NCLEX - W1 - TLAN 1

Question 1

Which statement accurately describes the role of a nurse, according to the American Nurses Association (ANA)?

a. Nurses primarily provide care under the direct supervision of physicians.
b. The primary role of a nurse is to administer medications and treatments.
c. Nurses offer skilled care to those recovering from illness or injury, advocate for patient rights, and help them navigate the complex healthcare system.
d. Nurses are responsible for diagnosing and treating medical conditions.

Answer 1

c. Nurses offer skilled care to those recovering from illness or injury, advocate for patient rights, and help them navigate the complex healthcare system.

Rationale:
The ANA defines nursing as encompassing the protection, promotion, and optimization of health.
This includes a wide range of activities, such as providing skilled care, advocating for patients, and helping them understand the healthcare system.

Question 2

What is the nursing process?

a. A linear, step-by-step guide to carrying out specific nursing procedures.
b. A problem-solving approach used to identify and treat patient problems.
c. A standardized set of interventions applied to all patients with similar diagnoses.
d. A framework for delegating tasks to assistive personnel.

Answer 2

b. A problem-solving approach used to identify and treat patient problems.

Rationale: The nursing process is a cyclical, problem-solving approach to patient care. It is not a linear process, and it involves critical thinking and clinical judgment to adapt to individual patient needs.

Question 3

Which of the following is NOT a phase of the nursing process?

a. Assessment
b. Diagnosis
c. Prescription
d. Implementation
e. Evaluation

Answer 3

c. Prescription

Rationale: The five phases of the nursing process are:

assessment,
diagnosis,
planning,
implementation, and evaluation.

Prescription is not included in the nursing process.

Question 4

What is the primary purpose of patient-centered care?

a. To ensure the patient’s family is involved in all aspects of care.
b. To provide compassionate and coordinated care based on each patient’s unique needs, preferences, values, and needs.
c. To minimize costs and streamline the delivery of care.
d. To emphasize the use of technology in providing patient care.

Answer 4

b. To provide compassionate and coordinated care based on each patient’s unique needs, preferences, values, and needs.

Rationale: Patient-centered care prioritizes the individual needs, preferences, and values of each patient, ensuring care is tailored and respectful of their unique circumstances.

Question 5

Which communication tool helps enhance communication and patient safety during transitions of care?

a. Formal patient handoff
b. Informal bedside report
c. Physician progress notes
d. Text messaging between healthcare providers

Answer 5

a. Formal patient handoff

Rationale: Formal patient handoffs provide a structured method for communicating essential patient information during care transitions, reducing the risk of errors and miscommunication

Question 6

What is the role of the National Database of Nursing Quality Indicators (NDNQI)?

a. To track the number of nurses employed in each state.
b. To regulate the scope of practice for registered nurses.
c. To provide data on nursing-sensitive patient outcomes that improve with the quantity or quality of nursing care.
d. To investigate complaints of malpractice against nurses.

Answer 6

c. To provide data on nursing-sensitive patient outcomes that improve with the quantity or quality of nursing care.

Rationale: The NDNQI collects and analyzes data on patient outcomes that are directly influenced by the quality and quantity of nursing care. This data is used to improve nursing practice and patient safety.

Question 7

How has informatics impacted nursing practice?

a. It has decreased the need for nurses to communicate with other healthcare providers.
b. It has eliminated the need for nurses to document patient care.
c. It has transformed how nurses access and review diagnostic information, make decisions, communicate, document, and provide care.
d. It has replaced the need for nurses to have strong critical thinking skills.

Answer 7

c. It has transformed how nurses access and review diagnostic information, make decisions, communicate, document, and provide care.

Rationale: Informatics has significantly changed nursing practice, offering tools and technology that support all aspects of care, including communication, documentation, decision-making, and care delivery

Question 8

Which statement best describes evidence-based practice (EBP)?

a. EBP relies solely on the nurse’s intuition and experience.
b. EBP is a problem-solving approach that integrates the best available evidence with clinician expertise and patient preferences. c. EBP focuses primarily on minimizing the cost of patient care.
d. EBP ignores the individual needs of patients.

Answer 8

b. EBP is a problem-solving approach that integrates the best available evidence with clinician expertise and patient preferences.

