NCLEX Style Multiple Choice Exam Answer Key

## NCLEX Style Multiple Choice Exam This exam consists of 45 multiple-choice questions covering the specified topics, based solely on the provided source material. *** ### Legal Issues (3 Questions) **1. A patient suffers harm because the Registered Nurse (RN) failed to monitor vital signs in a timely fashion according to policy. This failure to carry out a duty that directly caused patient injury is categorized as which type of unintentional tort?** A. Assault B. False imprisonment C. Malpractice D. Battery **2. The nurse is witnessing the signing of an informed consent form by a competent adult patient. By signing the form, the nurse confirms which fact?** A. The nurse has verified that the patient understands all risks and benefits of the procedure. B. The nurse explained the procedure to the patient on behalf of the health care provider. C. The patient voluntarily gave consent, the signature is authentic, and the patient appears to be competent. D. The nurse agrees that the medical treatment is the best possible option for the patient. **3. A student nurse is providing direct patient care in the clinical setting. Which statement accurately describes the nursing student's legal responsibility?** A. The student is covered by the institution's insurance and is not liable for harm. B. The student is only liable if the supervising instructor is also found negligent. C. The student is liable if their actions cause harm to patients, and is expected to perform as a professional when rendering care. D. The student is liable only for unintentional torts, not intentional torts. ### Role of the Nurse (2 Questions) **4. When the nurse focuses on the diagnosis and treatment of human responses and acts to protect and optimize a patient's health, this practice aligns with which primary role, as defined by the American Nurses Association (ANA)?** A. Manager B. Researcher C. Collaborator D. Care provider **5. Which of the following historical actions is attributed to Florence Nightingale, the founder of modern nursing?** A. Establishing the American Red Cross (Clara Barton). B. Serving as Superintendent of the U.S. Navy Nurse Corps. C. Establishing nursing as a respected profession distinct from the medical profession. D. Becoming America's first trained nurse (Linda Richards). ### Ethics (2 Questions) **6. Which term describes the complex anguish that healthcare professionals experience when their fundamental beliefs of what is right and wrong or established ethical principles are challenged?** A. Ethics of Consequence B. Moral resilience C. Moral distress D. Ethical responsibility **7. A patient is about to undergo a controversial orthopedic procedure that may cause periods of pain, but the procedure may be the patient’s only remaining treatment choice. This scenario presents a potential conflict related to which ethical principle, which generally guides the nurse to "do no harm"?** A. Autonomy B. Justice C. Beneficence D. Nonmaleficence ### Vital signs (2 Questions) **8. The nurse is assessing the vital signs of an adult patient. Which parameter falls within the acceptable range for a healthy adult?** A. Pulse rate of 55 BPM. B. Respiratory rate of 28 breaths per minute. C. Blood pressure of 144/90 mmHg. D. Respiratory rate of 12-20 breaths per minute. **9. A postoperative patient is noted to be breathing rapidly (tachypnea). According to clinical judgment principles used during vital sign assessment, what is the nurse's priority immediate action?** A. Notify the physician immediately. B. Ask the patient if they are experiencing pain. C. Assess the oxygen saturation (SpO2). D. Document the respiratory rate in the electronic medical record (EMR). ### Hygiene (2 Questions) **10. A purpose of bathing a patient, beyond routine hygienic care, is to promote which physiological action?** A. Reducing the patient’s basal metabolic rate (BMR). B. Promoting circulation and blood flow. C. Preventing circulatory stasis in the lower extremities. D. Decreasing the possibility of developing hypothermia. **11. The nurse has completed a bed bath for a patient. Before leaving the patient’s room, the most appropriate safety intervention the nurse should implement is to:** A. Leave the bed in a position that is comfortable for the caregiver. B. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach. C. Place the call light within reach and ensure the intravenous (IV) pump is unplugged. D. Leave the bed elevated to caregiver working height and lower all four side rails. ### Mobility (3 Questions) **12. An immobile patient is at risk for developing complications due to decreased muscle activity and circulatory stasis. Which complication is directly associated with pooled blood combined with weakened calf muscles?