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lOMoAR cPSD| 30878495l NCLEX Review Exam Questions And AnswersWith Rationales Best Exam Solutions
NCLEX Review Exam Questions and
Answers with Rationales Best Exam
Solutions
1. To determine the standards of care for the institution, the nurse should consult?
1. Organizational Chart
2. Personnel policies
3. Policies and procedure manual
4. Job descriptions
Rationale:
#3 Correct Answer: It defines standards of care for an institution
#1 Shows which departments exist and their relationship with each other
#2 Policies for personnel not standards of care
#4 Doesn’t go into detail about standards of care
2. Which of the following goals is the most important for the nurse to address for a client
admitted to the cardiac rehabilitation unit?
1. Reduction of anxiety
2. Referral to community resources
3. Identification of life style changes
4. Verbalization of energy-conservation techniques
Rationale:
#3 Correct Answer: On admission, the best starting point is to survey what is good and what
needs to be changed.
#1 No, we need some anxiety to change.
#2 Not yet
#3 For cardiac rehab-we want to exercise not conserve at this point. Conserving energy is for
times of hypoxia or angina.
, lOMoAR cPSD| 30878495
3. The nurse manager is having a problem on the unit with one staff person having repetitive
tardiness and leaving the unit with orders not initiated. Which action by the manager would
be best?
1. Call the staff nurse in and place on work improvement after a 3 day suspension
2. Have the other staff gather additional information on the delinquent staff member
3. Call the staff nurse in for an interview to investigate the problem and possible
solutions
4. Assign her a mentor to call her at home and help her get to work on time
Rationale:
#3 Correct Answer: Give the nurse an opportunity to explain and then together work on a plan
of resolution.
#1 Jumping the gun, you need to investigate first.
#2 Turning the rest of the staff against the one member is not helpful in creating a team
environment and causes mistrust.
#4 This is enabling, not helpful or necessary.
4. A client is having a tubal ligation in the outpatient surgical clinic. Postoperatively it is
priority for the nurse to determine.
1. The client’s prior experiences with outpatient surgery.
2. The client’s medical plan and the extent of coverage for outpatient surgery.
3. The client’s plan for transportation and care at home.
4. The client’s plan to spend the night at the surgical center.
Rationale:
#3 Correct Answer: After outpatient surgery, the client should not be allowed to drive
themselves home. An available driver and assistance at home is necessary to be determined prior
to discharge.
#1 The client’s prior experience would be a factor in the PRE-Operative phase, but not as
important as Post Surgically.
#2 The medical plan’s coverage would not be assessed by the nurse in the postoperative phase,
but rather by the business office in the planning phase.
#4 It would be atypical for the client to spend the night in a surgical clinic, as they are not
generally open at night for overnight stays.
, lOMoAR cPSD| 30878495
5. A child with newly diagnosed leukemia is receiving chemotherapy. Which would be
included in his plan of care by the nurse?
1. Place him in a negative pressure isolation room
2. Administer prophylactic IV antibiotics
3. Avoid high protein food intake
4. Teach family and visitors handwashing techniques.
Rationale:
#4 Correct Answer: Any client on chemotherapy should have good infection control measures in
place such as handwashing by all who they encounter.
#1, and #2 This would be appropriate if the neutrophil count was low, however it is not
necessary for all clients who are receiving chemotherapy
#3 This client would likely need a high protein diet to meet the nutritional demands of the body
during chemotherapy
6. Which nursing diagnosis has the highest priority for a client with insomnia?
1. Ineffective breathing pattern.
2. Disturbed sensory perception
3. Ineffective coping
4. Sleep deprivation
Rationale:
#1 Correct Answer: An airway issue causing sleep disturbance such as sleep apnea would take
priority over other causes.
#2 Disturbed sensory perception would be a less life threatening condition.
#3 Ineffective coping would be less life threatening than an airway issue.
#4 Sleep deprivation can be caused by many reasons but continues to be less threatening than an
airway problem.
7. A client delivered a term male infant four hours ago. The infant was stillborn. Which room
assignment would be most appropriate for this client?
1. Request a private room on the GYN floor
2. Assign to a private room on the postpartum unit
3. Discharge her home as soon as her condition is stable
4. Room her with another client with a pregnancy loss
Rationale:
#1 Correct Answer: This client needs a private room so she can feel free to grieve and other
family members can stay with her for support. She should be transferred to a GYN unit so the
sights and sounds of the maternity unit do not contribute to her pain.
, lOMoAR cPSD| 30878495
#2 Difficult for mother with stillborn to be on postpartal unit with mothers and their babies.
#3 She does not need to be rushed out of the hospital. She needs to have time with her stillborn
and also still needs to assessed for postpartum complications.
#4 This client and family needs privacy.
8. A RN on your unit has had an argument with the family of a client regarding the way in
which the RN has changed the client’s dressing. The family is adamant that the dressing
change was performed incorrectly. The RN insists that sterile technique was observed. As
RN manager the best response is?
1. Meet with the family member and the RN to discuss the disagreement regarding the
dressing change.
2. Talk to the family member and assure him that the nurse followed the hospital
procedure
3. Discuss the dressing change procedure with the RN and compare to a current
textbook
4. Change the RN’s assignment the next day to another client.
Rationale:
#1 Correct Answer: When conflict occurs, meet with both parties together to discuss the
problem, is the BEST answer. Each part can hear what the other is saying and you are not
caught in the middle. They will be able to come up with solutions together or you can mediate.
#2 This is okay to do, but the family member will not believe you and try to convince you
otherwise.
#3 You may want to do this as well, but it will not address the conflict.
#4 Avoidance may be the solution, but if a frank discussion does not occur first, then the family
will think that the nurse really did do something wrong, and the nurse will feel like the manager
is not supportive.
9. The women’s health charge nurse is making assignments for the next shift. The unit is short
one staff member and will receive a nurse from the medical surgical unit. Which group of
clients should she assign to the medical surgical nurse?
1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with
breast reduction
2. C-section planning discharge, post-partal infection, mastectomy
3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with
lymphoma
4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast
reconstruction
Rationale:
#1 Correct Answer: This group of clients is primarily med surgical
#2 Needs too much specific teaching.
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