NCLEX RN Exam TEST BANK with RATIONALE-
(500 Q & A), Well Explained and Correct .
Safe and Effective Care Environment: Management of Care
1. A nurse is caring for a client who is scheduled for surgery. The client states, "I don't want to
sign the consent form. I have too many questions." Which of the following actions should the
nurse take first?
A. Witness the client's signature on the consent form.
B. Explain the procedure to the client in simple terms.
C. Notify the surgeon that the client has questions.
D. Document the client's refusal to sign the consent form.
Correct Answer: C
Rationale: The nurse's priority is to act as a client advocate. The surgeon is responsible for
obtaining informed consent, which includes explaining the procedure, risks, and benefits. The
nurse's role is to verify that the client understands the information and to witness the signature.
If the client has questions, the nurse must notify the surgeon. Explaining the procedure is not
the nurse's responsibility in this context and could be considered practicing outside their scope.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks is
appropriate for the nurse to delegate?
A. Administering oral pain medication to a stable client.
B. Assessing a client's new onset of confusion.
C. Ambulating a client who had surgery 2 days ago.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: C
Rationale: Ambulating a stable client is a standard, non-invasive task that can be safely
delegated to an AP. Administering medication, performing assessments, and providing client
teaching are all tasks that require the clinical judgment and knowledge of a licensed nurse and
cannot be delegated to an AP.
3. A nurse is preparing to administer medications and is interrupted by a client's family
member. Which of the following actions should the nurse take to prevent a medication error?
A. Quickly administer the medication and then speak with the family member.
B. Ask another nurse to administer the medication for them.
C. Complete the medication administration process before addressing the interruption.
D. Tell the family member to wait in the lobby until medications are passed.
, Correct Answer: C
Rationale: The "rights" of medication administration should never be rushed or interrupted.
The nurse should complete the task at hand to ensure client safety, which includes verifying the
right client, drug, dose, route, and time. Interruptions are a leading cause of medication errors.
The nurse should finish the administration process and then address the family member's
needs.
4. A nurse is receiving a change-of-shift report. Which of the following client information
should the nurse report to the provider immediately?
A. A client who is 2 days postoperative and has a temperature of 37.8° C (100.0° F).
B. A client who has a new onset of chest pain and is diaphoretic.
C. A client who is requesting pain medication for a headache.
D. A client who has not had a bowel movement in 24 hours.
Correct Answer: B
Rationale: New onset chest pain with diaphoresis is a classic sign of myocardial ischemia or
infarction and is a medical emergency. This finding requires immediate notification of the
provider. A low-grade fever, a request for pain medication, and a lack of bowel movement for 24
hours are important but not immediately life-threatening and can be addressed in a timely
manner.
5. A nurse is caring for a client who has a do-not-resuscitate (DNR) order. The client's family
member asks the nurse to perform CPR if the client's heart stops. Which of the following
actions should the nurse take?
A. Respect the family's wishes and perform CPR.
B. Explain the DNR order to the family and its implications.
C. Ask the provider to change the DNR order.
D. Ignore the family's request and follow the DNR order.
Correct Answer: B
Rationale: The nurse's role is to advocate for the client's wishes, which are legally
documented in the DNR order. The nurse should provide education and support to the family,
explaining what a DNR order means and why it is in place. Performing CPR would violate the
client's legal right to refuse treatment. The nurse should not ask the provider to change the
order based on the family's request, as this would be unethical and illegal.
6. A nurse is triaging clients following a mass casualty event. Which of the following clients
should the nurse assess first?
A. A client with a closed head injury who is confused.
B. A client with an open fracture of the femur.
,C. A client with a tension pneumothorax.
D. A client with a superficial laceration to the arm.
Correct Answer: C
Rationale: Using disaster triage principles, a tension pneumothorax is a life-threatening
condition that requires immediate intervention (e.g., needle decompression). Clients with life-
threatening but survivable injuries are the highest priority. A confused client with a head injury
and a client with an open fracture are urgent but can wait briefly. A superficial laceration is a
non-urgent, "walking wounded" client.
7. A nurse is reviewing a client's medical record and notes a handwritten order that is
illegible. Which of the following actions should the nurse take?
A. Ask the pharmacist to interpret the order.
B. Ask another nurse what they think the order is.
C. Contact the provider to clarify the order.
D. Administer the medication based on the most likely interpretation.
Correct Answer: C
Rationale: The nurse must never guess or interpret an illegible order. The safest and most
appropriate action is to contact the prescribing provider to clarify the order. This prevents a
potential medication error. Asking a pharmacist or another nurse to interpret the order is not a
safe practice.
8. A nurse is caring for a client who is on a clear liquid diet. Which of the following items
should the nurse remove from the client's meal tray?
