Test Bank for Saunders Comprehensive Review for the
NCLEX-RN® Examination, 9th Edition by Linda
Anne Silvestri and Angela Silvestri Isbn:
9780323795302 |Complete A+
SECTION 1: SAFE AND EFFECTIVE CARE ENVIRONMENT
Question 1
The nurse enters a client's room and finds a small fire on the bedside table. What is the
first action?
A) Attempt to extinguish the fire with water
B) Remove the client from the room
C) Activate the fire alarm
D) Call the physician
Answer: B) Remove the client from the room
Rationale: In fire safety, the RACE protocol (Rescue, Alarm, Contain, Extinguish)
must be followed. The first step is to rescue/remove anyone in immediate danger.
Activating the alarm and containing/extinguishing the fire come after ensuring
client safety. The physician should be notified after the immediate threat is
addressed .
,Question 2
During the planning phase of the nursing process, the nurse:
A) Collects baseline data
B) Establishes measurable goals and outcomes
C) Administers medications
D) Evaluates patient responses
Answer: B) Establishes measurable goals and outcomes
Rationale: The planning phase involves setting specific, measurable, achievable,
realistic, and time-bound (SMART) goals and outcomes to guide nursing
interventions. Data collection occurs during assessment, medication administration
is an intervention, and evaluation is the final step of the nursing process .
Question 3
A nurse delegates a task to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A) Administering oral medications
B) Measuring vital signs on a stable patient
C) Performing a wound assessment
D) Initiating IV therapy
Answer: B) Measuring vital signs on a stable patient
Rationale: UAPs can perform routine tasks for stable clients, such as measuring
vital signs, assisting with activities of daily living, and obtaining weights.
Assessment, medication administration, and IV therapy require nursing judgment
and are not appropriate for delegation to UAPs .
Question 4
A client refuses a prescribed procedure. The nurse should:
,A) Force the client to comply
B) Notify the physician immediately
C) Document the refusal and provide education
D) Ignore the refusal
Answer: C) Document the refusal and provide education
Rationale: Respect for patient autonomy requires providing education about the
procedure and its risks/benefits, documenting the refusal, and communicating with
the healthcare provider without coercion. Forcing compliance would violate ethical
principles .
Question 5
When using SBAR to communicate with a physician, the "A" stands for:
A) Assessment
B) Analysis
C) Action
D) Alert
Answer: A) Assessment
Rationale: SBAR is a structured communication tool for patient safety: Situation,
Background, Assessment, Recommendation. "A" represents Assessment—the nurse's
clinical assessment and findings .
Question 6
A client is at risk for falls. Which is the BEST intervention?
A) Raise all side rails
B) Keep the bed in the lowest position
C) Apply restraints
D) Limit fluid intake
Answer: B) Keep the bed in the lowest position
, Rationale: Keeping the bed in the lowest position reduces injury risk if the client
falls. Restraints should only be used as a last resort with physician order. Raising all
four side rails may be considered a restraint in some facilities. Limiting fluids is not
a fall prevention strategy .
Question 7
Which action demonstrates the principle of autonomy?
A) The nurse makes decisions for the client
B) The client makes their own healthcare decisions
C) The physician makes all treatment decisions
D) The family decides treatment for the client
Answer: B) The client makes their own healthcare decisions
Rationale: Autonomy is the ethical principle that respects the client's right to self-
determination and to make their own healthcare decisions. The nurse supports
informed decision-making without imposing personal values .
Question 8
The nurse is caring for a client with an infection. What is the priority action?
A) Administer antibiotics as prescribed
B) Perform hand hygiene before and after care
C) Document findings in the medical record
D) Check vital signs every 4 hours
Answer: B) Perform hand hygiene before and after care
Rationale: Hand hygiene is the single most important infection control measure to
prevent the spread of infection. While other options are appropriate, hand hygiene
takes priority as it protects both the client and healthcare workers .
NCLEX-RN® Examination, 9th Edition by Linda
Anne Silvestri and Angela Silvestri Isbn:
9780323795302 |Complete A+
SECTION 1: SAFE AND EFFECTIVE CARE ENVIRONMENT
Question 1
The nurse enters a client's room and finds a small fire on the bedside table. What is the
first action?
A) Attempt to extinguish the fire with water
B) Remove the client from the room
C) Activate the fire alarm
D) Call the physician
Answer: B) Remove the client from the room
Rationale: In fire safety, the RACE protocol (Rescue, Alarm, Contain, Extinguish)
must be followed. The first step is to rescue/remove anyone in immediate danger.
Activating the alarm and containing/extinguishing the fire come after ensuring
client safety. The physician should be notified after the immediate threat is
addressed .
,Question 2
During the planning phase of the nursing process, the nurse:
A) Collects baseline data
B) Establishes measurable goals and outcomes
C) Administers medications
D) Evaluates patient responses
Answer: B) Establishes measurable goals and outcomes
Rationale: The planning phase involves setting specific, measurable, achievable,
realistic, and time-bound (SMART) goals and outcomes to guide nursing
interventions. Data collection occurs during assessment, medication administration
is an intervention, and evaluation is the final step of the nursing process .
Question 3
A nurse delegates a task to an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate?
A) Administering oral medications
B) Measuring vital signs on a stable patient
C) Performing a wound assessment
D) Initiating IV therapy
Answer: B) Measuring vital signs on a stable patient
Rationale: UAPs can perform routine tasks for stable clients, such as measuring
vital signs, assisting with activities of daily living, and obtaining weights.
Assessment, medication administration, and IV therapy require nursing judgment
and are not appropriate for delegation to UAPs .
Question 4
A client refuses a prescribed procedure. The nurse should:
,A) Force the client to comply
B) Notify the physician immediately
C) Document the refusal and provide education
D) Ignore the refusal
Answer: C) Document the refusal and provide education
Rationale: Respect for patient autonomy requires providing education about the
procedure and its risks/benefits, documenting the refusal, and communicating with
the healthcare provider without coercion. Forcing compliance would violate ethical
principles .
Question 5
When using SBAR to communicate with a physician, the "A" stands for:
A) Assessment
B) Analysis
C) Action
D) Alert
Answer: A) Assessment
Rationale: SBAR is a structured communication tool for patient safety: Situation,
Background, Assessment, Recommendation. "A" represents Assessment—the nurse's
clinical assessment and findings .
Question 6
A client is at risk for falls. Which is the BEST intervention?
A) Raise all side rails
B) Keep the bed in the lowest position
C) Apply restraints
D) Limit fluid intake
Answer: B) Keep the bed in the lowest position
, Rationale: Keeping the bed in the lowest position reduces injury risk if the client
falls. Restraints should only be used as a last resort with physician order. Raising all
four side rails may be considered a restraint in some facilities. Limiting fluids is not
a fall prevention strategy .
Question 7
Which action demonstrates the principle of autonomy?
A) The nurse makes decisions for the client
B) The client makes their own healthcare decisions
C) The physician makes all treatment decisions
D) The family decides treatment for the client
Answer: B) The client makes their own healthcare decisions
Rationale: Autonomy is the ethical principle that respects the client's right to self-
determination and to make their own healthcare decisions. The nurse supports
informed decision-making without imposing personal values .
Question 8
The nurse is caring for a client with an infection. What is the priority action?
A) Administer antibiotics as prescribed
B) Perform hand hygiene before and after care
C) Document findings in the medical record
D) Check vital signs every 4 hours
Answer: B) Perform hand hygiene before and after care
Rationale: Hand hygiene is the single most important infection control measure to
prevent the spread of infection. While other options are appropriate, hand hygiene
takes priority as it protects both the client and healthcare workers .
