NCLEX
Chapter 6

Q1. Nurse is talking to a Japanese American patient about his upcoming surgery. The patient keeps nodding and smiling. What does that mean?
A1: The nodding and smiling is cultural/part patient’s culture.
A2: Patient agrees with treatment.
A3: Patient agrees that the procedure is required.
A4: Patient understands the process of preoperative procedures.
Correct answer is 1. Because answers 2 and 3 may not mean that patient agrees with the treatment, speaker, or understands the procedure. Option 4 falsely interprets patient’s behavior.

Q2. What is the best thing to do when the nurse is talking to a patient of different language?
A1: Talk slow and loud.
A2: Get an interpreter.
A3: Talk to the patient and family at once.
A4: Talk loud while being close to the patient.
Correct answer is 2. Answer 3 violates patient’s privacy rights, answers 1 and 4 are wrong because talking loud wouldn’t be therapeutic to the patient, but the opposite.

Q3. The nurse educator is educating staff transcultural nursing, when a staff member asks to explain acculturation. What is the most appropriate response?
A1: It is learning new culture and adapting to change.
A2: It is importance of person’s heritage and a desire to belong.
A3: It is a group of people that are culturally unique.
A4: It is a group that shares characteristics of the population that it is a part of.
Correct answer is 1 because the definition of acculturation means learning new culture and adapting a change. Answer 2 describes ethnic identity, answer 3 describes ethnic group, answer 4 describes a subculture.

Q4. While nurse is providing discharge instructions to a Chinese American patient, the patient keeps turning away. What is the best way to handle this?
A1: Keep explaining, while verifying that patient is understanding.
A2: Walk around the patient whichever way the head is turned to make sure that he/she sees you.
A3: Provide patient with dietary booklet and just come back later with instructions.
A4: Explain to the patient that discharge instructions are very important
Correct answer is 1 because many Chinese American people are not comfortable with face to face communications and distance is their form of respect. Answers 3 & 4 are wrong because they are not therapeutic, answer 2 is wrong because it doesn’t reflect patient’s culture.

Q5. Which is a low risk therapy? Select all that would apply.
A1: Herbal therapy
A2: Praying
A3: Touching
A4: Massaging.
A5: Relaxation.
A6: Acupuncture
Correct answers are 2, 3, 4, 5 because these therapies have no side effects and can be administered by the nurse who has experience. Options 1 and 6 are wrong because these could have adverse effects.

Q6. Which patient has a higher risk for diabetes? Select all that would apply.
A1: 40 y/o Latino American man
A2: 45 y/o Native American man
A3: 23 y/o Asian American woman
A4: 35 y/o Hispanic American man
A5: 40 y/o African American woman
Correct answers are 1, 2, 4, 5 because of the dietary practices in these cultures, also they are older than the option 3.

Q7. The nurse is preparing a surgery care plan for Jehovah’s Witness patient. What should she document?
A1: Patient believes that soul lives after death.
A2: Medication is wrong.
A3: Surgery is not allowed by patient’s religion.
A4: The blood transfusion is not allowed.
Correct answer is 4 because Jehovah’s Witness religion doesn’t allow blood transfusion. Answer 1 is wrong because that is the opposite of their belief. Answer 2 is wrong because medication is acceptable, answer 3 is wrong because surgery is allowed.

Q8. What kind of food should a nurse give to a Orthodox Judaism patient who is on kosher diet?
A1: Pork roast, rice, vegetables, mixed fruit, milk.
A2: Crab salad on croissant, vegetables with dip, potato salad, juice.
A3: Sweet and sour chicken with rice and vegetables, mixed fruit, juice.
A4: Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea.
Correct answer is 3 because combination of dairy and meat is not allowed on kosher diet, which makes option 1 wrong, and options 2 and 4 are wrong because they both contain shellfish, which is not allowed. On kosher diet only fish that have scales and fins are allowed.

Q9. Nurse knows that Asian American patient is likely to treat the fever him/herself by doing what?
A1: Praying.
A2: Magnetic therapy.
A3: Yin foods
A4: Yang foods
Correct answer is 3 because Yin food is cold, which means answer 4 is wrong because Yan food is hot. Options 1 and 2 is not something that Asian American culture practices.