** A. Muscle atrophy B. Pressure injuries C. Deep Vein Thrombosis (DVT) D. Negative nitrogen balance **13. The nurse is educating an immobile patient's family on interventions to maintain skin integrity. To reduce the risk of pressure injury formation, the nurse instructs the family to turn the patient at least every:** A. 4 hours. B. 3 hours. C. 2 hours. D. Hour. **14. A patient recovering from a stroke has weakness in their left leg and is learning to ambulate with a cane. The nurse correctly teaches the patient to hold the cane on which side of the body?** A. On the left side (weaker side). B. On the right side (stronger side). C. In the center, using both hands for support. D. It does not matter which side, as long as the cane is advanced first. ### Physical Assessment (7 Questions) **15. Which of the following is an example of objective data the nurse might gather during a physical assessment?** A. The patient reports severe nausea. B. The patient’s spouse states the patient is dizzy. C. The patient's reported pain rating of 8/10. D. The patient's blood pressure is 144/76 mmHg. **16. The nurse is conducting a General Survey during the physical examination. Which characteristic would be documented as part of the General Survey?** A. Clubbing of the fingernails B. Pupil equality and reactivity (PERRLA) C. Age, gait, posture, and hygiene D. Presence of bowel sounds (borborygmi) **17. When auscultating the patient’s chest, the nurse hears soft, breezy sounds located primarily over the periphery of the lung fields. The inspiratory phase is longer than the expiratory phase (I>E). These findings describe which type of normal breath sound?** A. Bronchial B. Bronchovesicular C. Adventitious D. Vesicular **18. To ensure the abdomen is assessed accurately, the nurse should begin the assessment with inspection, followed by which technique?** A. Deep palpation. B. Percussion. C. Auscultation. D. Light palpation. **19. When evaluating peripheral arterial pulses, the nurse notes a strong pulse that is difficult to obliterate. This finding should be documented using which pulse strength score?** A. 1 (diminished, barely palpable) B. 2 (expected/normal) C. 3 (full pulse, increased) D. 4 (bounding pulse) **20. The nurse is assessing a pigmented lesion on a patient's forearm. The nurse must document findings related to Asymmetry, Border irregularity, Color, and Diameter, collectively known as:** A. LOC (Level of Consciousness) B. BMR (Basal Metabolic Rate) C. PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation) D. ABCD **21. When assessing the carotid arteries, the nurse notes that these arteries are commonly auscultated because they reflect which function better than peripheral arteries?** A. Peripheral tissue perfusion B. Heart function C. Presence of edema D. Venous integrity ### Evidence Based practice (2 Questions) **22. Evidence-Based Practice (EBP) involves the integration of research findings, clinical expertise, and patient preferences. What must be present for evidence obtained from a study to be considered reliable?** A. The study can be repeated by other researchers (replicability). B. The findings are accurate of application (validity). C. The findings are consistent when a treatment leads to similar outcomes for similar disorders. D. The study uses a quantitative research design. **23. The nurse is formulating a question in the PICOT format to guide an EBP project. The ‘P’ in PICOT stands for:** A. Planning B. Prioritizing C. Patient, population, or problem D. Potential solution ### Nsg Process & Clin Judgment (5 Questions) **24. The nurse observes a patient awaiting surgery whose blood pressure (BP) is 90/60 mmHg. The nurse begins purposefully thinking to determine what is happening to the client, intending to protect the client from harm. This thought process is an example of:** A. Lateral thinking B. Brainstorming C. Clinical reasoning D. Reflective skepticism **25. Clinical judgment combines which essential elements of the nurse's cognitive and practical capabilities?** A. Lateral thinking and conceptual mapping only. B. Formal thinking strategies and problem definition. C. Critical thinking, critical reasoning, and repetitive decision-making skills. D. The ability to identify only actual nursing diagnoses. **26. Which activity is completed during the Planning step of the Nursing Process?** A. Gathering and analyzing assessment data. B. Identifying a potential health problem (diagnosis). C. Determining patient outcomes and setting goals. D. Performing direct care interventions (implementation). **27. The nurse is prioritizing care for four patients. Based on Maslow's Hierarchy of Needs, which patient need should the nurse address first?