NCLEX - W1 - Intro to Nursing

Question 1

A nurse is caring for a patient who is recovering from surgery. The nurse delegates the task of measuring the patient’s vital signs to an unlicensed assistive personnel (UAP). Which of the following is the most important right of delegation the nurse must consider?

a. Right task
b. Right circumstance
c. Right person
d. Right direction and communication

Answer 1

Correct Answer: d. Right direction and communication

Rationale:
While all the rights of delegation are important, clear and concise communication about the task, including its objective, limits, and expectations, is critical to ensuring patient safety and effective care. The nurse must provide specific instructions to the UAP, including what to report and when

Question 2

A nurse is developing a care plan for a patient with a chronic illness. The nurse wants to ensure the plan is based on the best available evidence. Which of the following actions should the nurse take first?

a. Implement the evidence in practice.
b. Evaluate the practice decision or change.
c. Ask the clinical question in the PICOT format.
d. Search for the best evidence based on the clinical question.

Answer 2

Correct Answer: c. Ask the clinical question in the PICOT format.

Rationale:
The first step in the evidence-based practice (EBP) process is to formulate a clear clinical question using the PICOT format:

Patient/population,
Intervention,
Comparison,
Outcome,
Time.

This focused question guides the subsequent steps of searching for evidence, appraising it, and implementing it in practice.

Question 3

A nurse is working on a unit that has recently implemented a new policy on fall prevention. The nurse is concerned that the policy is not effective and may even be putting patients at greater risk. Which of the following actions should the nurse take first?

a. Continue to follow the policy but document any concerns.
b. Discuss the concerns with the nurse manager.
c. Report the concerns to the hospital’s risk management department.
d. Search for evidence to support a change in the policy.

Answer 3

Correct Answer: b. Discuss the concerns with the nurse manager.

Rationale: When a nurse identifies a potential safety issue, the first step is to address it through the appropriate channels within the organization. Discussing the concerns with the nurse manager allows for open communication and potential problem-solving at the unit level.

Question 4

A nurse is preparing to delegate the task of ambulating a patient to a licensed practical/vocational nurse (LPN/VN). The nurse knows that the patient is unsteady on their feet and requires assistance. Which of the following actions should the nurse take?

a. Delegate the task to the LPN/VN and provide close supervision.
b. Delegate the task to the LPN/VN and tell them to call for help if needed.
c. Do not delegate the task and ambulate the patient themself.
d. Delegate the task to a UAP who is experienced in ambulating patients.

Answer 4

Correct Answer: a. Delegate the task to the LPN/VN and provide close supervision.

Rationale: Delegation of tasks should consider the patient’s needs, the delegatee’s skills, and the level of supervision required.
In this case, the LPN/VN may be capable of ambulating the patient with appropriate supervision from the RN.

Question 5

A nurse preceptor is orienting a new graduate nurse to the unit. The preceptor emphasizes the importance of clinical judgment in providing patient care. Which of the following best describes clinical judgment?

a. The ability to perform nursing skills accurately and efficiently.
b. The ability to follow physician orders and hospital policies.
c. A reflective thinking process that involves collecting information, analyzing the situation, and considering options for action.
d. The ability to communicate effectively with patients and families.

Answer 5

Correct Answer: c. A reflective thinking process that involves collecting information, analyzing the situation, and considering options for action.

Rationale: Clinical judgment is a complex cognitive process that involves critical thinking, problem-solving, and decision-making to provide safe and effective patient care. It is not simply about performing tasks but rather about using knowledge and experience to make informed decisions.

Question 6

A nurse is providing care to a patient who is experiencing pain. The nurse wants to use a patient-centered approach to pain management.
Which of the following actions is most consistent with patient-centered care?

a. Administering pain medication as prescribed by the physician.
b. Assessing the patient’s pain level and preferences for pain relief.
c. Following the hospital’s standard protocol for pain management.
d. Educating the patient about the risks and benefits of different pain medications.

Answer 6

Correct Answer: b. Assessing the patient’s pain level and preferences for pain relief.

Rationale: Patient-centered care involves respecting each patient’s unique needs, preferences, and values. Effective pain management requires assessing the patient’s individual pain experience and tailoring interventions to meet their specific needs and goals.

Question 7

A nurse is caring for a patient who has just been diagnosed with a terminal illness. The patient is visibly upset and states, “I don’t know what to do.”
Which of the following responses by the nurse best demonstrates the concept of presence?

a. “I’ll call the chaplain to come and talk with you.”
b. “I know this is a lot to take in. I’m here to listen if you want to talk.”
c. “Don’t worry, everything will be okay.”
d. “I’ll get you some information about support groups.”

Answer 7

Correct Answer: b. “I know this is a lot to take in. I’m here to listen if you want to talk.”

