record (MAR)?
A. Document the time the medication was *supposed* to be given.
B. Document the time the medication was *actually* given.
C. Document the time the pill was ingested.
D. Document the time the order was placed.
Correct Answer: B
Rationale:MARs must reflect the exact time the medication was given, not the
scheduled time.
6. Which nursing action is considered a risk to patient safety when preparing an
injection?
A. Identifying the patient using two identifiers.
B. Swabbing the vial's rubber stopper.
C. Drawing the correct dose.
D. Checking the medication label three times.
Correct Answer: B
Rationale:Swabbing the rubber stopper is an unaccepted action in most facilities
because it can introduce rubber particles into the medication. It is a direct, negligent
action that creates risk.
, 7. During the Planning phase of the nursing process, the nurse sets a goal: "Patient will
maintain a patent airway." This goal is considered a(n):
A. Short-term goal.
B. Long-term goal.
C. Problem statement.
D. Nursing diagnosis.
Correct Answer: A
Rationale:Short-term goals are measurable outcomes achievable in hours to days. A
long-term goal takes weeks to months to achieve.
8. A patient asks the nurse to explain what "living will" is. Which response accurately
explains this legal document?
A. It is a form that allows patients to refuse treatment, but only if they sign a form.
B. A: 'living will' is unique, and patients can add provisions to the template.
C. It guarantees no life-sustaining treatment can be overridden.
D. It must be signed by two physicians.
Correct Answer: B
Rationale:Advanced Directives (Living Wills) can be used flexibly to address specific
preferences (like refusing dialysis or artificial nutrition) provided the legal requirements
for validity are met.
9. When teaching a patient how to use an incentive spirometer, the nurse says, "Breat in
slowly, hold your breath for 5 seconds, and if you do not answer my questions, the laws
require the most rigorous standard of care." This is an example of:
A. Telling.
B. Standard Telling.
