RN test 3 NCLEX questions
The charge nurse overhears an AP yelling loudly to a patient who is hard
of hearing,
while transferring them from the bed to a chair. Upon entering the room,
which
by the response
charge nurse is most
appropriate?
a. "Please speak more quietly so you don't disturb the other
patients."
b. "Let me help you with your transfer
technique."
c. "When you are finished, be sure to apologize for
shouting."
d. "When your patient is safe and comfortable, meet me at the desk."
Correct
d. answers
The charge nurse should direct the AP to see to the patient's safety,
thenconcerns
any address privately. The nurse then can discuss appropriate use of
therapeutic
communicatio
n.
A public health nurse is leaving the home of a young mother who has an
infant with
special needs. The neighbor states, "How is she doing, since the baby's
father is
help?" Whatno is the nurse's best
response?
a. "New mothers need
support."
b. "The lack of a father is
difficult."
c. "How are you
today?"
d. "It is a very sad situation." Correct answers a. The nurse must maintain
confidentiality
when providing care. The statement "New mothers need support" is
a general that all new parents need help. The statement is not
statement
judgmental
family's of "How
roles. the are you today?" is dismissive of the neighbor's
question.
A toddler with vomiting, diarrhea, and dehydration is being seen at an acute
care center.
During the admission interview, what question will the nurse ask the parents
to elicit
most useful
the
information?
a. "Watching your child vomiting and in discomfort must have
been
b. scary."
"This started yesterday,
correct?"
c. "Has this child has had anything to
drink?"
d. Could you tell me the color and approximate amount of the
vomiting?d.Correct
answers Using a clarifying question or comment allows the nurse
to gain an
understanding of the parents' observations, avoiding misunderstandings
that
to ancould lead
inappropriate nursing diagnosis. A reflective question technique
involves
what the repeating
person has said or describes the person's feelings. Assertive
questions
direct, are
demonstrating the ability to stand up for self or others, using open
and honest
communication. Open-ended questions encourage free verbalization and
expression
what of
the parents believe to be
true.
A nurse enters a patient's room and examines the patient's intravenous
(IV) fluids
cardiac and When asked, "who are you?", which response by the
monitor.
nurse is most
appropriat
e?
,a. "I'm just the IV therapist checking
your
b. "I'veIV."been transferred to this division and will be caring
for"I'm
c. you." sorry, my name is John Smith and I am your
nurse."
d. "I am John Smith, your nurse, and I'll be caring for you until 11 PM."
Correct
d. The nurse answersshould identify themselves, ensure the patient knows
what will beand the duration of their
happening,
relationship.
A nurse enters the room of a patient with cancer. The patient is crying and l
states,
so alone." "I fee
How will the nurse best communicate a therapeutic
response?
a. The nurse stands at the patient's bedside and states, "I understand how
you feel.said
mother My the same thing when she
was
b. The ill."nurse places a hand on the patient's arm and states, "You feel
so The
c. alone."nurse stands in the patient's room and asks, "Why do you feel so
alone?
wife has Your
been here every
day."
d. The nurse holds the patient's hand and asks, "Tell me what feeling so
you?"
alone is Correct
like foranswers d. The use of touch conveys acceptance,
and the
implementation of an open-ended question allows the patient time to
verbalize freely.
A primary nurse is preparing a discharge plan for a patient who has been
hospitalized
following a double mastectomy. Which statement is most appropriate for
the nurse
use in the to termination phase of the therapeutic
relationship?
a. "Let's review the progress you've made in meeting
your
b. "I'dgoals."
like to review your medication schedule
with
c. you." to document today's teaching session in the electronic
"I need
health
d. "Should record."
we include your family in today's session?" Correct
answers a. The
termination phase occurs when the conclusion of the initial agreement is
acknowledged.
Discharge planning correlates with the termination phase of a therapeutic
relationship
and the progress toward the patient's goals are
reviewed.
A nursing student is nervous and concerned about working at a clinical
facility.would
action Whichbest decrease anxiety and help ensure successful delivery of
patient
a. care? the established goals of the
Determining
institution
b. Ensuring that verbal and nonverbal communication is
congruent
c. Engaging in self-talk to plan the day and
decrease
d. Speaking fearwith fellow colleagues about how they feel Correct answers c.
Bypositive
in engaging self-talk, or intrapersonal communication, the nursing student
can plan
day, decrease
the fear and anxiety, and enhance clinical
performance.
A nurse says to their nurse manager, "I need the day off, and you didn't
give manager
The it to me!"replies, "I wasn't aware you needed the day off, and it isn't
possibleissince
staffing inadequate." How could the nurse best modify the communication
for a more
positive
interaction?
a. "I placed a request to have 8th of August off for a doctor's
appointment,
scheduled to but I'm
work."
b. "Could I make an appointment to discuss my schedule with you? I
requested
of August off thefor
8tha doctor's
appointment."
