NCLEX-RN

A nurse is planning which tasks unlicensed assistive personnel (UAP) can take on. Which task is appropriate to assign to the UAP?

• AAdministering oral medications during the scheduled morning medication pass
• BMeasuring and recording vital signs
• CDeveloping an individualized nursing care plan for a newly admitted client
• DAssessing a surgical wound for signs of infection or dehiscence

A client refuses a blood transfusion based on religious beliefs. The nurse should:

• AAdminister the transfusion as ordered
• BContact the client's family to make the decision
• CDocument the refusal and notify the healthcare provider
• DExplain that the refusal could be life-threatening and proceed

A nurse is caring for four clients. Which client should the nurse assess first?

• AA client 1 day post-appendectomy with pain level of 4/10
• BA client with diabetes mellitus who has a blood glucose of 180 mg/dL
• CA client with pneumonia who has an oxygen saturation of 88%
• DA client with a urinary tract infection who has a temperature of 100.2°F

The nurse is preparing to delegate tasks for the shift. Which of the 'Five Rights of Delegation' should the nurse consider?

• ARight task, right circumstance, right person, right direction, right supervision
• BRight medication, right dose, right route, right time, right patient
• CRight diagnosis, right treatment, right outcome, right documentation, right billing
• DRight privacy, right access, right disclosure, right amendment, right accounting

A nurse witnesses a colleague remove controlled substances from the medication dispensing system without documenting administration. The nurse should:

• AConfront the colleague directly
• BWait to see if it happens again
• CReport the incident to the nurse manager
• DDocument the observation in the client's chart

A client is scheduled for surgery but tells the nurse they don't understand what the surgeon explained. The nurse should:

• AExplain the surgery to the client
• BHave the client sign the consent form anyway
• CNotify the surgeon to clarify the procedure
• DTell the client their questions aren't important

The charge nurse is making shift assignments. Which client should be assigned to the most experienced nurse?

• AA client who is 2 days post-hip replacement and currently ambulating independently with a…
• BA client with a new diagnosis of type 2 diabetes mellitus who requires insulin self-injec…
• CA client who is 4 hours post-cardiac catheterization via femoral approach
• DA client with chronic kidney disease who is scheduled for routine outpatient hemodialysis

A client with a terminal illness tells the nurse they want to stop all treatment. The client is alert and oriented. The nurse should:

• AEncourage the client to continue treatment despite their stated wishes
• BContact the client's family so they can make the decision instead
• CSupport the client's right to make this decision
• DTell the client that stopping treatment is not a good decision

Which task can the RN assign to an LPN/LVN?

• APerform initial client assessment
• BAdminister IV push medications
• CAdminister oral medications
• DDevelop the nursing care plan

A nurse receives a verbal order from a physician over the phone. The most appropriate action is to:

• AWrite the order in the chart and sign the physician's name to it
• BRead back the order and document it with date, time, and signature
• CWait until the physician arrives on the unit to write the order in person
• DAsk another nurse on the unit to listen in on the same order

A nurse discovers that a medication error occurred on the previous shift. The appropriate action is to:

• AWait to see if the client shows any adverse effects
• BReport the error and complete an incident report
• CTell the nurse who made the error to file the report
• DKeep it quiet to protect the colleague

A client asks to see their medical records. The nurse should:

• ATell the client that they are not permitted to see their own records
• BAllow the client to review their own medical records in accordance with HIPAA and facilit…
• CRemove certain pages from the chart before showing the client
• DTell the client to contact their lawyer to obtain the records