A. Apple juice
B. Gelatin
C. Milk
D. Clear broth
Correct Answer: C
Rationale: A clear liquid diet consists of liquids that are transparent and liquid at room
temperature. Milk is not a clear liquid because it is opaque and contains fat. Apple juice, gelatin,
and clear broth are all appropriate for a clear liquid diet.
9. A nurse is preparing to discharge a client who speaks a different language than the nurse.
Which of the following actions should the nurse take to ensure the client understands the
discharge instructions?
A. Provide written instructions in English and have the client sign them.
B. Ask a family member who speaks both languages to interpret.
, C. Use a medical interpreter to provide the discharge instructions.
D. Use gestures and pictures to explain the instructions.
Correct Answer: C
Rationale: Using a professional medical interpreter is the standard of care to ensure
accurate communication and client understanding. Family members should not be used as
interpreters, as they may not be proficient in medical terminology and it can lead to
misunderstandings or breaches of confidentiality. Written instructions in a language the client
does not read are useless. Gestures and pictures are insufficient for complex discharge teaching.
10. A nurse is assigned to care for four clients. Which of the following clients should the nurse
assess first?
A. A client who is scheduled for discharge later in the day.
B. A client who is requesting a bedpan.
C. A client who is 1 day postoperative and reports incisional pain of 4 on a 0-10 scale.
D. A client who is newly admitted with a diagnosis of a GI bleed and has a heart rate of 120/min.
Correct Answer: D
Rationale: The nurse should use the ABC (Airway, Breathing, Circulation) priority-setting
framework. A client with a GI bleed and tachycardia is at risk for hypovolemic shock, which is a
circulatory issue and a life-threatening emergency. This client is the highest priority. The other
clients have needs that are important but not immediately life-threatening.
11. A nurse is participating in a quality improvement (QI) committee. Which of the following is
an example of a QI activity?
A. Administering medications to a group of clients.
B. Auditing hand hygiene compliance rates on a unit.
C. Developing a new policy for the hospital.
D. Educating a new nurse on how to use the electronic health record.
Correct Answer: B
Rationale: Quality improvement involves systematic, data-driven activities designed to
monitor and improve healthcare processes and outcomes. Auditing hand hygiene compliance is
a direct measurement of a process (hand hygiene) with the goal of improving it. Administering
medications is a direct care task. Developing policies and educating staff are components of QI
but are not measurement activities themselves.
12. A nurse is caring for a client who has an advance directive. The client becomes
unresponsive and is not breathing. The nurse should:
A. Begin CPR immediately.
(500 Q & A), Well Explained and Correct .
Safe and Effective Care Environment: Management of Care
1. A nurse is caring for a client who is scheduled for surgery. The client states, "I don't want to
sign the consent form. I have too many questions." Which of the following actions should the
nurse take first?
A. Witness the client's signature on the consent form.
B. Explain the procedure to the client in simple terms.
C. Notify the surgeon that the client has questions.
D. Document the client's refusal to sign the consent form.
Correct Answer: C
Rationale: The nurse's priority is to act as a client advocate. The surgeon is responsible for
obtaining informed consent, which includes explaining the procedure, risks, and benefits. The
nurse's role is to verify that the client understands the information and to witness the signature.
If the client has questions, the nurse must notify the surgeon. Explaining the procedure is not
the nurse's responsibility in this context and could be considered practicing outside their scope.
2. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks is
appropriate for the nurse to delegate?
A. Administering oral pain medication to a stable client.
B. Assessing a client's new onset of confusion.
C. Ambulating a client who had surgery 2 days ago.
D. Teaching a client how to use an incentive spirometer.
Correct Answer: C
Rationale: Ambulating a stable client is a standard, non-invasive task that can be safely
delegated to an AP. Administering medication, performing assessments, and providing client
teaching are all tasks that require the clinical judgment and knowledge of a licensed nurse and
cannot be delegated to an AP.
3. A nurse is preparing to administer medications and is interrupted by a client's family
member. Which of the following actions should the nurse take to prevent a medication error?
A. Quickly administer the medication and then speak with the family member.
B. Ask another nurse to administer the medication for them.
C. Complete the medication administration process before addressing the interruption.
D. Tell the family member to wait in the lobby until medications are passed.
, Correct Answer: C
Rationale: The "rights" of medication administration should never be rushed or interrupted.
The nurse should complete the task at hand to ensure client safety, which includes verifying the
right client, drug, dose, route, and time. Interruptions are a leading cause of medication errors.
The nurse should finish the administration process and then address the family member's
needs.
4. A nurse is receiving a change-of-shift report. Which of the following client information
should the nurse report to the provider immediately?
A. A client who is 2 days postoperative and has a temperature of 37.8° C (100.0° F).
B. A client who has a new onset of chest pain and is diaphoretic.
C. A client who is requesting pain medication for a headache.
D. A client who has not had a bowel movement in 24 hours.
Correct Answer: B
Rationale: New onset chest pain with diaphoresis is a classic sign of myocardial ischemia or
infarction and is a medical emergency. This finding requires immediate notification of the
provider. A low-grade fever, a request for pain medication, and a lack of bowel movement for 24
hours are important but not immediately life-threatening and can be addressed in a timely
manner.