Rationale: EBP emphasizes a balanced approach to care, combining the best research evidence, the expertise of clinicians, and the unique preferences and values of patients to achieve optimal outcomes.

Question 9

A nurse is caring for a patient with a new diagnosis of diabetes. Which nursing action reflects the use of practical knowledge?

a. Explaining the pathophysiology of diabetes to the patient.
b. Administering insulin as prescribed by the physician.
c. Researching the latest evidence-based guidelines for diabetes management.
d. Reflecting on personal biases that may impact care for this patient.

Answer 9

b. Administering insulin as prescribed by the physician.

Rationale: Practical knowledge involves the “knowing how” aspect of nursing, including the ability to correctly perform procedures and skills, like administering insulin.

Question 10

Which of the following is an example of a nursing intervention that requires independent nursing knowledge, skill, or judgment?

a. Ambulating a stable patient
b. Taking routine vital signs
c. Assessing a patient’s wound for signs of infection
d. Assisting a patient with bathing

Answer 10

c. Assessing a patient’s wound for signs of infection

Rationale: Assessing a wound requires clinical judgment based on nursing knowledge and skills to determine if there are signs of infection and what actions, if any, need to be taken. This is not a task that can be delegated.

Question 11

What is the difference between a nursing diagnosis and a medical diagnosis?

a. Nursing diagnoses identify diseases, while medical diagnoses describe human responses.
b. Only physicians can make medical diagnoses, while nurses and physicians can both make nursing diagnoses.
c. Nursing diagnoses focus on the patient’s response to a health problem, while medical diagnoses identify the disease or pathology.
d. There is no difference; they are interchangeable terms.

Answer 11

c. Nursing diagnoses focus on the patient’s response to a health problem, while medical diagnoses identify the disease or pathology.

Rationale: Nursing diagnoses focus on the patient’s holistic response to health conditions, while medical diagnoses label the disease itself.

Question 12

Which of the following is an example of a collaborative problem?

a. Anxiety related to upcoming surgery
b. Risk for falls related to impaired mobility c. Potential complication of pneumonia: Respiratory insufficiency
d. Ineffective breastfeeding related to latch difficulties

Answer 12

c. Potential complication of pneumonia: Respiratory insufficiency

Rationale: Collaborative problems involve potential complications that require both medical and nursing interventions to manage. Respiratory insufficiency in a patient with pneumonia is a prime example.

Question 13

A patient reports feeling nauseous after surgery. This is an example of what type of data?

a. Objective
b. Subjective
c. Primary
d. Secondary

Answer 13

b. Subjective

Rationale: Subjective data is information provided directly by the patient, often regarding feelings or symptoms they are experiencing.

Question 14

A nurse reviews a patient’s laboratory results in the electronic health record. This is an example of what type of data source?

a. Primary
b. Secondary
c. Subjective
d. Objective

Answer 14

b. Secondary

Rationale: Secondary sources include all data sources other than the patient themselves, including the medical record and reports from other healthcare providers.

Question 15

What is the purpose of validating data?

a. To document all assessment findings thoroughly.
b. To ensure the assessment data you have collected is accurate and complete.
c. To make inferences about the patient’s health status.
d. To prioritize the patient’s nursing diagnoses.

Rationale: Data validation involves verifying that your assessment findings are complete and accurate, potentially through re-assessment or clarifying information with the patient.

Answer 15

a. To document all assessment findings thoroughly.

Rationale: Data validation involves verifying that your assessment findings are complete and accurate, potentially through re-assessment or clarifying information with the patient.

Question 16

A nurse observes a patient grimacing and holding their abdomen. When asked, the patient rates their pain as 8 out of 10. What is the best way to document this information?

a. “Patient is experiencing severe abdominal pain.”
b. “Patient appears to be in pain.”
c. “Patient grimacing and holding abdomen. States pain is 8 out of 10.”
d. “Patient’s pain is not well controlled.”

Answer 16

c. “Patient grimacing and holding abdomen. States pain is 8 out of 10.”

