Timby’s Fundamental Nursing Skills and Concepts, 12th
edition
Answers and Rationales for End-of-Chapter NCLEX-Style
Review Questions
Chapter 1
Test-Taking Strategy: Note the key word “first.” Apply principles concerning
delegation to select an answer.
1. Answer: 3. Rationale: Whenever delegating a task, it is essential to
determine the competency of the person who is being assigned to the
delegated task. Although all of the other actions are important to perform,
ensuring that the delegated task can be performed accurately is most
important.
Cognitive Level: Apply
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key word “first.” Apply principles concerning
delegation to select an answer.
2. Answer: 2. Rationale: The LPN’s priority is Client B, who is potentially the
most unstable. After determining that Client B is recovering safely
postoperatively, the LPN can attend to the needs of the other assigned clients.
Cognitive Level: Analyze
Category of Client Needs: Safe and Effective Care Environment
1
,Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key word and modifier “most important.”
Select the option that reflects the most pertinent data about the client’s
current condition.
3. Answer: 4. Rationale: When obtaining a report on a postoperative client,
an LPN should expect to be told the client’s most recent blood pressure, an
indication of the client’s recovery status. The client’s age and occupation are
facts the LPN may wish to know, but they are not essential to the forthcoming
plan for care. Whether or not the client consumed food is helpful, but it is not
the most important information the LPN needs to know at this time.
Cognitive Level: Analyze
Category of Client Needs: Physiological Integrity
Client Needs Subcategory: Reduction of Risk Potential
Test-Taking Strategy: Note the key word and modifier “most important.”
Recall that the person who delegates a task is still ultimately responsible for it.
4. Answer: 1. Rationale: Whenever a task is delegated, the delegator is
responsible for ensuring that the task is performed and determining the
outcome. The LPN may choose to recheck the client’s blood pressure to validate
its accuracy, if the reported blood pressure is unusual. Teaching the client
about controlling blood pressure and assessing the client’s family history for
heart disease are important aspects of client care, but neither is the most
important action at this time.
2
,Cognitive Level: Analyze
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key word and modifier “most reasonable.”
Use the process of elimination to select the client whose outcome is least
predictable.
5. Answer: 1. Rationale: LPNs should be assigned to clients who have
predictable outcomes. A client with unrelieved chest pain seems to the most
potentially unstable within this mix of assignments. Based on the information in
the questions, Clients B, C, and D appear to require care that is within the
LPN’s scope of practice.
Cognitive Level: Analyze
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Chapter 2
Test-Taking Strategy: Note the key words and modifier “most appropriate”
and “first.” Use the steps in the nursing process to guide the selection of the
answer.
1. Answer: 3. Rationale: The first step in the nursing process is assessment.
Data collection precedes determining needs, setting goals, and developing a
plan for care.
3
, Cognitive Level: Apply
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Apply the responsibilities of the practical nurse to help
select the answer.
2. Answer: 2. Rationale: A licensed practical nurse works under the direction
of a registered nurse. A registered nurse can delegate the task of acquiring
basic information from the client to a licensed practical nurse, but the
registered nurse is responsible for ensuring that the admission database is
complete. The registered nurse is responsible for identifying nursing diagnoses
and developing the initial plan of care for preventing, reducing, or resolving the
nursing diagnoses. The registered nurse delegates implementation of the plan
of care to the licensed practical nurse and encourages the licensed practical
nurse to make future contributions to the initial care plan.
Cognitive Level: Apply
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key words and modifier which in this case is
“highest priority.” Apply Maslow’s Hierarchy of Needs to select the answer.
3. Answer: 1. Rationale: Ineffective airway clearance reflects a problem
affecting breathing, a basic physiologic need. The remaining diagnoses affect
other levels of Maslow’s hierarchy. Ineffective coping affects the needs of
4
edition
Answers and Rationales for End-of-Chapter NCLEX-Style
Review Questions
Chapter 1
Test-Taking Strategy: Note the key word “first.” Apply principles concerning
delegation to select an answer.
1. Answer: 3. Rationale: Whenever delegating a task, it is essential to
determine the competency of the person who is being assigned to the
delegated task. Although all of the other actions are important to perform,
ensuring that the delegated task can be performed accurately is most
important.
Cognitive Level: Apply
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key word “first.” Apply principles concerning
delegation to select an answer.
2. Answer: 2. Rationale: The LPN’s priority is Client B, who is potentially the
most unstable. After determining that Client B is recovering safely
postoperatively, the LPN can attend to the needs of the other assigned clients.
Cognitive Level: Analyze
Category of Client Needs: Safe and Effective Care Environment
1
,Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key word and modifier “most important.”
Select the option that reflects the most pertinent data about the client’s
current condition.
3. Answer: 4. Rationale: When obtaining a report on a postoperative client,
an LPN should expect to be told the client’s most recent blood pressure, an
indication of the client’s recovery status. The client’s age and occupation are
facts the LPN may wish to know, but they are not essential to the forthcoming
plan for care. Whether or not the client consumed food is helpful, but it is not
the most important information the LPN needs to know at this time.
Cognitive Level: Analyze
Category of Client Needs: Physiological Integrity
Client Needs Subcategory: Reduction of Risk Potential
Test-Taking Strategy: Note the key word and modifier “most important.”
Recall that the person who delegates a task is still ultimately responsible for it.
4. Answer: 1. Rationale: Whenever a task is delegated, the delegator is
responsible for ensuring that the task is performed and determining the
outcome. The LPN may choose to recheck the client’s blood pressure to validate
its accuracy, if the reported blood pressure is unusual. Teaching the client
about controlling blood pressure and assessing the client’s family history for
heart disease are important aspects of client care, but neither is the most
important action at this time.
2
,Cognitive Level: Analyze
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key word and modifier “most reasonable.”
Use the process of elimination to select the client whose outcome is least
predictable.
5. Answer: 1. Rationale: LPNs should be assigned to clients who have
predictable outcomes. A client with unrelieved chest pain seems to the most
potentially unstable within this mix of assignments. Based on the information in
the questions, Clients B, C, and D appear to require care that is within the
LPN’s scope of practice.
Cognitive Level: Analyze
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Chapter 2
Test-Taking Strategy: Note the key words and modifier “most appropriate”
and “first.” Use the steps in the nursing process to guide the selection of the
answer.
1. Answer: 3. Rationale: The first step in the nursing process is assessment.
Data collection precedes determining needs, setting goals, and developing a
plan for care.
3
, Cognitive Level: Apply
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Apply the responsibilities of the practical nurse to help
select the answer.
2. Answer: 2. Rationale: A licensed practical nurse works under the direction
of a registered nurse. A registered nurse can delegate the task of acquiring
basic information from the client to a licensed practical nurse, but the
registered nurse is responsible for ensuring that the admission database is
complete. The registered nurse is responsible for identifying nursing diagnoses
and developing the initial plan of care for preventing, reducing, or resolving the
nursing diagnoses. The registered nurse delegates implementation of the plan
of care to the licensed practical nurse and encourages the licensed practical
nurse to make future contributions to the initial care plan.
Cognitive Level: Apply
Category of Client Needs: Safe and Effective Care Environment
Client Needs Subcategory: Coordinated Care
Test-Taking Strategy: Note the key words and modifier which in this case is
“highest priority.” Apply Maslow’s Hierarchy of Needs to select the answer.
3. Answer: 1. Rationale: Ineffective airway clearance reflects a problem
affecting breathing, a basic physiologic need. The remaining diagnoses affect
other levels of Maslow’s hierarchy. Ineffective coping affects the needs of
4
