NCLEX - W1 - TLAN 2

Question 1

A nurse is prioritizing care for a patient with multiple nursing diagnoses. Which of the following problems should the nurse address first?
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A. Risk for impaired skin integrity
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B. Impaired mobility
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C. Ineffective airway clearance
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D. Disturbed sleep pattern

Answer 1

Answer: C. Ineffective airway clearance

Rationale: Using the ABCs (Airway, Breathing, Circulation) prioritization framework, ineffective airway clearance poses the most immediate threat to the patient’s well-being as it can lead to respiratory distress and potentially life-threatening complications.

Question 2

Which of the following is an example of a SMART goal?
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A. Patient will feel better by the end of the shift.
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B. Patient will ambulate in the hallway by the end of the week.
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C. Patient will consume 1,500 mL of fluids within 24 hours.
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D. Patient will understand their new medication regimen.

Answer 2

Answer: C. Patient will consume 1,500 mL of fluids within 24 hours.

Rationale: A SMART goal is Specific, Measurable, Achievable, Relevant, and Time-bound.

Option C is the only option that meets all of these criteria.

Question 3

A nurse is developing a care plan for a patient with a nursing diagnosis of “Impaired Physical Mobility.” Which of the following interventions is an example of a collaborative intervention?
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A. Turn and reposition the patient every 2 hours.
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B. Consult with physical therapy for ambulation training.
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C. Encourage the patient to perform active range-of-motion exercises.
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D. Assess the patient’s pain level before and after ambulation.

Answer 3

Answer: B. Consult with physical therapy for ambulation training.

Rationale: Collaborative interventions involve working with other healthcare professionals to provide holistic care.

Option B reflects the collaboration between the nurse and the physical therapist.

Question 4

A nurse is caring for a patient with a new diagnosis of diabetes. Which type of goal would be most appropriate for this patient to demonstrate understanding of their condition?
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A. Cognitive
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B. Psychomotor
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C. Affective
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D. Physical

Answer 4

Answer: A. Cognitive

Rationale: Cognitive goals focus on intellectual outcomes, such as knowledge and understanding. Understanding their new diagnosis of diabetes involves intellectual processing and knowledge acquisition.

Question 5

Which of the following is a characteristic of a well-written nursing order?
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A. Vague and non-specific
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B. Focuses on patient behavior
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C. Includes the date, subject, action verb, times and limits, and signature
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D. Delegates all aspects of care to unlicensed personnel

Answer 5

Answer: C. Includes the date, subject, action verb, times and limits, and signature

Rationale: A nursing order should be clear and concise, outlining specific instructions for care. It should include the necessary elements to ensure proper understanding and implementation

Question 6

A nurse is preparing to delegate a task to a UAP. Which of the following tasks is appropriate to delegate?
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A. Assessing a patient’s wound
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B. Educating a patient about their medication
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C. Developing a care plan
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D. Assisting a patient with ambulation

Answer 6

Answer: D. Assisting a patient with ambulation

Rationale: UAPs can perform tasks that are routine and do not require nursing judgment. Assisting with ambulation, under the supervision of a nurse, is within the scope of practice for a UAP

Question 7

A nurse is evaluating the care plan for a patient with a nursing diagnosis of “Acute Pain.” The goal was “Patient will report pain level of 3 or less on a 0-10 scale within 1 hour of receiving pain medication.” The patient reports a pain level of 5 one hour after receiving medication. What is the appropriate nursing action?
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A. Document that the goal was met.
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B. Discontinue the care plan for acute pain.
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C. Reassess the patient and consider revising the care plan.
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D. Administer a placebo to see if the patient’s pain decreases.

Answer 7

Answer: C. Reassess the patient and consider revising the care plan.

Rationale: The goal was not fully met as the patient still reports a pain level of 5. The nurse should reassess the patient’s pain, explore potential reasons for inadequate pain relief, and consider modifying the care plan to achieve better pain management.

Question 8

What is the purpose of using standardized nursing languages, such as the Nursing Interventions Classification (NIC), when planning nursing interventions?
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A. To restrict nurses’ autonomy and decision-making
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B. To create a complex and confusing care plan
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C. To facilitate clear communication and enhance data collection
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D. To eliminate the need for individualized patient care

Answer 8

Answer: C. To facilitate clear communication and enhance data collection

Rationale: Standardized languages provide a consistent framework for describing nursing care, improving communication among healthcare providers and enabling better data collection for research and quality improvement purposes.