,c. "I will need to call in on the 8th of August because I have a doctor's
appointment."
d. "Since you didn't give me the 8th of August off, will I need to find
someone
me?" to work
Correct for b. Effective communication involves
answers
sending clear, and respectful information to the receiver. The nurse
nonthreatening,
identifies
subject ofthe
the meeting and determines a mutually agreed
upon time.
During a nursing staff meeting to discuss delayed documentation,
the nurses agree that they will ensure all vital signs are reported and
unanimously
charted
15 minuteswithin
following assessments. This decision is consistent with which
characteristics
of effective communication? Select all that
apply.
a. Group decision
making
b. Group
leadership
c. Group
power
d. Group
identity
e. Group patterns of
interaction
f. Group cohesiveness Correct answers a, d, e, f. Solving problems
involves
decision group
making; ascertaining the task is important and agreeing to
complete
on time is the task
characteristic of group identity. Group patterns of interaction
involve honest and member support; cohesiveness occurs when members
communication
generally
trust each other, have a high commitment to the group, and a high
degree of
cooperation. Group leadership occurs when groups use effective styles of
leadership
meet goals;towith group power, sources of power are recognized and
appropriately
to accomplish usedgroup
outcomes.
A nurse notices a patient is walking to the bathroom with a stooped
gait, facial and grunting sounds. Based on these nonverbal cues, what
grimacing,
action take
nurse will the
next?
a. Assess for pain and the need for
analgesia.
b. Ask the patient if they feel
anxious.
c. Offer to sit with the patient and listen to their
d. Suggest the patient increase their fluid intake to prevent
feelings.
constipation.
answers Correct who presents with nonverbal communication of a
a. A patient
stooped
facial gait,
grimacing, and grunting sounds is most likely communicating pain.
The nurse
should clarify this nonverbal
behavior.
A nursing student is preparing to administer morning care to a patient. What
question
the studentby is most important to
ask?
a. "Would you prefer a bath or a
shower?"
b. "May I help you with a bed bath now or later this
morning?"
c. "I will be giving you your bath. Do you use soap or
shower
d. gel?"
"I prefer a shower in the evening. When would you like your bath?"
Correct
b. answers
The nurse should ask permission to assist the patient with a bath. This
allows for
patient preferences and consent for care that involves entering the
patient's personal
space
.
, A nurse enters a patient's room and finds them vomiting bright red blood.
After signs,
vital takingthe nurse communicates the event to the health care
provider
SBAR usingWhich
format. the information will the nurse include in the "A" portion of
the SBAR
communicatio
n?
Exhibit: Electronic health record
(EHR)
Past medical
history
Vital
Signs
Peptic
ulcer
T 98.8°F, P 111, RR 20, BP
98/50
Bleeding
disorder
Pulse oximetry
96%
a. Admitted with peptic ulcer and bleeding
disorder
b. Found vomiting in
bathroom
c. Anti-ulcer medication
recommendation
d. Vital signs, oxygen saturation, bright red emesis Correct answers d.
The SBAR
method is used to improve hand-off communication. SBAR, which stands for
Situation,
Background, Assessment, and Recommendations, provides a clear,
structured,
easy to use andframework. Vital signs, oxygen saturation, and the presence of
emesis
its colorand
are
assessments.
The nurse preceptor and a new graduate nurse on the surgical unit are
performing
preoperative assessments on a group of patients. What statement by
the graduate
nurse requires the preceptor to
intervene?
a. "I am sure everything will be fine; you have nothing to
worry
b. "Whenabout."
you return from surgery, you'll need to cough and deep
breathe."
c. "Many people on this unit have had that procedure with good
success."
d. "You seem fearful, can I answer any questions about the
procedure?"
answers a. TellingCorrect
a patient that everything will be fine is a cliché. This
statement
false gives and may give the patient the impression that the nurse is
assurance
dismissive
a patient's ofconcerns or
condition.
A patient states, "I have been experiencing complications of diabetes."
What
will thequestion
nurse use to elicit additional
information?
a. "Do you take two injections of insulin to prevent
complications?"
b. "Are you using diet and exercise to help regulate your
blood
c. "Havesugar?"
you been experiencing the complications of
d. "Can you tell me about the complications you've experienced?" Correct
neuropathy?"
answers d. information regarding the patient's specific complications of
Requesting
diabetes
guide thewill
nurse to further questioning and related
assessments.
During an interaction with a patient diagnosed with epilepsy, a nurse
notes that
patient the after hearing the plan of care. How does the nurse best
is silent
respond?
all that Select
apply.
a. Fill the silence with lighter conversation directed at
theUse
b. patient.
the time to perform the care that is needed
uninterrupted.
c. Discuss the silence with the patient to ascertain its
meaning.