A10. What should a nurse in complementary and alternative medicine do?
A1: Educate patient about good and bad therapies.
A2: Recommend herbal therapy.
A3: Discourage patient from using alternative therapies.
A4: Educate the patient about therapies that he’she is interested in suing or is already using.
Correct answer is 4 because options 1, 2, 3 provide advice to the client.

Q11. The patient that’s on lowering blood pressure medication asks the nurse for herbal substance instead. What should the nurse do?
A1: Tell the patient that herbal medication is not safe.
A2: Educate the patient how to take their own blood pressure to monitor it closely.
A3: Advise the patient to discuss the herbal medicine with provider.
A4: Tell the patient that if he/ she switches to herbal medication, then blood pressure has to be monitored more often.
Correct answer is 3 because not all herbal medications are safe and combining the two could have bad side effects. This makes options 1, 2, 4 not correct.

Q12. The educator asks student to identify five categories of CAM. Which answer would show that the student knows them?
A1: Herbology, Hydrotherapy, acupuncture, nutrition, and chiropractic care.
A2: Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch.
A3: Biologically based practices, body-based practices, magnetic therapy, massage therapy, and aroma therapy.
A4: Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine.
Correct answer is 4 because the other options contain therapies within each category of CAM.

Chapter 7
Q13. Nurse responds to patient’s cry for help and finds him/her on the floor. What should the nurse document when filling out incident report?
A1: Patient fell out of bed.
A2: Patient climbed over the bed rails.
A3: Patient was found on the floor.
A4: Patient got tired of being in bed and tried to get out.
Correct answer is 3 because fact about the incident that the nurse witnessed. Other options are wrong because they were not observed by the nurse and are not facts.

Q14. EMS brought a patient that was hit by a car. Patient is unconscious and name is unknown. Craniotomy is required but consent is needed. What is the best action?
A1: Get a court order.
A2: Ask EMS to sign the consent.
A3: Take patient to the operating room.
A4: Call police to locate the family and identify the patient.
Correct answer is 3 because options 1 and 2 would delay the procedure, option 2 is not appropriate. In this case surgery consent would not be required.

Q15. Nurse and provider have assessed the patient for injuries after patient fell out bed. They determined patient didn’t sustain any injuries. Once the incident report is filled out, what should the nurse do next?
A1: Reassess the patient.
A2: Arrange a team meeting to describe the fall.
A3: Note the fall in nursing notes.
A4: Contact the supervisor with updates about the fall.
Correct answer is 1 because after fall patient needs to be reassessed more often for potential complications. Other options are wrong because incident report is kept private, doesn’t get noted in nurse’s notes and supervisor will contact the nurse if update is necessary.

Q16. The nurse who has never worked in the ICU is told to go work there for the day because they are understaffed. What should the nurse do first?
A1: Call hospital lawyer.
A2: Refuse to go to ICU.
A3: Call the supervisor.
A4: Identify what she can do safely in ICU.
Correct answer is 4 because all other options are wrong. Option 1 is not smart, option 2 is wrong because nurse can’t refuse to go unless the nursing union contract says so, and option 3 should only be taken if the nurse is asked to perform something she/he has no knowledge of.

Q17. Nurse finds a co-worker who is about to self-inject with a clear liquid in medication room. What is the best was to handle this?
A1: Call security.
A2: Call police.
A3: Call supervisor.
A4: Lock the co-worker in the medication room while he/she gets help.
Correct answer is 3 because NPA requires reporting impaired nurses. The supervisor will report the nurse to police not nurse. Option 1 should only be done if there is a problem. Option 4 is wrong because it is not safe.

Q18. The patient asks the nurse to find a witness to sign a living will. What is most appropriate way to tell the patient?
A1: I will sign as a witness.
A2: You will need to find a witness yourself.
A3: Whoever is available at the time will sign it for you.
A4: I will check with my supervisor about your request.
Correct answer is 4 because it the most appropriate. Other options are not appropriate because option 2 and 3 is illegal in many states, option 2 is not therapeutic.