Rationale: Presence involves providing emotional support and simply “being there” for the patient during difficult times. Active listening, conveying empathy, and offering emotional support demonstrate a caring presence.

Question 8

A nurse is working in a busy emergency department. The nurse is feeling overwhelmed by the number of patients and the acuity of their needs.
Which of the following actions would be most helpful for the nurse to take to manage stress and promote self-care?

a. Taking a few minutes to practice deep breathing and mindfulness.
b. Skipping meals to save time.
c. Venting frustrations to colleagues.
d. Working through breaks to catch up on tasks.

Answer 8

Correct Answer: a. Taking a few minutes to practice deep breathing and mindfulness.

Rationale: Self-care practices like mindfulness and deep breathing can help nurses manage stress and promote emotional well-being. These techniques can be incorporated into short breaks throughout the workday.

Question 9

A new graduate nurse is assigned to care for a patient with a complex medical condition. The nurse feels unsure about their ability to provide safe and effective care.
Which of the following actions should the nurse take?

a. Attempt to care for the patient independently to prove their competence.
b. Seek guidance from an experienced nurse on the unit.
c. Call the physician to request that the patient be assigned to another nurse.
d. Focus on completing tasks correctly, rather than understanding the patient’s overall condition.

Answer 9

Correct Answer: b. Seek guidance from an experienced nurse on the unit.

Rationale: New nurses are expected to seek guidance and support from experienced colleagues, especially when caring for patients with complex needs. Asking for help is essential for safe and effective care.

Question 10

A nurse is caring for a patient who is from a different culture than the nurse. The nurse wants to provide culturally competent care. Which of the following actions is most important for the nurse to take?

a. Assuming that the patient’s cultural beliefs are the same as the nurse’s.
b. Asking the patient about their cultural beliefs and practices.
c. Relying on the hospital’s interpreter services for all communication.
d. Educating the patient about the dominant culture in the healthcare setting.

Answer 10

Correct Answer: b. Asking the patient about their cultural beliefs and practices.

Rationale: Cultural competence involves respecting and valuing the unique cultural perspectives of each patient. Asking the patient about their beliefs and practices demonstrates a willingness to learn and provide individualized care

Question 11

A nurse is caring for a patient who is scheduled for a procedure that the patient does not fully understand. The nurse explains the procedure to the patient and answers the patient’s questions. Which ethical principle is the nurse demonstrating?
a. Beneficence
b. Nonmaleficence
c. Justice
d. Autonomy

Answer 11

Correct Answer: d. Autonomy

Rationale: Autonomy refers to the patient’s right to make informed decisions about their care. The nurse is upholding the patient’s autonomy by providing the information needed to make an informed decision.

Question 12

A nurse observes a colleague making a medication error. Which of the following actions is most important for the nurse to take?
a. Ignore the error to avoid conflict with the colleague.
b. Document the error in the patient’s chart.
c. Report the error to the nurse manager.
d. Discuss the error with the colleague privately.

Answer 12

Correct Answer:
c. Report the error to the nurse manager.

Rationale:
Patient safety is paramount. Medication errors must be reported through the appropriate channels to prevent potential harm.
Reporting to the nurse manager allows for investigation and implementation of corrective actions.

Question 13

A nurse is preparing to discharge a patient who will require ongoing wound care at home. The nurse recognizes that the patient has limited health literacy. Which of the following actions should the nurse take to ensure the patient understands the discharge instructions?

a. Providing the patient with written discharge instructions.
b. Using plain language and visual aids to explain the wound care procedures.
c. Asking the patient if they have any questions.
d. Referring the patient to a home health agency for wound care.

Answer 13

Correct Answer:
b. Using plain language and visual aids to explain the wound care procedures.

Rationale:
Patients with limited health literacy may struggle to understand complex medical information.
The nurse should use simple language, avoid jargon, and incorporate visual aids to enhance understanding

Question 14

A nurse is caring for a group of patients. Which of the following patients should the nurse assess first?

a. A patient who is complaining of pain rated 4 out of 10.
b. A patient who is scheduled for a physical therapy session in 30 minutes.
c. A patient who had a change in respiratory status and is exhibiting shortness of breath.
d. A patient who is requesting a snack.

Answer 14

Correct Answer:
c. A patient who had a change in respiratory status and is exhibiting shortness of breath.

Rationale:
Prioritization in nursing involves addressing the most urgent needs first.
A change in respiratory status, especially shortness of breath, can indicate a potentially life-threatening condition that requires immediate attention.

