Complete NCLEX Study Materials
c) places the bedside articles on the affected side
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1. A new nursing graduate is attending an agency orientation
regarding the nursing model of practice implemented in
the health care facility. The nurse is told that the nursing model
is a team nursing approach. The nurse understands that
planning care delivery will be based on which characteristic of
this type of nursing model of practice?
a) a task approach method is used to provide care to clients
b) managed care concepts and tools are used in providing client
care
c) an RN leads nursing personnel in providing care to a group of
clients
d) a single RN is responsible for providing nursing care to a
group of clients
2. The nurse manager has implemented a change in the method
of the nursing delivery system from functional to team nursing. A
nursing assistant is resistant to the change and is not taking an
active part in facilitating the process of change. Which of the
following is the best approach in dealing with the
nursing assistant?
a) ignore the resistance
b) exert coercion with the nursing assistant
c) provide a positive reward system for the nursing assistant
d) confront the nursing assistant to encourage verbalization of
feelings regarding the change
3. A nurse is giving a report to a nursing assistant who will be
caring for a client who has hand restraints. The nurse instructs
the nursing assistant to assess the skin integrity of the restrained
hands every:
a) 2 hours
b) 3 hours
c) 4 hours
d) 30 minutes
4. Fibrinolysin and desoxyribonuclease (Elase) is prescribed to
treat a skin ulcer, and the nurse is observing a nursing student
perform the treatment. The nurse intervenes if the nursing
student is observed doing which of the following?
a) applies a thin layer of medication
b) cleans the wound with a sterile solution
c) places petrolatum gauze over the fibrinolysin and
desoxyribonuclease
d) applies a thick layer of medication and covers with a dry
sterile dressings
5. A nursing student is caring for a client with a brain attack
(stroke) who is experiencing unilateral neglect. The nurse would
intervene if the student plans to use which of the following
strategies to help the client adapt to this deficit?
a) tells the client to scan the environment
b) approaches the client from the unaffected side
d) moves the commode and cahir to the affected side
6. A nursing instructor asks the nursing student to describe the
definition of a critical path. Which of the following statements, if
made by the student, indicates a need for further understanding
regarding critical paths?
a) they are developed through the collaborative efforts of all
members of the health care team
b) they provide an effective way of monitoring care and for
reducing or controlling the length of hospital stay for the client
c) they are developed based on appropriate standards of care
d) they are nursing care plans and use the steps of the nursing
process
7. A community health nurse is working with a disaster relief
following a tornado. The nurse's goal for the community is to
prevent as much injury and death as possible from the
uncontrollable event. Finding safe housing for survivors,
providing support to families, organizing counseling, and
securing physical care when needed allexamples of which type
of prevention?
a) primary level of prevention
b) secondary level of prevention
c) tertiary level of prevention
d) aggregate care prevention
8. The nurse manager is planning to implement a change in the
nursing unit from team nursing to primary nursing. The nurse
anticipates that there will be resistance to the change during the
change process. The primary technique that the nurse would use
in implementing this change is which of the following?
a) introduce the change gradually
b) confront the individuals involved in the change process
c) use coercion to implement the change
d) manipulate the participants in the change process
9. A nurse manager is providing an educational session to
nursing staff members about the phases of viral hepatitis. The
nurse manager tells the staff that which clinical manifestation(s)
are primarily characteristic of preicteric phase?
a) right upper quadrant pain
b) fatigue, anorexia and nausea
c) jaundice, dark-colored urine, and clay-colored stools
d) pruritus
10. A nurse is preparing a plan of care for a client who will be
hospitalized for insertion of an internal cervical radiation implant.
Which nursing intervention should the nurse implement in
preparation for the arrival of the client?
a) prepare a private room at the end of the hallway
b) place a sign on the door that indicates that visitors are limited
to 60-minute visits
c) assign one primary nurse to care for the client during the
hospital stay
d) place a linen bag outside of the client's room for discarding
linens after morning care
11. A nursing student is developing a plan of care for a client with
a chest tube that is attached to a Pleur-Evac drainage system.