The charge nurse overhears an AP yelling loudly to a patient who is hard
of hearing,
while transferring them from the bed to a chair. Upon entering the room,
which
by the response
charge nurse is most
appropriate?
a. "Please speak more quietly so you don't disturb the other
patients."
b. "Let me help you with your transfer
technique."
c. "When you are finished, be sure to apologize for
shouting."
d. "When your patient is safe and comfortable, meet me at the desk."
Correct
d. answers
The charge nurse should direct the AP to see to the patient's safety,
thenconcerns
any address privately. The nurse then can discuss appropriate use of
therapeutic
communicatio
n.
A public health nurse is leaving the home of a young mother who has an
infant with
special needs. The neighbor states, "How is she doing, since the baby's
father is
help?" Whatno is the nurse's best
response?
a. "New mothers need
support."
b. "The lack of a father is
difficult."
c. "How are you
today?"
d. "It is a very sad situation." Correct answers a. The nurse must maintain
confidentiality
when providing care. The statement "New mothers need support" is
a general that all new parents need help. The statement is not
statement
judgmental
family's of "How
roles. the are you today?" is dismissive of the neighbor's
question.
A toddler with vomiting, diarrhea, and dehydration is being seen at an acute
care center.
During the admission interview, what question will the nurse ask the parents
to elicit
most useful
the
information?
a. "Watching your child vomiting and in discomfort must have
been
b. scary."
"This started yesterday,
correct?"
c. "Has this child has had anything to
drink?"
d. Could you tell me the color and approximate amount of the
vomiting?d.Correct
answers Using a clarifying question or comment allows the nurse
to gain an
understanding of the parents' observations, avoiding misunderstandings
that
to ancould lead
inappropriate nursing diagnosis. A reflective question technique
involves
what the repeating
person has said or describes the person's feelings. Assertive
questions
direct, are
demonstrating the ability to stand up for self or others, using open
and honest
communication. Open-ended questions encourage free verbalization and
expression
what of
the parents believe to be
true.
A nurse enters a patient's room and examines the patient's intravenous
(IV) fluids
cardiac and When asked, "who are you?", which response by the
monitor.
nurse is most
appropriat
e?
,a. "I'm just the IV therapist checking
your
b. "I'veIV."been transferred to this division and will be caring
for"I'm
c. you." sorry, my name is John Smith and I am your
nurse."
d. "I am John Smith, your nurse, and I'll be caring for you until 11 PM."
Correct
d. The nurse answersshould identify themselves, ensure the patient knows
what will beand the duration of their
happening,
relationship.
A nurse enters the room of a patient with cancer. The patient is crying and l
states,
so alone." "I fee
How will the nurse best communicate a therapeutic
response?
a. The nurse stands at the patient's bedside and states, "I understand how
you feel.said
mother My the same thing when she
was
b. The ill."nurse places a hand on the patient's arm and states, "You feel
so The
c. alone."nurse stands in the patient's room and asks, "Why do you feel so
alone?
wife has Your
been here every
day."
d. The nurse holds the patient's hand and asks, "Tell me what feeling so
you?"
alone is Correct
like foranswers d. The use of touch conveys acceptance,
and the
implementation of an open-ended question allows the patient time to
verbalize freely.
A primary nurse is preparing a discharge plan for a patient who has been
hospitalized
following a double mastectomy. Which statement is most appropriate for
the nurse
use in the to termination phase of the therapeutic
relationship?
a. "Let's review the progress you've made in meeting
your
b. "I'dgoals."
like to review your medication schedule
with
c. you." to document today's teaching session in the electronic
"I need
health
d. "Should record."
we include your family in today's session?" Correct
answers a. The
termination phase occurs when the conclusion of the initial agreement is
acknowledged.
Discharge planning correlates with the termination phase of a therapeutic
relationship
and the progress toward the patient's goals are
reviewed.
A nursing student is nervous and concerned about working at a clinical
facility.would
action Whichbest decrease anxiety and help ensure successful delivery of
patient
a. care? the established goals of the
Determining
institution
b. Ensuring that verbal and nonverbal communication is
congruent
c. Engaging in self-talk to plan the day and
decrease
d. Speaking fearwith fellow colleagues about how they feel Correct answers c.
Bypositive
in engaging self-talk, or intrapersonal communication, the nursing student
can plan
day, decrease
the fear and anxiety, and enhance clinical
performance.
A nurse says to their nurse manager, "I need the day off, and you didn't
give manager
The it to me!"replies, "I wasn't aware you needed the day off, and it isn't
possibleissince
staffing inadequate." How could the nurse best modify the communication
for a more
positive
interaction?
a. "I placed a request to have 8th of August off for a doctor's
appointment,
scheduled to but I'm
work."
b. "Could I make an appointment to discuss my schedule with you? I
requested
of August off thefor
8tha doctor's
appointment."