Rationale: Documentation should be objective and specific, including both observable cues and the patient’s own words when possible

Question 17

Which of the following is a correctly written nursing diagnosis using the PES format?

a. Impaired Physical Mobility related to pain as evidenced by the patient’s statement, “It hurts to move.”
b. Pain related to surgical incision
c. Risk for falls due to a history of falls
d. Readiness for Enhanced Nutrition

Answer 17

a. Impaired Physical Mobility related to pain as evidenced by the patient’s statement, “It hurts to move.”

Rationale: The PES format includes the:

Problem (impaired physical mobility), Etiology (pain), and
Symptom (patient’s statement of pain).

Option b is incorrect because “surgical incision” is a medical treatment, not a nursing diagnosis.

Question 18

How does the etiology of a nursing diagnosis relate to nursing interventions?

a. The etiology identifies the patient’s primary medical diagnosis.
b. The etiology does not impact the selection of nursing interventions.
c. The etiology helps the nurse prioritize the patient’s problems.
d. The etiology directs the nursing interventions to address the underlying cause of the problem.

Answer 18

d. The etiology directs the nursing interventions to address the underlying cause of the problem.

Rationale: The etiology guides the nurse in selecting interventions that will address the root cause or contributing factors to the patient’s problem, making care more effective.

Question 19

A nurse is caring for a patient with chronic pain. The patient refuses to participate in physical therapy, stating, “It hurts too much.”
What is the nurse’s best response?

a. “You have to go to physical therapy; it’s doctor’s orders.”
b. “I understand that you’re in pain. Let’s discuss your concerns and see if we can find ways to make physical therapy more comfortable for you.”
c. “You won’t get better if you don’t go to physical therapy.”
d. “I’ll document that you refused physical therapy today.”

Answer 19

b. “I understand that you’re in pain. Let’s discuss your concerns and see if we can find ways to make physical therapy more comfortable for you.”

Rationale:
Acknowledging the patient’s pain, expressing empathy, and offering to work collaboratively to address their concerns promotes patient-centered care and encourages participation.

Question 20

Which of the following is an example of a nurse using clinical judgment?

a. Following a standardized care plan without considering the patient’s individual needs.
b. Delegating all tasks to assistive personnel.
c. Recognizing subtle changes in a patient’s condition and intervening appropriately.
d. Relying solely on textbook knowledge to make decisions.

Answer 20

c. Recognizing subtle changes in a patient’s condition and intervening appropriately.

Rationale: Clinical judgment involves interpreting assessment data, recognizing patterns, and making informed decisions based on knowledge, experience, and the specific patient context

Question 21

What is the significance of the “preparation-to-practice” gap in nursing?

a. It means that new graduate nurses are fully prepared to provide safe and effective care.
b. It highlights the need for experienced nurses to mentor new graduates.
c. It indicates that nursing schools are not adequately preparing students for the realities of practice.
d. It suggests that clinical judgment is not an important skill for nurses.

Answer 21

b. It highlights the need for experienced nurses to mentor new graduates.

Rationale: The “preparation-to-practice” gap refers to the finding that many new graduates lack the level of clinical judgment and decision-making ability needed to function effectively in complex healthcare environments.
This highlights the need for continued development of these skills during and after nursing school.

Question 22

A novice nurse is caring for a post-operative patient. Which action demonstrates effective use of the NCSBN Clinical Judgment Measurement Model?

a. Independently analyzing complex assessment data and making critical decisions without consulting experienced colleagues.
b. Recognizing limitations in knowledge and seeking guidance from a preceptor when faced with unfamiliar situations.
c. Ignoring subtle changes in the patient’s vital signs, assuming they are within normal limits.
d. Prioritizing tasks based on personal preference rather than the patient’s needs.

Answer 22

b. Recognizing limitations in knowledge and seeking guidance from a preceptor when faced with unfamiliar situations.

Rationale: The NCSBN Model emphasizes the importance of self-awareness and recognizing one’s own limitations, especially for novice nurses. Seeking guidance from more experienced nurses ensures safe and effective patient care

Question 23

Which of the following is an example of an environmental factor that can impact clinical judgment?

a. A nurse’s level of experience
b. Time constraints and staffing levels
c. A patient’s cultural beliefs
d. A nurse’s personal biases

Answer 23

b. Time constraints and staffing levels

Rationale: Environmental factors are external influences that can affect clinical judgment, such as limited time, inadequate staffing, or distractions in the workplace.