** A. A patient complaining that the television remote control is too far away. B. A patient reporting severe pain rated 9/10. C. A patient asking for documentation resources related to their diagnosis. D. A patient requesting a visitor's name be added to their approved list. **28. A goal established during the planning phase should be SMART (Specific, Measurable, Attainable, Realistic, Time-limited). Which characteristic of a goal is related to the goal being **Specific**?** A. The goal is achievable in less than 1 week (short-term). B. The goal uses outcome indicators to measure goal attainment. C. The goal is patient-centered. D. The goal requires weeks or months to achieve (long-term). ### Pressure Ulcer/Wound (3 Questions) **29. A patient's pressure injury assessment reveals partial thickness skin loss with exposed dermis, which may present as an intact or ruptured blister. This finding is characteristic of which pressure injury classification?** A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 **30. The nurse is evaluating a patient using the Braden Scale. This tool is specifically designed to assess which factor?** A. The likelihood of infection. B. Risk factors that put the patient at risk for skin breakdown. C. The degree of tunneling or undermining present in an existing wound. D. The client’s response to pain medication. **31. When changing the dressing for a patient with a surgical site drain, the nurse notes that the collecting device has minimal drainage, which is much less than expected. Which suspected condition would support the nurse's observation and require immediate intervention?** A. Accelerated wound healing requiring the removal of the drain. B. A blockage in the drainage tube. C. Expected serous drainage indicating the inflammatory phase. D. The drain needs to be advanced into the incision site. ### Pt. and Staff Safety/QI (5 Questions) **32. Which definition accurately describes a **Near Miss** event in healthcare?** A. An unexpected occurrence involving death or serious injury (Sentinel event). B. Unintended harm caused by an act of commission or omission (Adverse event). C. An error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance. D. An error involving diagnostic or treatment procedures. **33. In the healthcare system, a "Just Culture" aims to balance the need to learn from mistakes with the need for disciplinary action. The primary focus of a Just Culture is to:** A. Eliminate all errors immediately by imposing strict punitive measures. B. Ensure that staff report errors without fear of punishment. C. Identify the active error only and disregard latent errors. D. Use restraints to minimize the possibility of patient-inherent accidents. **34. The nurse identifies a need to assess the home environment of a patient who is at risk for falls. The nurse should perform a hazard assessment by:** A. Replacing all furniture with new, modern equipment. B. Requiring the patient to install an updated security system. C. Walking through the home with the patient and discussing normal daily activities and whether the environment poses problems. D. Educating the patient solely on the necessity of installing smoke detectors. **35. If physical restraints are deemed necessary for a patient, the nurse must ensure which intervention is prioritized?** A. Raising all four side rails to ensure the patient cannot exit the bed. B. Using the physical restraints as the first step in the facility's fall protocol. C. Obtaining a family member's consent before application. D. Providing ongoing assessment of the patient. **36. The nurse is utilizing safe patient handling practices to prevent staff injury. A key component of a comprehensive safe patient-handling program is implementing:** A. An ergonomics assessment protocol and enforcing a no-lift policy. B. Training staff only on techniques for "controlled falls." C. Restricting the movement of all high-risk patients to mechanical lifts. D. Scheduling fewer Registered Nurses (RNs) on the shift to improve efficiency. ### Informatics (2 Questions) **37. Which statement accurately describes Nursing Informatics?** A. It is focused solely on computer competency, such as using word processors and spreadsheets. B. It uses information and computer technology to support direct care, administration, education, and research. C. It is restricted to the Clinical Informatics domain. D. It focuses primarily on developing standardized care plans. **38. Nurses are legally and ethically obligated to keep all patient information confidential. What is one physical security measure nurses can use to protect electronic patient information from unauthorized readers in a clinical setting?