NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. All of the following are essential components of supervision EXCEPT:
- A. All tasks to be delegated or supervised are within the nurse's scope of practice
- B. The necessary tasks require repeated assessments
- C. The nurse has adequate time to develop staff assignments
- D. Policies have been developed that govern nursing practice
Correct answer: B
Rationale: Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.
2. Which example best describes a nurse who exhibits moral courage?
- A. A nurse feels angry when a parent refuses important treatment for his child.
- B. A nurse considers seeking help for depression when she feels she cannot meet the needs of her clients in the oncology unit.
- C. A nurse contacts a physician for further orders when he fails to order comfort measures for a client with a terminal illness.
- D. A nurse is frustrated when the laboratory is slow in responding to an order for a stat blood glucose.
Correct answer: C
Rationale: Moral courage involves taking action to do what is right, even when there might be negative consequences. The nurse who contacted a physician for further orders acted as a client advocate to seek help, even though she may have faced consequences such as lost time, decreased productivity, or criticism from the physician. Choices A, B, and D do not directly involve advocating for a client's needs or challenging a situation that goes against ethical standards. Feeling angry, seeking help for personal issues, or being frustrated with work processes do not necessarily demonstrate moral courage in the context of nursing practice.
3. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.
- A. ask for assistance before getting out of bed.
- B. remain in bed because it is safer and he will not fall.
- C. instruct him to stand up quickly from the bed.
- D. lean forward and push up and off the bed.
Correct answer: A
Rationale: The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.
4. What is the highest priority for post ECT care?
- A. Observe for confusion
- B. Monitor respiratory status
- C. Reorient to time, place, and person
- D. Document the client's response to the treatment
Correct answer: B
Rationale: The highest priority for post ECT care is to monitor respiratory status. This is crucial because a life-threatening side effect of ECT is respiratory arrest. While observing for confusion and reorienting the client are important aspects of post ECT care, they are not as critical as ensuring the client's respiratory status is stable. Documenting the client's response to treatment is also important for maintaining accurate medical records, but it is not the highest priority immediately post ECT.
5. What action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?
- A. Providing supportive care to patients diagnosed with pertussis
- B. Teaching family members about the importance of careful handwashing
- C. Teaching patients about the necessity of adult pertussis immunizations
- D. Encouraging patients to complete the prescribed course of antibiotics
Correct answer: C
Rationale: The most effective action by the nurse to decrease the spread of pertussis in a community setting is to teach patients about the necessity of adult pertussis immunizations. The increased rate of pertussis in adults is often attributed to waning immunity after childhood immunization. Immunization is highly effective in protecting communities from infectious diseases. While teaching about handwashing is important for overall infection control, pertussis is primarily spread through respiratory droplets and contact with secretions. Providing supportive care does not significantly impact the disease course or transmission risk. Encouraging completion of antibiotics may help reduce transmission, but patients likely have already spread the disease by the time the diagnosis is made. Therefore, the emphasis should be on prevention through immunization to reduce the spread of pertussis.
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