NCLEX Prep Final Exam
a nurse has been asked to administer a drug by IV push. she is uncertain whether or not this
task falls within her scope of practice. the nurse knows that which of the following are BEST
sources to refer to for info related to her scope of practice in her situation? (SATA)
a. hospital and unit policies and procedures
b. nurse practice act
c. ordering physician
d. hospital pharmacist - ANS-a, b
an RN is in charge of a team on a m/s unit that includes an LPN. the rn understands that which
of the following is an activity that falls within the scope of practice of an lpn?
a. administer oral meds to a patient
b. collaborate with social servies to develop a discharge plan
c. formulate a nursing diagnosis
d. develop a policy - ANS-a
the nurse is learning how to use the hospital's new electronic medication administration record.
the nurse knows this tool has the potential to do which of the following? (SATA)
a. reduce medication administration errors
b. improve access to information at the point of care
c. eliminate the need for the nurse to document med admin
d. eliminate the need for the nurse to verify dose calculations - ANS-a, b
the nurse administers the first dose of chemotherapy to a patient on an oncology unit. the nurse
knows that which of the following activities is appropriate to delegate to the lpn?
a. obtain the patients blood pressure
b. provide teaching about the side effects of chemo
c. administer the second dose of chemo
d. flush the patients central line with heparin - ANS-a
the nurse is preparing to transfer a patient to the OR. she knows that adhering to the hospital
policy for patient handoff's BEST ensures which of the following?
,a. case management
b. continuity of care
c. confidentiality protection
d. collaboration - ANS-b.
the nurse in a maternity unit is caring for a patient who has just delivered twins. the patient
voices concerns about her ability to manage when she gets home. which of the following
statements BEST illustrates the quality care delivery by the nurse? (SATA)
a. "just focus on how lucky you are to have 2 healthy babies"
b. "we can arrange for follow-up visits with a home health nurse"
c. "here is some info on support groups for parents of multiples"
d. "you will find it easier to formula feed your babies at home" - ANS-b, c
the nurse wants to delegate the task of showering an elderly patient in a wheelchair to the
nursing assistive personnel. before delegating a task to the NAP, the nurse should FIRST
ensure that which of the following is accomplished?
a. the NAP is supervised at all times
b. the NAP demonstrated competency for the task during orientation
c. the NAP has performed the task beforE
d. the NAP has received the assignment during report - ANS-b.
the nurse noticed an increase in the prevalence of pressure ulcers among patients in an ICU>
she documented her findings and worked with her manager to develop and implement a new
policy using a pressure ulcer risk assessment scale. which of the following best describes the
nurse's actions?
a. case management
b. advocacy
c. quality improvement
d. collaboration - ANS-c.
a 34-year old woman who developed stevens-johnson syndrome while undergoing treatment
with carbamazepine is being transferred in stable condition from the ICU to the medical unit.
there are 4 beds available. the nurse knows the BEST choice of roommates for this patient is
which of the following?
a. a 40-year-old man with MRSA
b. a 28-year-old woman diagnosed with diarrhea
,c. a 72-year-old man with fever of unknown origin
d. a 68-year-old with atrial fibrillation - ANS-d.
after receiving report at the start of the evening shift, which of the following patients should the
nurse attend to first?
a. a man undergoing treatment for non-Hodgkins lymphoma with a potassium level of 7.5 mEq/L
b. a woman with sickle-cell anemia with pain of 6 on a scale of 1-10
c. a woman with ovarian cancer waiting to be discharged
d. a man with COPD and a pulse ox of 96% RA - ANS-a.
the nurse discovers a patient on the floor in the hospital room. after examining the patient and
assisting him safely back to bed, which of the following should thenurse do FIRST?
a. file an incident report
b. put the bed alarm back on
c. find a patient sitter to sit with the patient to prevent further falls
d. notify the nurse manager - ANS-b.
the provider verbally orders a medication for a pt during an emergency code. which of the
following should the nurse do?
a. repeat the order back to the provider for confirmation and administer it
b. retrieve the med and administer it
c. write the order down, retrieve it, and administer it
d. read the order to another nurse, have the nurse retrieve the med, and stay with the patient -
ANS-a.
the nurse is preparing to administer a unit of PRBCs to an anemic pt. after obtaining the blood
from the blood bank, the nurse must begin administering it within which of the following time
periods?
a. 15 mins
b. 45 mins
c. 60 mins
d. 30 mins - ANS-d
an older adult has been admitted with diagnosis for stroke and a history of dementia. which of
the following nursing diagnosis has the highest priority for this pt.
a. bathing/hygiene self-care deficit
b. risk for injury
c. impaired physical mobility
d. disturbed thought process - ANS-b.
