NCLEX Practice Questions HURST
REVIEW (Fundamentals)
C. Assessment
A nurse is caring for a patient with chronic heart failure who is very ill. The patient has a "no
code" order. The patient goes into ventricular fibrillation and the nurse defibrillates the
patient. The nurse states she was unaware of the "no code" order. What part of the nursing
process did the nurse fail to perform?
A. Planning
B. Evaluation
C. Assessment
B. Implementation
B. Implementation
On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The
nurse does not want to "bother the physician this early." During the change-of-shift report,
the patient develops ventricular tachycardia and has to be resuscitated. What part of the
nursing process did the nurse fail to perform?
A. Evaluation
B. Implementation
C. Assessment
D. Planning
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B. Assess and analyze the level of care needed by the patient.
,A patient in the critical care unit has an order to be transported off the unit for a diagnostic
procedure. The nurse fails to ensure that the patient is properly monitored during transport,
and the patient experiences a cardiac arrest. Which of the following actions did the nurse fail
to adequately perform?
A. Make the proper nursing diagnosis.
B. Assess and analyze the level of care needed by the patient.
C. Act as a patient advocate to postpone the examination.
D. Communicate findings in a timely manner.
C. No. There were no damages associated with failure to document
The nurse fails to record a set of vital signs on a blood transfusion report, which is against
hospital policy. The patient does not sustain any damage as a result. Can the nurse be
charged with malpractice in this case?
A. No. Documentation is not part of the duty of nurse.
B. Yes. Even though there were no damages, the nurse failed to follow hospital protocol.
C. No. There were no damages associated with failure to document
D. Yes. Failure to document always results in negligence.
A. Beneficence
B. Nonmaleficence
C. Autonomy
A patient with metastatic cancer tells the nurse, “I am tired and do not want to be put on a
breathing machine.” The patient’s out-of-town son wants “everything done for my mother”
when his mother later develops respiratory distress. Which ethical principles are involved in
this dilemma? (Select all that apply.)
A. Beneficence
B. Nonmaleficence
C. Autonomy
D. Justice
E. Paternalism
A. The hospital ethics committee
C. The nursing supervisor
D. The nursing ethics committee
,The nurse is concerned that the physician is ignoring the wishes of the patient and family in
the care of a patient. The nurse should take these concerns to: (Select all that apply.)
A. The hospital ethics committee
B. The ANA (American Nurses Association)
C. The nursing supervisor
D. The nursing ethics committee
E. he policy and procedure committee
C. Nonmaleficence
The nurse observes a coworker diverting narcotics by administering normal saline to a
patient in pain. By not reporting this observation, the nurse is in violation of what ethical
principle concerning the patients under the care of the impaired nurse?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Veracity
A. Withdrawing treatment
The family of a patient who is receiving mechanical ventilation for respiratory distress
associated with an inoperable brain tumor asks that the patient be extubated to "allow
natural death" to occur. This is an example of what situation?
A. Withdrawing treatment
B. Rationing care
C. A criminal act
D. Withholding treatment
A. Moral distress
A nurse has been having difficulty sleeping since the death of a patient who had a stressful
family situation involving a DNR (do not resuscitate) order. She is arguing with her husband
and coworker and is complaining about working conditions. The nurse's symptoms could be
signs of what problem?
A. Moral distress
B. Moral confusion
, C. Immoral distress
D. Change fatigue
B. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area.
C. Second intercostal space to the right of the sternum to hear sounds from the aortic valve
area
Where should a nurse place the stethoscope when auscultating heart sounds?
Select all that apply
A. First intercostal space left of the sternum to hear sounds from the pulmonic valve area.
B. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area.
C. Second intercostal space to the right of the sternum to hear sounds from the aortic valve
area.
D. Fifth intercostal space left side of sternum to hear sounds from the mitral area.
E. Apex of the heart to hear the loudest 2nd heart sound (S2).
1. Stop the feeding and assess gastric residual volume in 1 hour
A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and
is reporting nausea. What is the appropriate nursing intervention?
1. Stop the feeding and assess gastric residual volume in 1 hour.
2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours.
3. Change the feeding schedule from continuous to intermittent delivery.
4. Discard the 200 mL and continue the feedings at the same rate.
4. You have some genuine concerns about the open heart surgery, and you feel as if your
children are not addressing your concerns.
A client states, "I really do not want to go through open heart surgery. I have told my children
this, but they still want me to go through with the surgery. I don’t know what to do." What is
the best response for the nurse as client advocate?
1. Your children are correct. The open heart surgery is the best thing for your health.
2. You feel as if your children are not addressing your concerns. You and your family will
need to resolve this before you go to surgery.
3. I can contact your primary healthcare provider so that you can discuss your concerns
regarding open heart surgery.
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