NCLEX Prep Questions with Complete Solutions 100% Correct
1. DELEGATION
2. The team is providing emergency 4. Applying oxygen per nasal cannula as
care to a client who received an ordered
excessive dose of opioid pain
medication. Which task is best to Rationale: The LPN/LVN is well trained
assign to the LPN/LVN? to administer 02 via nasal cannula. This
client is considered unstable; therefore,
1. Calling the health care provider the RN should take responsibility for
(HCP) to report SBAR (situation, administering drugs and monitoring re-
background, assessment, recom- sponses to therapy, which include the
mendation) effects on the respiratory system. The
2. Giving naloxone and evaluating RN should also take responsibility to
response to therapy communicate with the HCP for ongoing
3. Monitoring the respiratory sta- treatment and therapy.
tus for the first 30 minutes
4. Applying oxygen per nasal can-
nula as ordered
3. In the care of a patient with neu- 1. Taking vital signs every 4 hours
tropenia, what tasks should the 2. Reporting temperature of more than
nurse instruct unlicensed assis- 100.4°F (38°C)
tive personnel (UAP) to perform? 4. Gathering the supplies to prepare the
Select all that apply. room for protective isolation
6. Practicing good hand-washing tech-
1. Taking vital signs every 4 hours nique
2. Reporting temperature of more
than 100.4°F (38°C) Rationale: Measuring vital signs and re-
3. Assessing for sore throat, porting on specific parameters, practic-
cough, or burning with urination ing good hand washing, and gathering
4. Gathering the supplies to pre- equipment are within the scope of du-
pare the room for protective isola- ties for a UAP. Assessing for symptoms
tion of infections and superinfections is the
5. Reporting superinfections, responsibility of the RN.
such as candidiasis
6. Practicing good hand-washing
technique
4.
, NCLEX Prep Questions with Complete Solutions 100% Correct
Which tasks are appropriate to as- 1. Administering sulfacetamide sodium
sign to an LPN/LVN who is func- 10% to a child with conjunctivitis
tioning under the supervision of 2. Reviewing hand-washing and hy-
an RN? Select all that apply. giene practices with clients who have
eye infections
1. Administering sulfacetamide 3. Showing clients how to gently cleanse
sodium 10% to a child with con- eyelid margins to remove crusting
junctivitis 6. Performing a routine check of a
2. Reviewing hand-washing and client's visual acuity using the Snellen
hygiene practices with clients eye chart
who have eye infections
3. Showing clients how to gently Rationale: Administering medications,
cleanse eyelid margins to remove reviewing and demonstrating standard
crusting procedures, and performing standard-
4. Assessing nutritional factors ized assessments with predictable out-
for a client with age-related mac- comes in noncomplex cases are within
ular degeneration the scope of the LPN/LVN. Assessing for
5. Reviewing the health history of systemic manifestations and behaviors,
a client to identify risk for ocular risk factors, and nutritional factors is the
manifestations responsibility of the RN.
6. Performing a routine check of
a client's visual acuity using the
Snellen eye chart
5. After a client has a seizure, which 3. Checking the client's vital signs
action can the nurse delegate to
the unlicensed assistive person- Rationale: Measurement of vital signs is
nel (UAP)? within the education and scope of prac-
tice of UAPs. The nurse should perform
1. Documenting the seizure neurologic checks and document the
2. Performing neurologic checks seizure. Clients with seizures should not
3. Checking the client's vital signs be restrained; however, the nurse may
4. Restraining the client for protec- guide the client's movements, if neces-
tion sary, to prevent injury.
6. The nurse is working in a hos- 2. Collecting data about the patients' re-
pice facility for patients with sponses to medications used for pain
acquired immunodeficiency syn- and anorexia
drome (AIDS). The facility is
1. DELEGATION
2. The team is providing emergency 4. Applying oxygen per nasal cannula as
care to a client who received an ordered
excessive dose of opioid pain
medication. Which task is best to Rationale: The LPN/LVN is well trained
assign to the LPN/LVN? to administer 02 via nasal cannula. This
client is considered unstable; therefore,
1. Calling the health care provider the RN should take responsibility for
(HCP) to report SBAR (situation, administering drugs and monitoring re-
background, assessment, recom- sponses to therapy, which include the
mendation) effects on the respiratory system. The
2. Giving naloxone and evaluating RN should also take responsibility to
response to therapy communicate with the HCP for ongoing
3. Monitoring the respiratory sta- treatment and therapy.
tus for the first 30 minutes
4. Applying oxygen per nasal can-
nula as ordered
3. In the care of a patient with neu- 1. Taking vital signs every 4 hours
tropenia, what tasks should the 2. Reporting temperature of more than
nurse instruct unlicensed assis- 100.4°F (38°C)
tive personnel (UAP) to perform? 4. Gathering the supplies to prepare the
Select all that apply. room for protective isolation
6. Practicing good hand-washing tech-
1. Taking vital signs every 4 hours nique
2. Reporting temperature of more
than 100.4°F (38°C) Rationale: Measuring vital signs and re-
3. Assessing for sore throat, porting on specific parameters, practic-
cough, or burning with urination ing good hand washing, and gathering
4. Gathering the supplies to pre- equipment are within the scope of du-
pare the room for protective isola- ties for a UAP. Assessing for symptoms
tion of infections and superinfections is the
5. Reporting superinfections, responsibility of the RN.
such as candidiasis
6. Practicing good hand-washing
technique
4.
, NCLEX Prep Questions with Complete Solutions 100% Correct
Which tasks are appropriate to as- 1. Administering sulfacetamide sodium
sign to an LPN/LVN who is func- 10% to a child with conjunctivitis
tioning under the supervision of 2. Reviewing hand-washing and hy-
an RN? Select all that apply. giene practices with clients who have
eye infections
1. Administering sulfacetamide 3. Showing clients how to gently cleanse
sodium 10% to a child with con- eyelid margins to remove crusting
junctivitis 6. Performing a routine check of a
2. Reviewing hand-washing and client's visual acuity using the Snellen
hygiene practices with clients eye chart
who have eye infections
3. Showing clients how to gently Rationale: Administering medications,
cleanse eyelid margins to remove reviewing and demonstrating standard
crusting procedures, and performing standard-
4. Assessing nutritional factors ized assessments with predictable out-
for a client with age-related mac- comes in noncomplex cases are within
ular degeneration the scope of the LPN/LVN. Assessing for
5. Reviewing the health history of systemic manifestations and behaviors,
a client to identify risk for ocular risk factors, and nutritional factors is the
manifestations responsibility of the RN.
6. Performing a routine check of
a client's visual acuity using the
Snellen eye chart
5. After a client has a seizure, which 3. Checking the client's vital signs
action can the nurse delegate to
the unlicensed assistive person- Rationale: Measurement of vital signs is
nel (UAP)? within the education and scope of prac-
tice of UAPs. The nurse should perform
1. Documenting the seizure neurologic checks and document the
2. Performing neurologic checks seizure. Clients with seizures should not
3. Checking the client's vital signs be restrained; however, the nurse may
4. Restraining the client for protec- guide the client's movements, if neces-
tion sary, to prevent injury.
6. The nurse is working in a hos- 2. Collecting data about the patients' re-
pice facility for patients with sponses to medications used for pain
acquired immunodeficiency syn- and anorexia
drome (AIDS). The facility is
