NCLEX Final Exam for 2023 Makeup 50 Q A Rated

NCLEX Final Exam for 2023 Makeup 50 Q & A Rated A+

• The nurse hears a client calling out for help, hurries down the hallway to the

client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

• The client fell out of bed.
• The client climbed over the side rails.
• The client was found lying on the floor.
• The client became restless and tried to get out of bed.

• The client was found lying on the floor.

• A client is brought to the emergency department by emergency medical

services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

• Obtain a court order for the surgical procedure.
• Ask the EMS team to sign the informed consent.
• Transport the victim to the operating room for surgery.
• Call the police to identify the client and locate the family.

• Transport the victim to the operating room for surgery.

• The nurse arrives at work and is told to report (float) to the intensive care unit

(ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first?

• Call the hospital lawyer.
• Refuse to float to the ICU.
• Call the nursing supervisor.
• Identify tasks that can be performed safely in the ICU.

• Identify tasks that can be performed safely in the ICU.

• The nurse who works on the night shift enters the medication room and finds a

co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

• Call security.
• Call the police.
• Call the nursing supervisor.
• Lock the co-worker in the medication room until help is obtained.

• Call the nursing supervisor.

• A hospitalized client tells the nurse that a living will is being prepared and that

the lawyer will be bringing the will to the hospital today for witness signatures.The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

• "I will sign as a witness to your signature."
• "You will need to find a witness on your own."
• "Whoever is available at the time will sign as a witness for you."
• "I will call the nursing supervisor to seek assistance regarding your request."

• "I will call the nursing supervisor to seek assistance regarding your request."

• The nurse has made an error in a narrative documentation of an assessment

finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error?

• Documenting a late entry into the client's record
• Trying to erase the error for space to write in the correct data
• Using whiteout to delete the error to write in the correct data
• Drawing one line through the error, initialing and dating, and then

documenting the correct information

• Drawing one line through the error, initialing and dating, and then documenting the

correct information

• Which identifies accurate nursing documentation notations? Select all that

apply.

• The client slept through the night.
• Abdominal wound dressing is dry and intact without drainage.
• The client seemed angry when awakened for vital sign measurement.
• The client appears to become anxious when it is time for respiratory

treatments.

• The client's left lower medial leg wound is 3 cm in length without redness,

drainage, or edema.

• The client slept through the night.
• Abdominal wound dressing is dry and intact without drainage.
• The client's left lower medial leg wound is 3 cm in length without redness,

drainage, or edema.

• A nursing instructor delivers a lecture to nursing students regarding the issue of

client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

• Performing a procedure without consent
• Threatening to give a client a medication
• Telling the client that he or she cannot leave the hospital
• Observing care provided to the client without the client's permission

• Observing care provided to the client without the client's permission

• Nursing staff members are sitting in the lounge taking their morning break. An

unlicensed assistive personnel (UAP) tells the group that she thinks that the

unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated?

• Libel
• Slander
• Assault
• Negligence

• Slander

• An 87-year-old woman is brought to the emergency department for treatment of

a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

• "Oh, really. I will discuss this situation with your son."
• "Let's talk about the ways you can manage your time to prevent this from

happening."

• "Do you have any friends that can help you out until you resolve these

important issues with your son?"

• "As a nurse, I am legally bound to report abuse. I will stay with you while you

give the report and help find a safe place for you to stay."

• "As a nurse, I am legally bound to report abuse. I will stay with you while you give

the report and help find a safe place for you to stay."

• The nurse calls the heath care provider (HCP) regarding a new medication

prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?

• Contact the nursing supervisor.
• Administer the dose prescribed.
• Withhold the medication until the HCP can be contacted.
• Administer the recommended dose until the HCP can be located.

• Contact the nursing supervisor.

• The nurse employed in a hospital is waiting to receive a report from the

laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph.Which is the most appropriate nursing action?

• Call the police.
• Cut up the photograph and throw it away.
• Call the nursing supervisor and report the incident.
• Call the laboratory and ask for the individual's name who sent the

photograph.

• Call the nursing supervisor and report the incident.

• The nurse manager has implemented a change in the method of the nursing

delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP?

• Ignore the resistance.
• Exert coercion on the UAP.
• Provide a positive reward system for the UAP.
• Confront the UAP to encourage verbalization of feelings regarding the

change.

• Confront the UAP to encourage verbalization of feelings regarding the change.

• The nurse manager is observing a new nursing graduate caring for a burn client

in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

• Using sterile sheets and linens
• Performing strict handwashing technique
• Wearing gloves and a gown only when giving direct care to the client
• Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns,

and plastic apron

• Wearing gloves and a gown only when giving direct care to the client

• A client admitted voluntarily for treatment of an anxiety disorder demands to be

released from the hospital. Which action should the nurse take initially?

• Contact the client's health care provider (HCP).
• Call the client's family to arrange for transportation.
• Attempt to persuade the client to stay "for only a few more days."
• Tell the client that leaving would likely result in an involuntary commitment.

• Contact the client's health care provider (HCP).

• The nurse is providing care to a client admitted to the hospital with a diagnosis

of acute anxiety disorder. The client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the most appropriate nursing response?

• "No, I won't tell anyone."
• "I cannot promise to keep a secret."
• "It depends on what the secret is about."
• "If you tell me the secret, I may need to document it."

• "I cannot promise to keep a secret."

• The nurse employed in a mental health clinic is greeted by a neighbor in a local

grocery store. The neighbor says to the nurse, "How is Carol doing? She is my