NCLEX Computer Adaptive Testing
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1. A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan?
2. A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?
3. When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response?
4. A newly oriented home health nurse on a first visit checks the client’s vital signs and obtains a blood sample for an international normalization ratio (INR). After completion of these tasks, the client asks the nurse to straighten the blankets on the bed. What is the nurse’s most appropriate response?
5. What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients?
6. A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter’s behavior reflect?
7. Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission?
8. A nurse is evaluating the appropriateness of a family member’s initial response to grief. What is the most important factor for the nurse to consider?
9. During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse’s action be interpreted?
10. A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch?
11. Which nursing behavior is an intentional tort?
12. A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child?
13. A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen?
14. A client is voluntarily admitted to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy?
15. A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?
16. A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child’s temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurologic impairment. Legally, who is responsible for the child’s injury?
17. A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a registered professional nurse. What group primarily is protected under the regulations of the practice of nursing?
18. A nurse is evaluating a client’s knowledge of ambulating with crutches. The nurse identifies the need for further teaching when the client states, “I must practice:
19. A nurse is instructing a group of volunteer nurses on the technique of administering the smallpox vaccine. What injection method should the nurse teach?
20. The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding?
21. A pregnant client is now in the third trimester. The client tells the nurse, “I want to be knocked out for the birth.” How should the nurse respond?
22. A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the clients plan of care include?
23. A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, “See, the strap is worn just at the spot where it snapped.” What is the nurses accountability regarding this incident?
24. A nurse is teaching staff members about the legal terminol ogy used in child abuse. What definition of battery should the nurse include in the teaching?
25. A 3-year-old child with eczema of the face and arms has disregarded the nurse’s warnings to “stop scratching, or else!” The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler’s arms to the crib sides, saying, “I’m going to teach you one way or another.” How should the nurse’s behavior be interpreted?
26. Which nursing action is protected from legal action?
27. A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction?
28. A nurse is reviewing a client’s plan of care. What is the determining factor in the revision of the plan?
29. A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion?
30. What should a nurse consider when trying to promote affective learning in a client with a newly diagnosed disease?
31. A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation?
32. An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse’s responsibility in this situation?
33. A nurse is teaching a client how to use the call bell system. Which level of Maslow’s Hierarchy of Needs does this nursing action address?
34. A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child’s emotional development?
35. The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah’s Witnesses. What action should the nurse take?
36. A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse’s behavior be interpreted?
37. A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication?
38. A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client?
39. Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action?
40. A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence?
41. What should the nurse do initially when obtaining consent for surgery?
42. A toddler screams and cries noisily after parental visits, dis turbing all the other children. When the crying is particu larly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted?
43. What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent?
44. A nurse in the health clinic is counseling a college student who was recently diagnosed with asthma. On what aspect of care should the nurse focus?
45. Several recently licensed registered nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance?
46. A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements orders to start an IV infusion, administer oxygen, and draw blood for laboratory tests. The client’s apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be all right, and that everything is under control. What is the best interpretation of the nurse’s statement?
47. Nurses are held responsible for the commission of a tort. The nurse understands that a tort is:
48. A client is receiving an antihypertensive drug intravenously for control of severe hypertension. The client’s blood pressure is unstable and is 160/94 mm Hg before the infusion. Fifteen minutes after the infusion is started, the blood pressure increases to 180/100 mm Hg. Which type of response is the client demonstrating?
49. A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful?
50. A client who has been told she needs a hysterectomy for cervical cancer is upset about being unable to have a third child. What is the next nursing action?