The nurse intervenes if the student writes which incorrect
intervention in the plan?
a) position the client in semi-fowler's position
b) add water to the suction chamber as it evaporates
c) tape the connection sites between the chest tube and
the drainage system
d) instruct the client to avoid coughing and deep breathing
12. A nurse is caring for a client who has just had a plaster leg
cast applied. The nurse would plan to prevent the development
of compartment syndrome is instructing the licensed practical
nurseassigned to care for the client to:
a) elevate the limb and apply ice to the affected leg
b) elevate the limb and cover the limb with bath blankets
c) place the leg in a slightly dependent position and apply ice to
the affected leg
d) keep the leg horizontal and apply ice to the affected leg
13. A registered nurse (RN) is supervising a licensed practical
nurse (LPN) administering an intramuscular (IM) injection of iron
to an assigned client. The RN would intervene if the LPN is
observed to perform which of the following?
a) changing the needle after drawing up the dose and before
injection
b) preparing an air lock when drawing up the medication
c) using a Z-track method for injection
d) massaging the injection site after injection
14. A nursing student develops a plan of care for a client with
paraplegia who has a risk for injury related to spasticity of the leg
muscles. On reviewing the plan, the co-assigned nurse identifies
which of the following as an incorrect intervention.
a) use of padded restraints to immobilize the limb
b) performing range of motion to the affected limbs
c) removing potentially harmful objects near the spastic limbs
d) use of prescribed muscle relaxants as needed
15. A registered nurse (RN) is observing a licensed practical
nurse (LPN) preparing a client for treatment with a continuous
passive motion (CPM) machine. Which observation by the RN
would indicate that the LPN is performing an incorrect action?
a) places the client's knee in a slightly externally rotated position
b) keeps the client's knee at the hinged joint of the machine
c) assesses the client for pressure areas at the knee and the
groin
d) checks the degree of extension and flexion and the speed of
the CPM machine per the physician's orders
16. A client who is mouth breathing is receiving oxygen by face
mask. The nursing assistant asks the registered nurse (RN) why
a water bottle is attached to the oxygen tubing near the wall
oxygen outlet. The RN responds that the primary purpose of this
feature is to:
a) prevent fluid loss from the lungs during mouth breathing
b) give the client added fluid via the respiratory rate
c) humidify the oxygen that is bypassing the client's nose
d) prevent the client from getting nosebleed
17. A nurse and a nursing assistant are assisting the respiratory
therapist to position a client for postural drainage. The
nursing assistant asks the nurse how the respiratory
therapists selects the position used for the procedure. The nurse
responds that a position is chosen that will use gravity to help
drain secretions from which of the following areas?
a) trachea
b) main bronchi
c) lobes
d) alveoli
18. A registered nurse (RN) is observing a licensed practical
nurse (LPN) caring for a deceased client whose eyes will be
donated. The RN intervenes if the LPN performs which action?
a) elevates the head of the bed
b) closes the client's eyes
c) places wet saline gauze pads and ice pack on the eyes
d) closes the client's eyes and places a dry sterile dressing over
the eyes
19. The nurse has recently been assigned to manage a
pulmonary progressive unit at a large urban hospital. The
nurse's leadership style is participative, with the belief that all
staff members assist in decision making and the development of
the unit's goals. The nurse is implementing which leadership
style?
a) democratic
b) laissez faire
c) auticratic
d) situational
20. A physician has written an order for a vest restraint to be
applied on a client from 10:00 pm to 7:00 am because the client
becomes disoriented during the night and is at risk for falls. At
11:00 pm, the charge nurse makes rounds on all of the clients
with the vest restraint, which observation by the charge nurse
would indicate that the nurse who cared for this client performed
an unsafe action in the use of the restraint?