5. A nurse is caring for a client who has a do-not-resuscitate (DNR) order. The client's family
member asks the nurse to perform CPR if the client's heart stops. Which of the following
actions should the nurse take?
A. Respect the family's wishes and perform CPR.
B. Explain the DNR order to the family and its implications.
C. Ask the provider to change the DNR order.
D. Ignore the family's request and follow the DNR order.
Correct Answer: B
Rationale: The nurse's role is to advocate for the client's wishes, which are legally
documented in the DNR order. The nurse should provide education and support to the family,
explaining what a DNR order means and why it is in place. Performing CPR would violate the
client's legal right to refuse treatment. The nurse should not ask the provider to change the
order based on the family's request, as this would be unethical and illegal.
6. A nurse is triaging clients following a mass casualty event. Which of the following clients
should the nurse assess first?
A. A client with a closed head injury who is confused.
B. A client with an open fracture of the femur.
,C. A client with a tension pneumothorax.
D. A client with a superficial laceration to the arm.
Correct Answer: C
Rationale: Using disaster triage principles, a tension pneumothorax is a life-threatening
condition that requires immediate intervention (e.g., needle decompression). Clients with life-
threatening but survivable injuries are the highest priority. A confused client with a head injury
and a client with an open fracture are urgent but can wait briefly. A superficial laceration is a
non-urgent, "walking wounded" client.
7. A nurse is reviewing a client's medical record and notes a handwritten order that is
illegible. Which of the following actions should the nurse take?
A. Ask the pharmacist to interpret the order.
B. Ask another nurse what they think the order is.
C. Contact the provider to clarify the order.
D. Administer the medication based on the most likely interpretation.
Correct Answer: C
Rationale: The nurse must never guess or interpret an illegible order. The safest and most
appropriate action is to contact the prescribing provider to clarify the order. This prevents a
potential medication error. Asking a pharmacist or another nurse to interpret the order is not a
safe practice.
8. A nurse is caring for a client who is on a clear liquid diet. Which of the following items
should the nurse remove from the client's meal tray?
A. Apple juice
B. Gelatin
C. Milk
D. Clear broth
Correct Answer: C
Rationale: A clear liquid diet consists of liquids that are transparent and liquid at room
temperature. Milk is not a clear liquid because it is opaque and contains fat. Apple juice, gelatin,
and clear broth are all appropriate for a clear liquid diet.
9. A nurse is preparing to discharge a client who speaks a different language than the nurse.
Which of the following actions should the nurse take to ensure the client understands the
discharge instructions?
A. Provide written instructions in English and have the client sign them.
B. Ask a family member who speaks both languages to interpret.
, C. Use a medical interpreter to provide the discharge instructions.
D. Use gestures and pictures to explain the instructions.
Correct Answer: C
Rationale: Using a professional medical interpreter is the standard of care to ensure
accurate communication and client understanding. Family members should not be used as
interpreters, as they may not be proficient in medical terminology and it can lead to
misunderstandings or breaches of confidentiality. Written instructions in a language the client
does not read are useless. Gestures and pictures are insufficient for complex discharge teaching.
10. A nurse is assigned to care for four clients. Which of the following clients should the nurse
assess first?
A. A client who is scheduled for discharge later in the day.
B. A client who is requesting a bedpan.
C. A client who is 1 day postoperative and reports incisional pain of 4 on a 0-10 scale.
D. A client who is newly admitted with a diagnosis of a GI bleed and has a heart rate of 120/min.
Correct Answer: D
Rationale: The nurse should use the ABC (Airway, Breathing, Circulation) priority-setting
framework. A client with a GI bleed and tachycardia is at risk for hypovolemic shock, which is a
circulatory issue and a life-threatening emergency. This client is the highest priority. The other
clients have needs that are important but not immediately life-threatening.
11. A nurse is participating in a quality improvement (QI) committee. Which of the following is
an example of a QI activity?
A. Administering medications to a group of clients.
B. Auditing hand hygiene compliance rates on a unit.
C. Developing a new policy for the hospital.
D. Educating a new nurse on how to use the electronic health record.
Correct Answer: B
Rationale: Quality improvement involves systematic, data-driven activities designed to
monitor and improve healthcare processes and outcomes. Auditing hand hygiene compliance is
a direct measurement of a process (hand hygiene) with the goal of improving it. Administering
medications is a direct care task. Developing policies and educating staff are components of QI
but are not measurement activities themselves.
12. A nurse is caring for a client who has an advance directive. The client becomes
unresponsive and is not breathing. The nurse should:
A. Begin CPR immediately.
