NURS 115 FINAL: NCLEX QUESTIONS WITH ACCURATE
ANSWERS
A disoriented patient is admitted to the hospital accompanied by the spouse.
From whom would the nurse collect subjective data on this patient?
a. An experienced nurse on the unit
b. The patient's medical record
c. The patient's spouse
d. The provider correct answer C
Subjective data (i.e., symptoms) are spoken. Patients' feelings about a situation or
comments about how they are feeling are examples of subjective data. Data
shared by a source verbally are considered subjective. Subjective data may be
difficult to validate because they cannot be independently and objectively
measured. Subjective data are most often gathered during a patient interview or
health history. The best source of subjective data is the patient, but with a
disoriented patient, the spouse or other family member or close friend can
provide data second hand.
A nurse admits a patient to the cardiac care unit following the placement of a
cardiac stent. Which step of the nursing process does the nurse do first?
a. Planning
b. Assessment
c. Evaluation
d. Implementation correct answer B
The first step of the nursing process is assessment, followed by diagnosis,
planning, implementation, and evaluation
,A nurse has admitted a 5 year old to the postanesthesia unit following a
tonsillectomy. The child is stable but crying. What action does the nurse take
first?
a. Tell the child that if he/she stops crying, the parents can visit.
b. Check to see what pain medication is ordered for the child.
c. Notify the surgeon of the child's postoperative condition.
d. Assess the child to determine why he/she is crying. correct answer D
Assessment is the first step of the nursing process. Plans cannot be made and
interventions cannot be delivered without first assessing the problem
A nurse has graduated from a nursing school and is participating in a new
graduate program at a local hospital as a continuing socialization to the role of the
nurse. At what level is the nurse functioning at this point in the nurse's career?
a. Expert
b. Competent
c. Novice
d. Advanced beginner correct answer D
The nurse is an advanced beginner for 2 to 3 years after graduating and doesn't
reach the level of competence until the end of that time period. An expert has an
intuitive grasp of situations. A novice is rigid and rule-bound because he or she
has no experience.
,A nurse has performed a physical examination of the patient and reviewed the
laboratory results and diagnostics on the patient's chart. The nurse is performing
which specific nursing function?
a. Diagnosis
b. Assessment
c. Education
d. Advocacy correct answer B
The nurse is performing the first step in the nursing process—assessment
A nurse is caring for a patient in the acute care setting who has a do-not-
resuscitate order in place. The family approaches the nurse as he/she is walking
down the hall and says, "I think my mother has died." To facilitate acceptance of
the death by the family, an important nursing intervention is to:
a. notify the physician that death has occurred while in the room with the family.
b. ask another nurse to come into the room to confirm that death has occurred.
c. assess the patient for pulse, respirations, or blood pressure with the family
present.
d. check that the cardiac monitor that was in place still has the appropriate leads
attached. correct answer C
Experienced nurses will intuitively know when death has occurred, but the act of
placing the stethoscope on a patient's chest and listening for heart sounds while
assessing for any respiratory effort can act to confirm, thus facilitate the
acceptance of death by family members who may have been present at the time
of death.
, A nurse is planning a program for educating a Hispanic community regarding
nutritional practices. What would be the most important aspects that the nurse
takes into consideration first? (Select all that apply.)
a. Change theory and Health Belief Model
b. Previous educational programs
c. Cultural influences
d. Hospital admissions from this community
e. Vital statistics such as death rates correct answer A, C
Since the nurse will be discussing nutrition to a specific cultural group, the nurse
needs to understand the cultural influences on their nutritional practices. In
addition, the nurse needs to understand change theory to plan her education if
she is attempting to have the group make changes in their nutritional practices.
The Health Belief Model would also help in understanding the community's
perceptions regarding barriers that facilitate or discourage adoption of the
promoted behaviors. Vital statistics are not essential.
A nurse makes a medication error, immediately assesses the patient, and reports
the error to the nurse manager and the primary care provider (PCP). Which
characteristic of a professional is the nurse demonstrating?
a. Autonomy
b. Collaboration
c. Accountability
d. Altruism correct answer C
The nurse is demonstrating accountability by taking responsibility for the error
and reporting it after an initial assessment of the patient. Criteria of a profession
include altruism (public service over personal gain), autonomy (independence),
ANSWERS
A disoriented patient is admitted to the hospital accompanied by the spouse.