Question 9

Which of the following is an example of a nurse-sensitive outcome?
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A. Blood glucose levels within target range
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B. Surgical wound infection rate
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C. Patient satisfaction with pain management
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D. Length of hospital stay

Answer 9

Answer: C. Patient satisfaction with pain management

Rationale: Nurse-sensitive outcomes are those that are directly influenced by nursing care. Patient satisfaction with pain management is a measure of the effectiveness of nursing interventions related to pain assessment and relief

Question 10

A nurse is evaluating the care of a patient with a nursing diagnosis of “Risk for Falls.” The goal was “Patient will not experience any falls during hospitalization.” The patient did not experience any falls. Which of the following statements is the most appropriate evaluation statement?
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A. Goal met. Patient experienced no falls.
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B. Goal partially met. Patient experienced no falls, but required assistance with ambulation.
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C. Goal not met. Patient experienced one fall.
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D. Goal not applicable. Patient was discharged before the evaluation period.

Answer 10

Answer: A. Goal met. Patient experienced no falls.

Rationale: The goal was specifically that the patient would experience no falls during hospitalization. Since the patient did not fall, the goal was met. The evaluation statement should be clear, concise, and directly related to the stated goal

Question 11

A nurse is planning care for a patient with a nursing diagnosis of “Activity Intolerance.” Which of the following is an example of an independent nursing intervention?
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A. Administering oxygen as prescribed by the physician
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B. Pacing activities and providing rest periods
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C. Consulting with physical therapy for an exercise program
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D. Ordering a chest x-ray to rule out respiratory complications

Answer 11

Answer: B. Pacing activities and providing rest periods

Rationale: Independent nursing interventions are those that nurses can implement based on their knowledge and skills without requiring a physician’s order. Pacing activities and providing rest periods are within the scope of nursing practice and can be implemented independently to address activity intolerance.

Question 12

What is the primary purpose of the evaluation phase of the nursing process?
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A. To gather initial assessment data about the patient
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B. To identify the patient’s nursing diagnoses
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C. To determine the effectiveness of nursing care and make necessary adjustments
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D. To delegate tasks to unlicensed assistive personnel

Answer 12

Answer: C. To determine the effectiveness of nursing care and make necessary adjustments

Rationale: The evaluation phase focuses on assessing the patient’s progress toward goals and the effectiveness of the nursing interventions. Based on the evaluation findings, the nurse can determine whether to continue, modify, or discontinue the care plan

Question 13

A nurse is caring for a patient who is recovering from a stroke. Which of the following is an example of a long-term goal?
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A. Patient will be able to transfer from bed to chair with assistance by the end of the shift.
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B. Patient will be able to ambulate independently within the home by the time of discharge from rehabilitation.
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C. Patient will be able to consume 50% of their meals by the end of the day.
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D. Patient will report pain level of 4 or less within 30 minutes of receiving pain medication.

Answer 13

Answer: B. Patient will be able to ambulate independently within the home by the time of discharge from rehabilitation.

Rationale: Long-term goals represent desired outcomes that are expected to be achieved over a longer period, often weeks or months. Ambulating independently within the home by discharge from rehabilitation is a long-term goal that requires ongoing therapy and rehabilitation.

Question 14

Which of the following is an example of an ongoing evaluation?
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A. Assessing a patient’s vital signs every 4 hours
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B. Reviewing a patient’s progress at a weekly care conference
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C. Documenting a patient’s discharge teaching
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D. Monitoring a patient’s pain level after administering pain medication

Answer 14

Answer: D. Monitoring a patient’s pain level after administering pain medication

Rationale: Ongoing evaluation occurs continuously throughout the provision of nursing care. Monitoring a patient’s pain level immediately after giving pain medication allows for immediate adjustments if the intervention is not effective

Question 15

Which of the following is a barrier to effective discharge planning?
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A. Early identification of the patient’s discharge needs
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B. Collaboration with the interprofessional team
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C. Inadequate assessment of the patient’s home environment and support system
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D. Patient and family involvement in the planning process

Answer 15

Answer: C. Inadequate assessment of the patient’s home environment and support system

Rationale: Effective discharge planning requires a thorough understanding of the patient’s home environment, support system, and resources to ensure a safe and smooth transition to home. Inadequate assessment can lead to complications and readmissions

Question 16

A nurse is evaluating a patient’s response to a new medication. Which of the following findings indicates a need to revise the care plan?
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A. The patient’s blood pressure has decreased to within normal limits.
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B. The patient reports a decrease in pain level.
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C. The patient has developed a new rash and itching.
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D. The patient is able to ambulate to the bathroom with assistance.

Answer 16

Answer: C. The patient has developed a new rash and itching.

