NCLEX-PN Exam Review V1
1. Which is a recommended guideline for safe computerized charting?
1) Passwords to the computer system should only be changed if lost.
2) Computer terminals may be left unattended during client-care activities.
3) Accidental deletions from the computerized file need to be reported to the nursing manager
or supervisor.
4) Copies of printouts from computerized files should be kept on a clipboard at the nurses' station
for other nurses to access.: 3; After any inadvertent deletions of permanent computerized
records, the nurse should type an explanation into the computer file with the date, time, and his
or her initials. The nurse should also contact the nursing manager or supervisor with a written
explanation of the situation.
2. The LPN enters a client's room and finds the client sitting on the floor. The LPN calls the
RN, who checks the client thoroughly and then assists theclient back into bed. The LPN
completes an incident report, and the nursing supervisor and health care provider (HCP) are
notified of the incident. Whichis the next nursing action regarding the incident?
1) Place the incident report in the client's chart.
2) Make a copy of the incident report for the HCP.
3) Document a complete entry in the client's record concerning this incident.
4) Document in the client's record that an incident report has been complet-ed.: 3; The
incident report is confidential and privileged information, and it shouldnot be copied, placed
in the chart, or have any reference made to it in the client'srecord. The incident report is not a
substitute for a complete entry in the client's record concerning the incident.
3. An unconscious client, bleeding profusely, is brought to the emergency department after
a serious accident. Surgery is required immediately to savethe client's life. With regard to
informed consent for the surgical procedure, which is the best action?
1) Call the nursing supervisor to initiate a court order for the surgical proce-dure.
2) Try calling the client's spouse to obtain telephone consent before thesurgical procedure.
3) Ask the friend who accompanied the client to the emergency department tosign the consent
form.
4) Transport the client to the operating department immediately, as required by the health
,care provider, without obtaining an informed consent.: 4; Only 2instances in which the
informed consent of an adult client is not needed: when an emergency is present and delaying
treatment for the purpose of obtaining consentwould result in injury or death to the client, and
when the client waives the right to give consent.
4. The nurse arrives at work and is told to report (float) to the pediatric unit for the day
because the unit is understaffed and needs additional nurses to care for the clients. The nurse
has never worked in the pediatric unit. Which isthe appropriate nursing action?
1) Call the hospital lawyer.
2) Call the nursing supervisor.
3) Refuse to float to the pediatric unit.
4) Report to the pediatric unit and identify tasks that can be safely per- formed.: 4; Floating is
an acceptable legal practice used by hospitals to solve theirunderstaffing problems. Legally
the nurse cannot refuse to float unless a union contact guarantees that the nurse can only work
in a specified area or the nurse can prove a lack of knowledge for the performance of assigned
tasks. When facedwith this situation, the nurse should identify potential areas of harm to the
client.
5. The nurse enters a client's room and notes that the client's lawyer is present and that the
client is preparing a living will.The living will requires thatthe client's signature be witnessed,
and the client asks the nurse to witness the signature. Which is the appropriate nursing action?
1) Decline to sign the will.
2) Sign the will as a witness to the signature only.
3) Call the hospital lawyer before signing the will.
4) Sign the will, clearly identifying credentials and employment agency.: 1; Living wills are
required to be in writing and signed by the client. The client's signature either must be
witnesses by specified individuals or notarized. Many statesprohibit any employee from being a
witness, including the nurse in a facility where a client is receiving care.
6. The nurse finds the client lying on the floor. The nurse calls the RN, who checks the client
and then calls the nursing supervisor and the health care provider to inform them of the
occurrence. The nurse completes the incidentreport for which purpose?
1) Providing clients with necessary stabilizing treatments.
2) A method of promoting quality care and risk management.
, 3) Determining the effectiveness of interventions in relation to outcomes.
4) The appropriate method of reporting to local, state, and federal agencies.: 2; Proper
documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a
result of the occurrence are internal to the institution. Documentation on the incident report
allows the nurse and administration to review the quality of care and determine any potential
risks present.
7. The nurse observes that a client received pain medication an hour ago from another nurse,
but the client still has severe pain. The nurse has previously observed this same occurrence.
Based on the nurse practice act, theobserving nurse should plan to take which action?
1) Report the information to the police.
2) Call the impaired nurse organization.
3) Talk with the nurse who gave the medication.
4) Report the information to a nursing supervisor.: 4; Nurse practice acts re- quire reporting
the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice
of nursing and may develop plans for treatment and supervision. This suspicion needs to be
reported to the nursing supervisor, who willthen report to the board of nursing.
8. A client has died, and the nurse asks a family member about the funeral arrangements.
The family member refuses to discuss the issue. Which is theappropriate nursing action?
1) Show acceptance of feelings.
2) Provide information needed for decision making.
3) Suggest a referral to a mental health professional.
4) Remain with the family member without discussing funeral arrangements.-
: 4; The family member is exhibiting the first stage of grief (denial) and the nurseshould
remain with the family member.
9. A nurse lawyer provides an education session to the nursing staff re- garding client rights.
The nurse asks the lawyer to describe an example thatmay relate to the invasion of client
privacy. Which nursing action indicates aviolation of client privacy?
1) Threatening to place a client in restraints.
2) Performing a surgical procedure without consent.