,c. "I will need to call in on the 8th of August because I have a doctor's
appointment."
d. "Since you didn't give me the 8th of August off, will I need to find
someone
me?" to work
Correct for b. Effective communication involves
answers
sending clear, and respectful information to the receiver. The nurse
nonthreatening,
identifies
subject ofthe
the meeting and determines a mutually agreed
upon time.
During a nursing staff meeting to discuss delayed documentation,
the nurses agree that they will ensure all vital signs are reported and
unanimously
charted
15 minuteswithin
following assessments. This decision is consistent with which
characteristics
of effective communication? Select all that
apply.
a. Group decision
making
b. Group
leadership
c. Group
power
d. Group
identity
e. Group patterns of
interaction
f. Group cohesiveness Correct answers a, d, e, f. Solving problems
involves
decision group
making; ascertaining the task is important and agreeing to
complete
on time is the task
characteristic of group identity. Group patterns of interaction
involve honest and member support; cohesiveness occurs when members
communication
generally
trust each other, have a high commitment to the group, and a high
degree of
cooperation. Group leadership occurs when groups use effective styles of
leadership
meet goals;towith group power, sources of power are recognized and
appropriately
to accomplish usedgroup
outcomes.
A nurse notices a patient is walking to the bathroom with a stooped
gait, facial and grunting sounds. Based on these nonverbal cues, what
grimacing,
action take
nurse will the
next?
a. Assess for pain and the need for
analgesia.
b. Ask the patient if they feel
anxious.
c. Offer to sit with the patient and listen to their
d. Suggest the patient increase their fluid intake to prevent
feelings.
constipation.
answers Correct who presents with nonverbal communication of a
a. A patient
stooped
facial gait,
grimacing, and grunting sounds is most likely communicating pain.
The nurse
should clarify this nonverbal
behavior.
A nursing student is preparing to administer morning care to a patient. What
question
the studentby is most important to
ask?
a. "Would you prefer a bath or a
shower?"
b. "May I help you with a bed bath now or later this
morning?"
c. "I will be giving you your bath. Do you use soap or
shower
d. gel?"
"I prefer a shower in the evening. When would you like your bath?"
Correct
b. answers
The nurse should ask permission to assist the patient with a bath. This
allows for
patient preferences and consent for care that involves entering the
patient's personal
space
.
, A nurse enters a patient's room and finds them vomiting bright red blood.
After signs,
vital takingthe nurse communicates the event to the health care
provider
SBAR usingWhich
format. the information will the nurse include in the "A" portion of
the SBAR
communicatio
n?
Exhibit: Electronic health record
(EHR)
Past medical
history
Vital
Signs
Peptic
ulcer
T 98.8°F, P 111, RR 20, BP
98/50
Bleeding
disorder
Pulse oximetry
96%
a. Admitted with peptic ulcer and bleeding
disorder
b. Found vomiting in
bathroom
c. Anti-ulcer medication
recommendation
d. Vital signs, oxygen saturation, bright red emesis Correct answers d.
The SBAR
method is used to improve hand-off communication. SBAR, which stands for
Situation,
Background, Assessment, and Recommendations, provides a clear,
structured,
easy to use andframework. Vital signs, oxygen saturation, and the presence of
emesis
its colorand
are
assessments.
The nurse preceptor and a new graduate nurse on the surgical unit are
performing
preoperative assessments on a group of patients. What statement by
the graduate
nurse requires the preceptor to
intervene?
a. "I am sure everything will be fine; you have nothing to
worry
b. "Whenabout."
you return from surgery, you'll need to cough and deep
breathe."
c. "Many people on this unit have had that procedure with good
success."
d. "You seem fearful, can I answer any questions about the
procedure?"
answers a. TellingCorrect
a patient that everything will be fine is a cliché. This
statement
false gives and may give the patient the impression that the nurse is
assurance
dismissive
a patient's ofconcerns or
condition.
A patient states, "I have been experiencing complications of diabetes."
What
will thequestion
nurse use to elicit additional
information?
a. "Do you take two injections of insulin to prevent
complications?"
b. "Are you using diet and exercise to help regulate your
blood
c. "Havesugar?"
you been experiencing the complications of
d. "Can you tell me about the complications you've experienced?" Correct
neuropathy?"
answers d. information regarding the patient's specific complications of
Requesting
diabetes
guide thewill
nurse to further questioning and related
assessments.
During an interaction with a patient diagnosed with epilepsy, a nurse
notes that
patient the after hearing the plan of care. How does the nurse best
is silent
respond?
all that Select
apply.
a. Fill the silence with lighter conversation directed at
theUse
b. patient.
the time to perform the care that is needed
uninterrupted.
c. Discuss the silence with the patient to ascertain its
meaning.