Q19. Nurse obtains patient’s record to correct a narrative error he/she made. What should nurse do to correct the error?
A1: Document a late entry.
A2: Try to erase the error and write in the correct information.
A3: Use whiteout to delete the error and write correct information.
A4: Draw one line through error, initial, date, and then document correct information.
Correct answer is 4 because the other answers are wrong because they violate agency policies about correcting errors.

Q20. Which identifies correct nursing documentation notations? Select all that apply.
A1: Patient slept all night.
A2: Abdominal wound dressing is dry and intact without damage.
A3: The patient seemed angry when awakened to measure vital signs.
A4: The patient appears anxious when it is time for respiratory treatments.
A5: The patient’s left lower leg would is 3 cm in length without redness, drainage, or edema.
Correct answer is 1, 2, 5 because options 3 and 4 are inappropriate because they are not factual and include vague terms. Q21. Instructor asks a nursing student to identify a situation that represents violation of patient’s privacy. Which situation shows that student understands and knows that information?
A1: Performing a procedure without patient’s consent.
A2: Threatening the patient with medication.
A3: Telling the patient that he/she can’t leave the hospital.
A4: Observing patient’s care without his/her permission.
Correct answer is 4 because patient didn’t provide the permission to be observed. Other answers are wrong because option 1 is example of battery, option 2 is assault, option 3 is false imprisonment.

Q22. The UAP tells the group that unit secretary most likely got AIDS from her husband, who is a drug addict. What has UAP violated?
A1: Libel.
A2: Slander.
A3: Assault.
A4: Negligence.
Correct answer is 2 because verbal damage has been done to unit secretary’s reputation. Option 1 is wrong because it wasn’t done in writing, option 3 is wrong because this wasn’t assault, option 4 is wrong because this wasn’t negligence.

Q23. Emergency department nurse is assessing 87 year old women who tells her that her son frequently hits her if dinner isn’t ready on time after he comes home from work. What is the most appropriate way to respond?
A1: I will talk to you son about it.
A2: Let’s discuss how you can manage your time better so it doesn’t happen again.
A3: Do you have anyone to help you out until these issues with your son are resolved?
A4: I am legally bound to report abuse. I will help you find a safe place to stay once report is finished.
Correct answer is 4 because by law nurse has to report abuse. Other answers are not appropriate because they do not protect the patient.

Q24. The nurse is needs to administer new medication prescription and notices that dosage prescribed is higher than what is recommended. She tries to locate HCO but is not successful. What does she do?
A1: Get in contact with nursing supervisor.
A2: Administer the medication in dosage prescribed.
A3: Don’t give medication he/ she get in touch with HCP.
A4: Give recommended dose instead of prescribed one until he/ she talks to HCP.
Correct answer is 1 because if there is an issue with prescription that HCP wrote and needs clarification, nurse should not give the medication without clarifying the information first. Nurse needs to contact supervisor for clarification on what the next step should be. Answers 2 and 4 are not correct because they are unsafe. Answer 3 is wrong because nurse needs to take action.

Q25. Nurse is expecting faxed lab report but instead receives a sexual photo. What is the most appropriate action?
A1: Call police.
A2: Shred the photo and throw it away.
A3: Report the incident to nursing supervisor.
A4: Call the lab and ask the name of the person that faxed the photo.
Correct answer is 3 because this is an example of sexual conduct/ harassment and has to be reported. Answer 1 is unnecessary at this time. Answers 2 and 4 are not appropriate.

Q26. Nurse is assigned 4 patients. Which would need to be assessed first?
A1: Patient scheduled for chest x-ray.
A2: Patient requiring dressing changes daily.
A3: Post-op patient that’s about to be discharged.
A4: Patient who had difficulty breathing during last shift and is on oxygen.
Correct answer is 4 because airway is always the highest priority. Other answers are because they are intermediate priorities.

Q27. An evening shift ER nurse should see which patient first?
A1: Patient complaining of headache, malaise, and muscle aches.
A2: Patient who fell and twisted ankle while rollerblading.
A3: Patient with minor laceration.
A4: Patient with chest pain after eating a very spicy pizza.
Correct answer is 4 because patient with chest pain in emergent and is number 1 priority. Other answers are wrong because they are priority 2 and 3.