1. Which is a recommended guideline for safe computerized charting?
1) Passwords to the computer system should only be changed if lost.
2) Computer terminals may be left unattended during client-care activities.
3) Accidental deletions from the computerized file need to be reported to the nursing manager
or supervisor.
4) Copies of printouts from computerized files should be kept on a clipboard at the nurses' station
for other nurses to access.: 3; After any inadvertent deletions of permanent computerized
records, the nurse should type an explanation into the computer file with the date, time, and his
or her initials. The nurse should also contact the nursing manager or supervisor with a written
explanation of the situation.
2. The LPN enters a client's room and finds the client sitting on the floor. The LPN calls the
RN, who checks the client thoroughly and then assists theclient back into bed. The LPN
completes an incident report, and the nursing supervisor and health care provider (HCP) are
notified of the incident. Whichis the next nursing action regarding the incident?
1) Place the incident report in the client's chart.
2) Make a copy of the incident report for the HCP.
3) Document a complete entry in the client's record concerning this incident.
4) Document in the client's record that an incident report has been complet-ed.: 3; The
incident report is confidential and privileged information, and it shouldnot be copied, placed
in the chart, or have any reference made to it in the client'srecord. The incident report is not a
substitute for a complete entry in the client's record concerning the incident.
3. An unconscious client, bleeding profusely, is brought to the emergency department after
a serious accident. Surgery is required immediately to savethe client's life. With regard to
informed consent for the surgical procedure, which is the best action?
1) Call the nursing supervisor to initiate a court order for the surgical proce-dure.
2) Try calling the client's spouse to obtain telephone consent before thesurgical procedure.
3) Ask the friend who accompanied the client to the emergency department tosign the consent
form.
4) Transport the client to the operating department immediately, as required by the health
,care provider, without obtaining an informed consent.: 4; Only 2instances in which the
informed consent of an adult client is not needed: when an emergency is present and delaying
treatment for the purpose of obtaining consentwould result in injury or death to the client, and
when the client waives the right to give consent.
4. The nurse arrives at work and is told to report (float) to the pediatric unit for the day
because the unit is understaffed and needs additional nurses to care for the clients. The nurse
has never worked in the pediatric unit. Which isthe appropriate nursing action?
1) Call the hospital lawyer.
2) Call the nursing supervisor.
3) Refuse to float to the pediatric unit.
4) Report to the pediatric unit and identify tasks that can be safely per- formed.: 4; Floating is
an acceptable legal practice used by hospitals to solve theirunderstaffing problems. Legally
the nurse cannot refuse to float unless a union contact guarantees that the nurse can only work
in a specified area or the nurse can prove a lack of knowledge for the performance of assigned
tasks. When facedwith this situation, the nurse should identify potential areas of harm to the
client.
5. The nurse enters a client's room and notes that the client's lawyer is present and that the
client is preparing a living will.The living will requires thatthe client's signature be witnessed,
and the client asks the nurse to witness the signature. Which is the appropriate nursing action?
1) Decline to sign the will.
2) Sign the will as a witness to the signature only.
3) Call the hospital lawyer before signing the will.
4) Sign the will, clearly identifying credentials and employment agency.: 1; Living wills are
required to be in writing and signed by the client. The client's signature either must be
witnesses by specified individuals or notarized. Many statesprohibit any employee from being a
witness, including the nurse in a facility where a client is receiving care.
6. The nurse finds the client lying on the floor. The nurse calls the RN, who checks the client
and then calls the nursing supervisor and the health care provider to inform them of the
occurrence. The nurse completes the incidentreport for which purpose?
1) Providing clients with necessary stabilizing treatments.
2) A method of promoting quality care and risk management.
, 3) Determining the effectiveness of interventions in relation to outcomes.
4) The appropriate method of reporting to local, state, and federal agencies.: 2; Proper
documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a
result of the occurrence are internal to the institution. Documentation on the incident report
allows the nurse and administration to review the quality of care and determine any potential
risks present.
7. The nurse observes that a client received pain medication an hour ago from another nurse,
but the client still has severe pain. The nurse has previously observed this same occurrence.
Based on the nurse practice act, theobserving nurse should plan to take which action?
1) Report the information to the police.
2) Call the impaired nurse organization.
3) Talk with the nurse who gave the medication.
4) Report the information to a nursing supervisor.: 4; Nurse practice acts re- quire reporting
the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice
of nursing and may develop plans for treatment and supervision. This suspicion needs to be
reported to the nursing supervisor, who willthen report to the board of nursing.
8. A client has died, and the nurse asks a family member about the funeral arrangements.
The family member refuses to discuss the issue. Which is theappropriate nursing action?
1) Show acceptance of feelings.
2) Provide information needed for decision making.
3) Suggest a referral to a mental health professional.
4) Remain with the family member without discussing funeral arrangements.-
: 4; The family member is exhibiting the first stage of grief (denial) and the nurseshould
remain with the family member.
9. A nurse lawyer provides an education session to the nursing staff re- garding client rights.
The nurse asks the lawyer to describe an example thatmay relate to the invasion of client
privacy. Which nursing action indicates aviolation of client privacy?
1) Threatening to place a client in restraints.
2) Performing a surgical procedure without consent.