, in the ED, the nurse assesses a 4-year-old child suspected of having measles. which of the
following kinds of precautions should the nurse initiate?
a. contact
b. droplet
c. airborne
d. reverse - ANS-c.
the nurse has just administered insulin to a diabetic pt. in which of the following ways should the
nurse dispose of the needle?
a. break the needle and dispose of it in the nearest sharps container
b. discard the needle in the sharps container
c. re-cap the needle and discard it in the nearest biohazard container
d. re-cap the needle and discard it in the nearest puncture-resistant container - ANS-b.
the nurse completes a PICC line dressing change for a home care pt. when removing the PPE,
the nurse should do which of the following?
a. remove the gloves then the mask
b. remove only the mask; there is no need to remove the gloves
c. remove the mask and then the gloves
d. remove only the gloves; there is no need for a mask - ANS-a.
the nurse is making a home visit to an elderly pt during the winter. the nurse notices upon arrival
the the pt has the oven turned on with the oven door open, using it as a form of heat. which of
the following actions by the nurse is most appropriate?
a. take care of pts medical needs and do not get invovled in the pts private matters
b. shut the oven off and continue w/ home visit
c. have a meeting with the patient and family and warn them of the fire and safety risks of using
the oven for heat
d. report the event to the local fire department - ANS-c.
the nurse is developing a care plan for a patient with Hepatitis C. the nurse knows that the
primary route of transmission of this hepatitis virus is whihc of the following?
a. contaminated food
b. sputum
c. feces
d. blood - ANS-d.
a nurse has been asked to administer a drug by IV push. she is uncertain whether or not this
task falls within her scope of practice. the nurse knows that which of the following are BEST
sources to refer to for info related to her scope of practice in her situation? (SATA)
a. hospital and unit policies and procedures
b. nurse practice act
c. ordering physician
d. hospital pharmacist - ANS-a, b
an RN is in charge of a team on a m/s unit that includes an LPN. the rn understands that which
of the following is an activity that falls within the scope of practice of an lpn?
a. administer oral meds to a patient
b. collaborate with social servies to develop a discharge plan
c. formulate a nursing diagnosis
d. develop a policy - ANS-a
the nurse is learning how to use the hospital's new electronic medication administration record.
the nurse knows this tool has the potential to do which of the following? (SATA)
a. reduce medication administration errors
b. improve access to information at the point of care
c. eliminate the need for the nurse to document med admin
d. eliminate the need for the nurse to verify dose calculations - ANS-a, b
the nurse administers the first dose of chemotherapy to a patient on an oncology unit. the nurse
knows that which of the following activities is appropriate to delegate to the lpn?
a. obtain the patients blood pressure
b. provide teaching about the side effects of chemo
c. administer the second dose of chemo
d. flush the patients central line with heparin - ANS-a
the nurse is preparing to transfer a patient to the OR. she knows that adhering to the hospital
policy for patient handoff's BEST ensures which of the following?
,a. case management
b. continuity of care
c. confidentiality protection
d. collaboration - ANS-b.
the nurse in a maternity unit is caring for a patient who has just delivered twins. the patient
voices concerns about her ability to manage when she gets home. which of the following
statements BEST illustrates the quality care delivery by the nurse? (SATA)
a. "just focus on how lucky you are to have 2 healthy babies"
b. "we can arrange for follow-up visits with a home health nurse"
c. "here is some info on support groups for parents of multiples"
d. "you will find it easier to formula feed your babies at home" - ANS-b, c
the nurse wants to delegate the task of showering an elderly patient in a wheelchair to the
nursing assistive personnel. before delegating a task to the NAP, the nurse should FIRST
ensure that which of the following is accomplished?