Question 15

A nurse is working on a quality improvement project aimed at reducing hospital-acquired infections. Which of the following actions by the nurse is most likely to contribute to the success of the project?

a. Collecting data on hand hygiene compliance rates among staff.
b. Implementing a new hand hygiene protocol without consulting staff.
c. Educating patients about the importance of hand hygiene.
d. Blaming staff members for high infection rates.

Answer 15

Correct Answer: a. Collecting data on hand hygiene compliance rates among staff.

Rationale: Quality improvement initiatives require data collection to identify areas for improvement and measure the effectiveness of interventions.
Collecting data on hand hygiene compliance allows for objective assessment and targeted interventions.

Question 16

A nurse is caring for a patient who is receiving palliative care. Which of the following is the primary goal of palliative care?

a. To cure the patient’s illness.
b. To prolong the patient’s life.
c. To provide comfort and symptom management.
d. To help the patient transition to hospice care.

Answer 16

Correct Answer:
c. To provide comfort and symptom management.

Rationale:
Palliative care focuses on relieving suffering and improving quality of life for patients with serious illnesses, regardless of prognosis.
The emphasis is on symptom management, emotional support, and shared decision-making.

Question 17

A nurse is delegating the task of feeding a patient to a UAP. The patient has a history of swallowing difficulties. Which of the following is essential for the nurse to do before delegating this task?
a. Assess the patient’s swallowing ability.
b. Provide the UAP with a list of foods to avoid.
c. Ensure the UAP has completed a course on safe feeding techniques.
d. Instruct the UAP to report any signs of aspiration.

Answer 17

Correct Answer:
a. Assess the patient’s swallowing ability.

Rationale:
The nurse is responsible for assessing the patient’s condition and determining the appropriateness of delegation.
A patient with swallowing difficulties requires careful monitoring during feeding, which may be beyond the scope of a UAP.

Question 18

A nurse is caring for a patient who is experiencing anxiety related to an upcoming surgery. Which of the following nursing interventions is most likely to reduce the patient’s anxiety?

a. Distracting the patient with television.
b. Providing the patient with information about the surgical procedure.
c. Administering an anxiolytic medication.
d. Leaving the patient alone to rest.

Answer 18

Correct Answer:
b. Providing the patient with information about the surgical procedure.

Rationale:
Anxiety often stems from fear and uncertainty.
Providing the patient with clear and accurate information about the surgery can help alleviate anxiety by addressing their concerns.

Question 19

A nurse is working in a community clinic that serves a population with limited access to healthcare. The nurse wants to implement a health promotion program focused on preventing type 2 diabetes. Which of the following actions should the nurse take first?

a. Developing a teaching plan about diabetes management.
b. Assessing the community’s needs and resources.
c. Distributing educational brochures about diabetes.
d. Referring patients to a diabetes specialist.

Answer 19

Correct Answer:
b. Assessing the community’s needs and resources.

Rationale:
Effective health promotion programs are tailored to the specific needs and resources of the community.
Assessment helps identify existing health beliefs, practices, and barriers to care, which informs program development.

Question 20

A nurse manager is implementing a shared governance model on the unit. Which of the following is a key characteristic of shared governance?
a. Centralized decision-making by the nurse manager.
b. Increased autonomy and decision-making authority for staff nurses.
c. Reduced accountability for patient outcomes.
d. Top-down communication from management to staff.

Answer 20

Correct Answer:
b. Increased autonomy and decision-making authority for staff nurses.

Rationale:
Shared governance empowers staff nurses to participate in decision-making processes that affect their practice and patient care.
It fosters collaboration, accountability, and professional development.

Question 21

A nurse is caring for a patient who is postoperative and has a new surgical incision. The nurse notes that the incision is red, swollen, and tender. Which of the following actions should the nurse take first?

a. Document the findings in the patient’s chart.
b. Administer a prescribed analgesic medication.
c. Notify the physician of the findings.
d. Apply a warm compress to the incision.

Answer 21

Correct Answer: c.
Notify the physician of the findings.

Rationale:
Redness, swelling, and tenderness at a surgical incision are signs of potential infection, which requires prompt medical attention.
The nurse should notify the physician immediately to allow for assessment and intervention.

Question 22

A nurse is admitting a patient to the hospital. The patient is anxious and asks the nurse, “What’s going to happen to me?”
Which of the following responses by the nurse is most therapeutic?

a. “Don’t worry, everything will be fine.”
b. “I know this is stressful. What are your specific concerns?”
c. “I’ll call the doctor to come and talk to you.”
d. “Let me finish your admission paperwork, and then we can talk.”

Answer 22

Correct Answer:
b. “I know this is stressful. What are your specific concerns?”

Rationale:
Acknowledging the patient’s anxiety and inviting them to share their specific concerns demonstrates empathy and encourages open communication, which can help reduce anxiety.