From whom would the nurse collect subjective data on this patient?
a. An experienced nurse on the unit
b. The patient's medical record
c. The patient's spouse
d. The provider correct answer C
Subjective data (i.e., symptoms) are spoken. Patients' feelings about a situation or
comments about how they are feeling are examples of subjective data. Data
shared by a source verbally are considered subjective. Subjective data may be
difficult to validate because they cannot be independently and objectively
measured. Subjective data are most often gathered during a patient interview or
health history. The best source of subjective data is the patient, but with a
disoriented patient, the spouse or other family member or close friend can
provide data second hand.
A nurse admits a patient to the cardiac care unit following the placement of a
cardiac stent. Which step of the nursing process does the nurse do first?
a. Planning
b. Assessment
c. Evaluation
d. Implementation correct answer B
The first step of the nursing process is assessment, followed by diagnosis,
planning, implementation, and evaluation
,A nurse has admitted a 5 year old to the postanesthesia unit following a
tonsillectomy. The child is stable but crying. What action does the nurse take
first?
a. Tell the child that if he/she stops crying, the parents can visit.
b. Check to see what pain medication is ordered for the child.
c. Notify the surgeon of the child's postoperative condition.
d. Assess the child to determine why he/she is crying. correct answer D
Assessment is the first step of the nursing process. Plans cannot be made and
interventions cannot be delivered without first assessing the problem
A nurse has graduated from a nursing school and is participating in a new
graduate program at a local hospital as a continuing socialization to the role of the
nurse. At what level is the nurse functioning at this point in the nurse's career?
a. Expert
b. Competent
c. Novice
d. Advanced beginner correct answer D
The nurse is an advanced beginner for 2 to 3 years after graduating and doesn't
reach the level of competence until the end of that time period. An expert has an
intuitive grasp of situations. A novice is rigid and rule-bound because he or she
has no experience.
,A nurse has performed a physical examination of the patient and reviewed the
laboratory results and diagnostics on the patient's chart. The nurse is performing
which specific nursing function?
a. Diagnosis
b. Assessment
c. Education
d. Advocacy correct answer B
The nurse is performing the first step in the nursing process—assessment
A nurse is caring for a patient in the acute care setting who has a do-not-
resuscitate order in place. The family approaches the nurse as he/she is walking
down the hall and says, "I think my mother has died." To facilitate acceptance of
the death by the family, an important nursing intervention is to:
a. notify the physician that death has occurred while in the room with the family.
b. ask another nurse to come into the room to confirm that death has occurred.
c. assess the patient for pulse, respirations, or blood pressure with the family
present.
d. check that the cardiac monitor that was in place still has the appropriate leads
attached. correct answer C
Experienced nurses will intuitively know when death has occurred, but the act of
placing the stethoscope on a patient's chest and listening for heart sounds while
assessing for any respiratory effort can act to confirm, thus facilitate the
acceptance of death by family members who may have been present at the time
of death.
, A nurse is planning a program for educating a Hispanic community regarding
nutritional practices. What would be the most important aspects that the nurse
takes into consideration first? (Select all that apply.)
a. Change theory and Health Belief Model
b. Previous educational programs
c. Cultural influences
d. Hospital admissions from this community
e. Vital statistics such as death rates correct answer A, C
Since the nurse will be discussing nutrition to a specific cultural group, the nurse
needs to understand the cultural influences on their nutritional practices. In
addition, the nurse needs to understand change theory to plan her education if
she is attempting to have the group make changes in their nutritional practices.
The Health Belief Model would also help in understanding the community's
perceptions regarding barriers that facilitate or discourage adoption of the
promoted behaviors. Vital statistics are not essential.
A nurse makes a medication error, immediately assesses the patient, and reports
the error to the nurse manager and the primary care provider (PCP). Which
characteristic of a professional is the nurse demonstrating?
a. Autonomy
b. Collaboration
c. Accountability
d. Altruism correct answer C
The nurse is demonstrating accountability by taking responsibility for the error
and reporting it after an initial assessment of the patient. Criteria of a profession
include altruism (public service over personal gain), autonomy (independence),