a) a safety knot was used to secure the restraint
b) the client's record indicates that the restraint will be released
every 2 hours
c) the restraint was applied tightly
d) the call light was placed within reach of the client
21. A nursing student prepares a postoperative plan of care for a
client scheduled for hypophysectomy. The registered nurse
reviews the plan and informs the nursing student that the plan
needs to be corrected if which of the following was noted?
a) obtain daily weights
b) administer mouth care
c) monitor intake and output
d) encourage coughing and deep breathing
22. A nurse manager is reviewing with the nursing staff the
purposes for applying wrist and ankle restraints (security
devices) to a client. The nurse manager determines that further
review is necessary when a nursing staff member states that an
indication for the use of a restraint is to:
a) limit movement of a limb
b) keep the client in bed at night
c) prevent the violent client from injuring self and others
d) prevent the client from pulling out intravenous lines and
catheters
23. A hospitalized client with a diagnosis of anorexia
nervosa and in a state of starvation is in two-bed hospital room.
A newly admitted client will be assigned to this client's room.
Which client would be inappropriate to assign to this two-bed
room?
a) a client with pneumonia
b) a client who can perform self-care
c) a client with a fractured leg that is casted
d) a client who is scheduled for a diagnostic test
24. A multidisciplinary health care team is planning care for a
client with hyperparathyroidism. The nurse identifies which client
outcome to the health care team?
a) describes how to take antacids
b) restricts fluids to 1000 ml per day
c) describes how to take antidiarrheal medications
d) walks down the hall for 15 minutes, three times a day
25. A clinic nurse wants to develop a diabetic teaching program.
In order to meet the client's needs, the nurse must first:
a) assess the client's functional abilities
b) ensure that insurance will pay for participation in the program
c) discuss the focus of the program with the multidisciplinary
team
d) include everyone who comes into the clinic in the teaching
sessions
26. A nurse notes that a postoperative client has not been
obtaining relief from pain with the prescribed opioid analgesics
when a particular licensed practical nurse (LPN) is assigned to
the client. The appropriate action for the nurse to take is to:
a) reassign the LPN to the care of clients not receiving opioids
b) notify the physician that the client needs an increase in opioid
dosage
c) review the client's medication administration record
immediately and discuss the observations with the nursing
supervisor
d) confront the LPN with the information about the client having
pain control problems and ask if the LPN is using the opioids
personally
27. A medication nurse is supervising a newly hired licensed
practical nurse (LPN) during the administration of oral
pyridostigmine bromide (Mestinon) to a client with myasthenia
gravis. Which observation by the medication nurse would
indicate safe practice by the LPN?
a) asking the client to take sips of water
b) asking the client to lie down on his right side
c) asking the client to look up at the ceiling for 30 seconds
d) instructing the client to void before taking the medication
28. During orientation, a graduate nurse learns that the nursing
model of practice implemented in the facility is a primary nursing
approach. When the nurse attends report on the medical unit,
the nurse will verify with the staff which of the following
characteristics of primary nursing?
a) critical paths are used when providing client care
b) the nurse manager assigns tasks to the staff members
c) a registered nurse (RN) leads nursing staff in providing care to
a group of clients
d) a single RN is responsible for planning and providing
individualized nursing care to clients
29. A clinical nurse manager conducts an inservice educational
session for the staff nurses about case management. The
clinical nurse manager determines that a review of the material
needs to be done if a staff nurse stated that case management:
a) manages client care by managing the client care environment
b) maximizes hospital revenues while providing for optimal client
care
c) is designed to promote appropriate use of hospital personnel
and material resources
d) represents a primary health prevention focus managed by a
single case manager
30. A nurse manager is reviewing the critical paths of the clients
on the nursing unit. The nurse manager collaborates with each
nurse assigned to the clients and performs a variance analysis.