Question 23

A nurse is caring for a patient who is refusing a blood transfusion due to religious beliefs.
Which of the following actions by the nurse demonstrates respect for the patient’s autonomy?

a. Attempting to persuade the patient to accept the blood transfusion.
b. Documenting the patient’s refusal and notifying the physician.
c. Administering the blood transfusion despite the patient’s objections.
d. Calling the hospital’s ethics committee to intervene.

Answer 23

Correct Answer:
b. Documenting the patient’s refusal and notifying the physician.

Rationale:
Respecting autonomy involves honoring the patient’s right to refuse treatment, even if the nurse disagrees with the decision.
Documenting the refusal and notifying the physician ensures that the patient’s wishes are followed and that other healthcare providers are aware of the situation.

Question 24

A nurse is caring for a patient who is terminally ill and is experiencing pain. The physician has prescribed a high dose of pain medication. The nurse is concerned that administering the medication may hasten the patient’s death.
Which ethical principle is the nurse grappling with?

a. Beneficence
b. Nonmaleficence
c. Justice
d. Autonomy

Answer 24

Correct Answer:
b. Nonmaleficence

Rationale:
Nonmaleficence means “do no harm”.
The nurse is struggling with the potential for the medication to have a negative consequence, even though the intention is to relieve pain.

Question 25

A nurse is preparing to administer a medication to a patient. The nurse checks the patient’s name and date of birth against the medication administration record (MAR).
Which of the following rights of medication administration is the nurse demonstrating?

a. Right medication
b. Right patient
c. Right dose
d. Right route

Answer 25

Correct Answer:
b. Right patient

Rationale:
Verifying the patient’s identity is crucial to ensuring the medication is administered to the correct person.

Question 26

A nurse is caring for a patient who is at risk of falls. The nurse implements several interventions to prevent falls, including placing a bed alarm, providing non-slip footwear, and keeping the call light within reach.
Which of the following nursing diagnoses is most appropriate for this patient?

a. Risk for Falls
b. Impaired Physical Mobility
c. Activity Intolerance
d. Risk for Injury

Answer 26

Correct Answer:
a. Risk for Falls

Rationale:
The nursing diagnosis “Risk for Falls” is used when a patient has specific risk factors that increase their susceptibility to falls.

Question 27

A nurse is providing discharge teaching to a patient who will be going home with a new colostomy. The nurse recognizes that the patient is overwhelmed and having difficulty processing the information. Which of the following actions should the nurse take?

a. Continue with the teaching as planned.
b. Break the teaching down into smaller sessions.
c. Provide the patient with written materials only.
d. Refer the patient to a support group.

Answer 27

Correct Answer:
b. Break the teaching down into smaller sessions.

Rationale:
When a patient is overwhelmed, it is important to adjust the teaching approach.

Breaking the information down into smaller, more manageable chunks allows for better comprehension and retention.

Question 28

A nurse is working on a unit that has experienced a recent increase in patient falls. The nurse manager wants to implement a plan to improve patient safety. Which of the following strategies is most likely to be effective?
a. Disciplining staff members who have been involved in patient falls.
b. Conducting a root cause analysis to identify contributing factors.
c. Implementing a new fall prevention protocol without staff input.
d. Ignoring the problem and hoping it will resolve on its own.

Answer 28

Correct Answer:
b. Conducting a root cause analysis to identify contributing factors.

Rationale:
A root cause analysis is a systematic approach to identifying the underlying causes of an event or problem.
By understanding the contributing factors to patient falls, the nurse manager can develop targeted interventions to prevent future occurrences.

Question 29

A nurse is caring for a patient who is experiencing difficulty breathing. The nurse elevates the head of the bed and administers oxygen as prescribed.
Which step of the nursing process is the nurse demonstrating?

a. Assessment
b. Diagnosis
c. Planning
d. Implementation

Answer 29

Correct Answer:
d. Implementation

Rationale:
Implementation involves putting the nursing care plan into action.
Elevating the head of the bed and administering oxygen are interventions aimed at improving the patient’s breathing.

Question 30

A nurse is caring for a patient who is unconscious and unable to make decisions about their care. The patient’s family members disagree about the best course of treatment.
Which of the following actions is most appropriate for the nurse to take?

a. Following the wishes of the family member who is most vocal.
b. Making decisions about the patient’s care independently.
c. Facilitating a family meeting to discuss the patient’s goals of care and explore options.
d. Contacting the hospital’s legal department for guidance.

Answer 30

Correct Answer: c.
Facilitating a family meeting to discuss the patient’s goals of care and explore options.

Rationale:
When family members disagree about a patient’s care, it is essential to facilitate communication and shared decision-making.
A family meeting can provide a structured setting to discuss the patient’s values, wishes, and treatment options.