Rationale: The development of a new rash and itching suggests a potential adverse reaction to the medication. The nurse should immediately assess the situation, notify the provider, and revise the care plan to address this unexpected finding.

Question 17

Which of the following is an example of a structure evaluation?
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A. Assessing a nurse’s documentation of patient care
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B. Evaluating the availability of essential equipment on a nursing unit
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C. Measuring the rate of hospital-acquired infections
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D. Surveying patients about their satisfaction with nursing care

Answer 17

Answer: B. Evaluating the availability of essential equipment on a nursing unit

Rationale: Structure evaluation focuses on the setting in which care is provided. Evaluating the availability of essential equipment, such as a resuscitation cart, assesses the structural aspects that support safe and effective care.

Question 18

What is the difference between assigning and delegating a task?
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A. Assigning involves transferring responsibility to another RN, while delegating involves transferring responsibility to a UAP.
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B. Assigning is appropriate for any nursing task, while delegating is only appropriate for tasks that are within the UAP’s scope of practice.
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C. Assigning does not require supervision, while delegating requires ongoing supervision by the RN.
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D. Assigning is done by the charge nurse, while delegating is done by the staff nurse.

Answer 18

Answer: A. Assigning involves transferring responsibility to another RN, while delegating involves transferring responsibility to a UAP.

Rationale: Assigning tasks involves distributing workload among qualified and licensed personnel, while delegation involves transferring responsibility for specific tasks to unlicensed personnel while the RN retains accountability.

Question 19

A nurse is caring for a patient who is experiencing anxiety related to an upcoming surgery. Which of the following interventions addresses the etiology of the patient’s anxiety?
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A. Administering an anti-anxiety medication as prescribed
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B. Providing a quiet and calming environment
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C. Teaching the patient relaxation techniques
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D. Educating the patient about the surgical procedure and expected recovery

Answer 19

Answer: D. Educating the patient about the surgical procedure and expected recovery

Rationale: The etiology of the patient’s anxiety is the upcoming surgery and related uncertainties. By educating the patient about the procedure and recovery process, the nurse addresses the root cause of the anxiety, promoting better understanding and potentially reducing anxiety levels

Question 20

Which of the following actions by the nurse demonstrates patient-centered care during discharge planning?
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A. Developing a discharge plan based on the nurse’s perception of the patient’s needs
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B. Providing the patient with a standardized discharge instruction sheet
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C. Involving the patient and family in setting realistic goals and identifying support systems
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D. Discharging the patient as soon as medically stable, regardless of their psychosocial needs

Answer 20

Answer: C. Involving the patient and family in setting realistic goals and identifying support systems

Rationale: Patient-centered care involves recognizing the patient’s autonomy and preferences. Involving the patient and family in discharge planning ensures that the plan is tailored to their specific needs, promoting better adherence and outcomes.

Question 21

A nurse is implementing a care plan for a patient with a nursing diagnosis of “Impaired Gas Exchange.” Which of the following interventions is most directly related to the “AMB/AEB” part of the diagnosis?
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A. Administering oxygen as prescribed
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B. Encouraging deep breathing and coughing exercises
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C. Monitoring the patient’s oxygen saturation levels
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D. Elevating the head of the bed

Answer 21

Answer: C. Monitoring the patient’s oxygen saturation levels

Rationale: The “AMB/AEB” (as manifested by/as evidenced by) part of a nursing diagnosis describes the signs and symptoms that support the diagnosis.

Monitoring oxygen saturation levels directly assesses the patient’s gas exchange status, providing data related to the “AMB/AEB” component

Question 22

A nurse is providing discharge teaching to a patient who will be self-administering insulin injections at home. Which of the following methods of evaluation is most effective in determining the patient’s learning?
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A. Asking the patient to verbally repeat the instructions
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B. Providing the patient with a written pamphlet about insulin administration
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C. Observing the patient demonstrate the injection technique
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D. Having the patient complete a multiple-choice quiz about insulin

Answer 22

Answer: C. Observing the patient demonstrate the injection technique

Rationale: Return demonstration is the most effective way to evaluate a patient’s understanding and ability to perform a skill.
By observing the patient demonstrate the injection technique, the nurse can directly assess their competency and provide immediate feedback.