a. the NAP is supervised at all times
b. the NAP demonstrated competency for the task during orientation
c. the NAP has performed the task beforE
d. the NAP has received the assignment during report - ANS-b.
the nurse noticed an increase in the prevalence of pressure ulcers among patients in an ICU>
she documented her findings and worked with her manager to develop and implement a new
policy using a pressure ulcer risk assessment scale. which of the following best describes the
nurse's actions?
a. case management
b. advocacy
c. quality improvement
d. collaboration - ANS-c.
a 34-year old woman who developed stevens-johnson syndrome while undergoing treatment
with carbamazepine is being transferred in stable condition from the ICU to the medical unit.
there are 4 beds available. the nurse knows the BEST choice of roommates for this patient is
which of the following?
a. a 40-year-old man with MRSA
b. a 28-year-old woman diagnosed with diarrhea
,c. a 72-year-old man with fever of unknown origin
d. a 68-year-old with atrial fibrillation - ANS-d.
after receiving report at the start of the evening shift, which of the following patients should the
nurse attend to first?
a. a man undergoing treatment for non-Hodgkins lymphoma with a potassium level of 7.5 mEq/L
b. a woman with sickle-cell anemia with pain of 6 on a scale of 1-10
c. a woman with ovarian cancer waiting to be discharged
d. a man with COPD and a pulse ox of 96% RA - ANS-a.
the nurse discovers a patient on the floor in the hospital room. after examining the patient and
assisting him safely back to bed, which of the following should thenurse do FIRST?
a. file an incident report
b. put the bed alarm back on
c. find a patient sitter to sit with the patient to prevent further falls
d. notify the nurse manager - ANS-b.
the provider verbally orders a medication for a pt during an emergency code. which of the
following should the nurse do?
a. repeat the order back to the provider for confirmation and administer it
b. retrieve the med and administer it
c. write the order down, retrieve it, and administer it
d. read the order to another nurse, have the nurse retrieve the med, and stay with the patient -
ANS-a.
the nurse is preparing to administer a unit of PRBCs to an anemic pt. after obtaining the blood
from the blood bank, the nurse must begin administering it within which of the following time
periods?
a. 15 mins
b. 45 mins
c. 60 mins
d. 30 mins - ANS-d
an older adult has been admitted with diagnosis for stroke and a history of dementia. which of
the following nursing diagnosis has the highest priority for this pt.
a. bathing/hygiene self-care deficit
b. risk for injury
c. impaired physical mobility
d. disturbed thought process - ANS-b.
, in the ED, the nurse assesses a 4-year-old child suspected of having measles. which of the
following kinds of precautions should the nurse initiate?
a. contact
b. droplet
c. airborne
d. reverse - ANS-c.
the nurse has just administered insulin to a diabetic pt. in which of the following ways should the
nurse dispose of the needle?
a. break the needle and dispose of it in the nearest sharps container
b. discard the needle in the sharps container
c. re-cap the needle and discard it in the nearest biohazard container
d. re-cap the needle and discard it in the nearest puncture-resistant container - ANS-b.
the nurse completes a PICC line dressing change for a home care pt. when removing the PPE,
the nurse should do which of the following?
a. remove the gloves then the mask
b. remove only the mask; there is no need to remove the gloves
c. remove the mask and then the gloves
d. remove only the gloves; there is no need for a mask - ANS-a.
the nurse is making a home visit to an elderly pt during the winter. the nurse notices upon arrival
the the pt has the oven turned on with the oven door open, using it as a form of heat. which of
the following actions by the nurse is most appropriate?
a. take care of pts medical needs and do not get invovled in the pts private matters
b. shut the oven off and continue w/ home visit
c. have a meeting with the patient and family and warn them of the fire and safety risks of using
the oven for heat
d. report the event to the local fire department - ANS-c.
the nurse is developing a care plan for a patient with Hepatitis C. the nurse knows that the
primary route of transmission of this hepatitis virus is whihc of the following?
a. contaminated food
b. sputum
c. feces
d. blood - ANS-d.