Question 24

What is the relationship between clinical reasoning and clinical judgment?

a. They are unrelated concepts in nursing practice.
b. Clinical reasoning is the outcome of clinical judgment.
c. Clinical reasoning is a component of clinical judgment.
d. Clinical judgment is a component of clinical reasoning.

Answer 24

c. Clinical reasoning is a component of clinical judgment.

Rationale: Clinical judgment encompasses a broader set of cognitive skills, including clinical reasoning, which involves analyzing data, forming hypotheses, and making decisions based on the available information.

Question 25

Which statement about critical thinking is true?

a. Critical thinking is a passive process.
b. Critical thinking does not require nurses to be open to alternatives.
c. Critical thinking involves analyzing and evaluating information to make informed decisions.
d. Critical thinking skills are not essential for safe nursing practice.

Answer 25

c. Critical thinking involves analyzing and evaluating information to make informed decisions.

Rationale: Critical thinking is an active and deliberate process that requires nurses to analyze, evaluate, and synthesize information to make sound clinical judgments.

Question 26

A nurse is caring for a patient who is recovering from a stroke. The patient is frustrated with their limitations and expresses anger towards the nursing staff. What is the nurse’s best action, using a trauma-informed care approach?

a. Tell the patient to calm down and behave appropriately.
b. Recognize the patient’s behavior as a possible response to trauma and approach them with empathy and understanding.
c. Avoid interacting with the patient as much as possible.
d. Document the patient’s behavior as uncooperative and hostile.

Rationale: Trauma-informed care recognizes that challenging behaviors can be a manifestation of past trauma or stress. Approaching the patient with empathy and understanding helps build trust and create a safe healing environment.

Answer 26

b. Recognize the patient’s behavior as a possible response to trauma and approach them with empathy and understanding.

Rationale: Trauma-informed care recognizes that challenging behaviors can be a manifestation of past trauma or stress. Approaching the patient with empathy and understanding helps build trust and create a safe healing environment.

Question 27

Which of the following is an example of a nurse demonstrating intellectual humility?

a. Being confident in one’s own knowledge and rarely seeking input from others.
b. Dismissing evidence that contradicts personal beliefs.
c. Acknowledging limitations in knowledge and seeking guidance from experienced colleagues.
d. Refusing to change practice based on new research findings.

Rationale: Intellectual humility involves recognizing that one’s knowledge is not absolute and being open to learning from others, especially those with more experience or expertise.

Answer 27

c. Acknowledging limitations in knowledge and seeking guidance from experienced colleagues.

Rationale: Intellectual humility involves recognizing that one’s knowledge is not absolute and being open to learning from others, especially those with more experience or expertise.

Question 28

Why is it important for nurses to reflect on their own assumptions and biases?

a. To avoid taking responsibility for errors in judgment.
b. To justify making decisions based on personal opinions.
c. To ensure that care is provided in a non-judgmental and culturally sensitive manner.
d. To reinforce existing stereotypes about patients.

Answer 28

c. To ensure that care is provided in a non-judgmental and culturally sensitive manner.

Rationale: Reflecting on personal biases helps nurses provide care that is unbiased, respectful, and responsive to the unique needs of each patient.

Question 29

How can a nurse create a more inclusive healthcare environment?

a. By treating all patients the same, regardless of their background or beliefs.
b. By valuing and respecting the diverse lived experiences of all patients.
c. By imposing personal beliefs on patients.
d. By avoiding conversations about cultural differences.

Answer 29

b. By valuing and respecting the diverse lived experiences of all patients.

Rationale:
An inclusive environment embraces diversity and recognizes that each patient’s unique experiences and perspectives contribute to their overall health and well-being.

Question 30

What is the primary goal of full-spectrum nursing?

a. To complete tasks efficiently, regardless of patient outcomes.
b. To provide safe, effective care and achieve good patient outcomes.
c. To focus solely on the physical aspects of patient care.
d. To minimize the need for critical thinking in nursing practice.

.

Answer 30

b. To provide safe, effective care and achieve good patient outcomes.

Rationale: Full-spectrum nursing integrates thinking, doing, and caring to ensure that nursing practice is safe, effective, and focused on achieving optimal patient outcomes