Which of the following would indicate the need for further action
and analysis?
a) a client is performing his own colostomy care
b) purulent drainage is noted from a postoperative wound
incision
c) a 1-day postoperative client has a temperature of 98.8F
d) a client newly diagnosed with diabetes mellitus is preparing
his own insulin for injection
31. Based upon a request made by the client's spouse and
children, a physician asks a nurse to discontinue the feeding
tube in a client who is in chronic debilitated and comatose state.
The nurse understands the legal basis for carrying out the order
and first checks the client's record for documentation of:
a) a court approval to discontinue the treatment
b) approval by the institutional Ethics Committee
c) a written order by the physician to remove the tube
d) authorization by the family to discontinue the treatment
32. A nurse plans to carry out a multidisciplinary research project
on the effects of immobility on client's stress levels. Of the
following statements, which principle is most important when
planning this project?
a) any client has the right to refuse to participate in research
studies
b) collaboration with other disciplines is essential to the
successful practice of nursing
c) the cooperation of the physicians on staff must be ensured in
order for the project to succeed
d) the corporate nurse executive should be consulted, because
the project will take nursing time
33. A nurse manager has identified a problem on the nursing unit
and holds unit meetings for all shifts. The nurse manager
presents an analysis of the problem and proposals for actions to
team members and invites the team members to comment and
provide input. Which style of leadership is the nurse manager
specifically employing?
a) situational
b) laissez-faire
c) participative
d) authoritarian
34. A charge nurse observes that a staff nurse is not able to
meet client needs in a reasonable time frame, does not problem-
solve situations, and does not prioritize nursing care. The charge
nurse has the responsibility to:
a) supervise the staff nurse more closely so that tasks are
completed
b) ask other staff members to help the staff nurse get the
work done
c) provide support and identify the underlying cause of the staff
nurse's problem
d) report the staff nurse to the supervisor so that something is
done to resolve the problem
35. A registered nurse is preceptor for a new nursing graduate
and is observing the new nursing graduate organizethe client
assignment and daily tasks. The registered nurse intervenes if
the new nursing graduate does which of the following?
a) provide time for unexpected tasks
b) lists the supplies needed for a task
c) prioritizes client needs and daily tasks
d) plans to document task completion at the end of the day
36. A registered nurse is a preceptor for a new nursing graduate
an is describing critical paths and variance analysis to the new
nursing graduate. The registered nurse instructs the new nursing
graduate that a variance analysis is performed on all clients:
a) continuously
b) daily during hospitalization
c) every third day of hospitalization
d) every other day of hospitalization
37. When a nurse manager makes a decisions regarding the
management of the nursing unit without input from the staff, the
type of leadership style that the nurse manager is demonstrating
is:
a) autocratic
b) situational
c) democratic
d) laissez-faire
38. A charge nurse knows that drug and alcohol use by nurses is
a reason for the increasing numbers ofdisciplinary cares by the
Board of Nursing. The charge nurse understands that when
dealing with a nurse with such an illness, it is most important to
assess the impaired nurse to determine:
a) the magnitude of drug diversion over time
b) if falsification of clients records occurred
c) the types of illegal activities related to the abuse
d) the physiological impact of the illness on practice
39. A nurse manager is planning to implement a change in the
method of the documentation system for the nursing unit. Many
problems have occurred as a result of the present
documentation system, and the nurse manager determines that
a change is required. The initial step in the process of change for
the nurse manager is which of the following?
a) plan strategies to implement the change
b) set goals and priorities regarding the change process
c) identify the inefficiency that needs improvement or correction
d) identify potential solutions and strategies for the change
process
40. A nurse receives a telephone call from the emergency
department and is told that a child with a diagnosis of tonic-
clonic seizures will be admitted to the pediatric unit. The nurse
prepares for the admission of the child and instructs assistant to
place which items at the bedside?
a) a tracheostomy set and oxygen
b) suction apparatus and an airway
c) an endotracheal tube and an airway
d) an emergency cart and laryngoscope