** A. Documenting care only in narrative format. B. Ensuring all patient data is de-identified before printing. C. Using privacy filters for computer screens visible to visitors. D. Restricting documentation to flow sheets and graphic records. ### Sleep (2 Questions) **39. A patient diagnosed with Obstructive Sleep Apnea (OSA) results when the airway is occluded due to structural abnormalities. Which non-invasive medical device is commonly used to treat this condition by delivering positive air pressure to hold the airway open?** A. Electroencephalography (EEG) B. Reticular activating system (RAS) C. Continuous Positive Airway Pressure (CPAP) D. Pulse oximetry **40. The nurse is teaching a patient about improving sleep hygiene. Which intervention should the nurse recommend?** A. Consume hypnotics every night to ensure restorative sleep. B. Engage in intense aerobic exercise immediately before bedtime. C. Offer appropriate bedtime snacks and beverages. D. Ensure the environment is loud to activate the Bulbar synchronizing region. ### Nursing Team Roles (2 Questions) **41. The collaborative process of assessing, planning, facilitating, and advocating for options and services to meet an individual's health needs, often overseen by an Advanced Practice Nurse (APN), describes which nursing care delivery model?** A. Team nursing B. Total patient care C. Primary nursing D. Case management **42. The National Council of State Boards of Nursing (NCSBN) defines delegation as the transfer of authority. The RN remains accountable for outcomes and cannot delegate which step of the nursing process?** A. Implementation B. Accountability C. Assessment D. Evaluation *(Select all that apply)* A. Accountability B. Planning C. Evaluation D. Assessment ### Communication (3 Questions) **43. The Quality and Safety Education in Nursing (QSEN) initiative anticipates that effective collaboration among healthcare professionals will have a significant impact on:** A. Reducing the number of Registered Nurses (RNs) needed per shift. B. Improving the quality of care and leading to positive patient outcomes. C. Increasing the reliance on traditional nursing models like team nursing. D. Minimizing the need for ongoing staff education. **44. According to The Joint Commission (TJC), the primary factor cited in the occurrence of sentinel events is the breakdown in which process among team members?** A. Documentation standards B. Communication C. Professional ethical standards D. Use of clinical decision support systems (CDSSS) **45. Quality of patient care depends on the ability of the nurse to communicate effectively with other members of the health care team. If a care plan is not communicated, the consequence is that:** A. Auditing and monitoring become impossible. B. Care becomes fragmented, tasks are repeated, and delays or omissions in care often occur. C. The patient cannot be reimbursed for services. D. The legal risk associated with electronic documentation is lowered. ### Math/Dosage (2 Questions) **46. The provider orders amoxicillin 500 mg PO every 8 hours. The medication is available as amoxicillin suspension 250 mg/5 mL. How many milliliters should the nurse administer per dose? A. 5 mL B. 7.5 mL C. 10 mL D. 15 mL **47. The provider orders furosemide 20 mg IV push daily. The vial label reads furosemide 10 mg/mL. How many milliliters should the nurse draw up for one dose? A. 1 mL B. 1.5 mL C. 2 mL D. 2.5 mL *** ## Answer Key | Question | Topic | Correct Answer | Citation | | :---: | :---: | :---: | :---: | | 1 | Legal Issues | C | | | 2 | Legal Issues | C | | | 3 | Legal Issues | C | | | 4 | Role of the Nurse | D | | | 5 | Role of the Nurse | C | | | 6 | Ethics | C | | | 7 | Ethics | D | | | 8 | Vital signs | D | | | 9 | Vital signs | C | | | 10 | Hygiene | B | | | 11 | Hygiene | B | | | 12 | Mobility | C | | | 13 | Mobility | C | | | 14 | Mobility | B | | | 15 | Physical Assessment | D | | | 16 | Physical Assessment | C | | | 17 | Physical Assessment | D | | | 18 | Physical Assessment | C | | | 19 | Physical Assessment | D | | | 20 | Physical Assessment | D | | | 21 | Physical Assessment | B | | | 22 | Evidence Based practice | C | | | 23 | Evidence Based practice | C | | | 24 | Nsg Process & Clin Judgment | C | | | 25 | Nsg Process & Clin Judgment | C | | | 26 | Nsg Process & Clin Judgment | C | | | 27 | Nsg Process & Clin Judgment | B | | | 28 | Nsg Process & Clin Judgment | C | | | 29 | Pressure Ulcer/Wound | B | | | 30 | Pressure Ulcer/Wound | B | | | 31 | Pressure Ulcer/Wound | B | | | 32 | Pt. and Staff Safety/QI | D | | | 33 | Pt. and Staff Safety/QI | B | | | 34 | Pt. and Staff Safety/QI | C | | | 35 | Pt. and Staff Safety/QI | D | | | 36 | Pt. and Staff Safety/QI | A | | | 37 | Informatics | B | | | 38 | Informatics | C | | | 39 | Sleep | D | | | 40 | Sleep | C | | | 41 | Nursing Team Roles | D | | | 42 | Nursing Team Roles | A, B, C, D | | | 43 | Communication | B | | | 44 | Communication | B | | | 45 | Communication | B | | | 46 | Math/Dosage | C | | | 47 | Math/Dosage | C | |