Q28. Nurse is told that the nursing model is a team approach while attending an orientation in health care facility. Which characteristic is the planning care delivery based on?
A1: A task approach method used to care for patients.
A2: Managed care concepts and tools.
A3: A single RN is responsible to care a group of patients.
A4: RN personnel leads nursing staff in caring for a group of patients.
Correct answer is 4 because in team nursing, the staff is led by RN leader in caring for a group of patients. Answer 1 is wrong because it is functional nursing. Answer 2 is component of case management. Answer 3 is primary nursing/ relationship-based practice.

Q29. Nurse received is working day shift. Which patient will she need to plan to care for first?
A1: Ambulatory patient.
A2: Patient scheduled for physical therapy at 1pm.
A3: Diaphoretic and restless patient with fever.
A4: Post-op patient who just received pain medication.
Correct answer is 3 because that patient’s needs are priority. Answers 1, 2 and 4 do not have priority needs related to care.

Q30. UAP walks into a room where nurse is bed bathing patient and says that another patient is in pain and needs pain medication. What is the most appropriate action?
A1: Finish bathing patient and then give pain medication to another patient.
A2: Ask UAP to find out when another patient had his last medication?
A3: Ask UAP to tell patient in pain that as soon as the nurse finishes washing this patient, he/ she will come in and administer the pain medication.
A4: Cover the patient, put up the bed rails, tell patient that you’ll be back soon, and go give pain medication to patient in pain.
Correct answer is 4 because nurse’s responsibility is to care for patients. To care for patient in pain, he/ she first needs to provide safety to bathing patient and go administer medication. Answers 1 and 3 are not correct because they delay medication to patient in pain. Answer 2 is not UAP’s respobsibility.

Q31. The nurse manager changed nursing delivery method from functional to team. UAP doesn’t agree with new process and is facilitating the change. What is the best way to deal with UAP?
A1: Ignore.
A2: Exert coercion.
A3: Provide positive reward system.
A4: Confront and encourage to talk about it.
Correct answer is 4 because confrontation is important in dealing with resistance. This will allow to develop strategies to solve problems. Answer 1 doesn’t address the problem. Answer 3 might provide temporary solution but will not solve it. Answer 2 is wrong just based on wording alone.

Q32. RN is planning patient assignments. Which assignment would be appropriate for UAP?
A1: Patient requiring colostomy irrigation.
A2: Patient on feeding tube.
A3: Patient who requires collection of urine specimen.
A4: Patient who has difficulty swallowing.
Correct answer is 3 because assignments need to be assigned based on skills. UAP is skilled in this procedure. Answers 1 and 2 are not something UAP is skilled in. Based on this, answer 4 can be eliminated.

Q33. New unit nurse manager explains a plan and tasks that everyone has to perform. What type of leader does this characterize her as?
A1: Autocratic.
A2: Situational.
A3: Democratic.
A4: Laissez-faire.
Correct answer is 1 because autocratic leader is focused and addresses all problems, dominates and commands rather than seeks suggestions. Answer 2 is wrong because leader would work with group to validate information for accuracy. Answer 3 leader would meet with each staff in person for input. Answer 4 is passive and nondirective.

Q34. Nurse in long-term care facility has a LPN and UAP and needs to assign 4 patients. Which patient would be most appropriate to be assigned to LPN?
A1: Patient needing a bath.
A2: Older patient who requires frequent ambulation.
A3: Patient who needs vital signs checks.
A4: Patient needing wound irrigations and dressing changes every 3 hours.
Correct answer is 4 because it’s something that LPN is skilled in. Answers 1, 2, and 3 provide tasks that can be completed UAP.

Q35. Which guidelines does the nurse need to use in planning delegation and assignment-making? Select all that apply.
A1: Ensuring patient safety.
A2: Staff requests.
A3: Unit room clustering.
A4: Anticipated patient discharges.
A5: Patient needs and staff needs and abilities.
Correct answers are 1 and 5 because they are following guidelines that nurse needs to follow. Other answers are not part of specific guidelines in delegating and planning assignments.