Question 23

Which of the following is an example of a process evaluation?
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A. Auditing medical records to determine compliance with documentation standards
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B. Surveying patients about their satisfaction with the hospital’s food service
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C. Evaluating the effectiveness of a new fall prevention program
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D. Assessing the availability of hand hygiene stations throughout the hospital

Answer 23

Answer: A. Auditing medical records to determine compliance with documentation standards

Rationale: Process evaluation focuses on how care is delivered.
Auditing medical records evaluates the documentation process and its adherence to established standards

Question 24

Which of the following statements regarding the use of critical pathways is true?
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A. Critical pathways are individualized care plans that are developed for each patient.
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B. Critical pathways are based on evidence-based practice guidelines and best practices.
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C. Critical pathways eliminate the need for nurses to use clinical judgment.
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D. Critical pathways are only used in long-term care settings.

Answer 24

Answer: B. Critical pathways are based on evidence-based practice guidelines and best practices.

Rationale: Critical pathways are standardized plans of care that outline the expected course of treatment and interventions for patients with specific conditions.

They are developed based on best practices and evidence-based guidelines to promote consistent and efficient care

Question 25

A nurse is caring for a patient who is post-operative day 1 following abdominal surgery. The patient is experiencing pain, nausea, and difficulty ambulating. Which of the following interventions should the nurse prioritize?
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A. Administer pain medication as prescribed.
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B. Encourage the patient to eat a light meal to prevent nausea.
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C. Assist the patient to ambulate to the bathroom to promote bowel function.
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D. Provide emotional support and reassurance to the patient.

Answer 25

Answer: A. Administer pain medication as prescribed.

Rationale: Using Maslow’s hierarchy of needs and the ABCs prioritization framework, addressing the patient’s pain should be the priority in this scenario.

Uncontrolled pain can hinder recovery and contribute to other complications.

Question 26

A nurse is developing a care plan for a patient who is at risk for developing pressure ulcers. Which of the following interventions is an example of a preventive intervention?
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A. Applying a topical barrier cream to the patient’s sacrum
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B. Turning and repositioning the patient every 2 hours
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C. Assessing the patient’s skin for signs of redness or breakdown
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D. Consulting with a wound care specialist

Answer 26

Answer: B. Turning and repositioning the patient every 2 hours

Rationale: Preventive interventions aim to prevent the occurrence of a potential problem.

Turning and repositioning the patient every 2 hours helps to relieve pressure and reduce the risk of pressure ulcer development.

Question 27

Which of the following statements regarding the documentation of nursing interventions is true?
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A. Documentation should be concise and only include objective data.
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B. Documentation should be completed at the end of the shift to save time.
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C. Documentation should reflect the patient’s response to the interventions.
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D. Documentation can be delegated to unlicensed assistive personnel.

Answer 27

Answer: C. Documentation should reflect the patient’s response to the interventions.

Rationale: Documentation of nursing interventions should include not only the actions taken but also the patient’s response to those actions.

This provides valuable information for evaluating the effectiveness of the care plan and communicating patient status to other healthcare providers

Question 28

A nurse is caring for a patient who is receiving intravenous fluids. The physician has ordered the fluids to be discontinued. Which of the following actions by the nurse is an example of a dependent intervention?
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A. Assessing the patient’s IV site for signs of infiltration or phlebitis
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B. Discontinuing the IV fluids as ordered by the physician
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C. Monitoring the patient’s fluid intake and output
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D. Educating the patient about the importance of staying hydrated

Answer 28

Answer: B. Discontinuing the IV fluids as ordered by the physician

Rationale: Dependent interventions are those that are initiated by a physician or other healthcare provider but carried out by the nurse.

Discontinuing the IV fluids is a dependent intervention that requires a physician’s order

Question 29

A nurse is reflecting on their clinical judgment after caring for a patient who experienced a decline in respiratory status. Which of the following questions is most helpful for the nurse to consider during this reflection process?
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A. “Did I document all of my interventions accurately?”
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B. “What factors could have contributed to the patient’s decline?”
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C. “Was I following the hospital’s policies and procedures?”
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D. “Did I delegate tasks appropriately to the UAP?”

Answer 29

Answer: B. “What factors could have contributed to the patient’s decline?”

Rationale: Reflection on clinical judgment should involve analyzing the situation and identifying potential factors that influenced the patient’s outcome.

By considering factors that contributed to the patient’s decline, the nurse can learn from the experience and improve future practice

Question 30

Which of the following is an example of a process evaluation?
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A. Auditing medical records to determine compliance with documentation standards
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B. Surveying patients about their satisfaction with the hospital’s food service
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C. Evaluating the effectiveness of a new fall prevention program
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D. Assessing the availability of hand hygiene stations throughout the hospital

Answer 30

Answer: A. Auditing medical records to determine compliance with documentation standards

Rationale: Process evaluation focuses on how care is delivered.
Auditing medical records evaluates the documentation process and its adherence to established standards.