NCLEX Practice Questions HURST REVIEW (Fundamentals)

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• AssessmentA nurse is caring for a patient with chronic heart failure who is very ill. The patient

has a "no code" order. The patient goes into ventricular fibrillation and the nurse defibrillates the patient. The nurse states she was unaware of the "no code" order.What part of the nursing process did the nurse fail to perform?

• Planning
• Evaluation
• Assessment
• Implementation
• ImplementationOn the morning laboratory report, the patient's potassium is noted to be 2.5

mEq/L. The nurse does not want to "bother the physician this early." During the change-of-shift report, the patient develops ventricular tachycardia and has to be resuscitated. What part of the nursing process did the nurse fail to perform?

• Evaluation
• Implementation
• Assessment
• Planning

• Assess and analyze the level of care needed by the

patient.A patient in the critical care unit has an order to be transported off the unit for a diagnostic procedure. The nurse fails to ensure that the patient is properly monitored during transport, and the patient experiences a cardiac arrest. Which of the following actions did the nurse fail to adequately perform?

• Make the proper nursing diagnosis.
• Assess and analyze the level of care needed by the patient.
• Act as a patient advocate to postpone the examination.
• Communicate findings in a timely manner.
• No. There were no damages associated with failure to

document The nurse fails to record a set of vital signs on a blood transfusion report, which is against hospital policy. The patient does not sustain any damage as a result. Can the nurse be charged with malpractice in this case?

• No. Documentation is not part of the duty of nurse.
• Yes. Even though there were no damages, the nurse failed to follow hospital

protocol.

• No. There were no damages associated with failure to document
• Yes. Failure to document always results in negligence.
• Beneficence
• Nonmaleficence
• Autonomy

A patient with metastatic cancer tells the nurse, “I am tired and do not want to be put on a breathing machine.” The patient’s out-of-town son wants “everything done for my mother” when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply.)

• Beneficence
• Nonmaleficence
• Autonomy
• Justice
• Paternalism
• The hospital ethics committee
• The nursing supervisor
• The nursing ethics committee

The nurse is concerned that the physician is ignoring the wishes of the patient and family in the care of a patient. The nurse should take these concerns to: (Select all that apply.)

• The hospital ethics committee
• The ANA (American Nurses Association)
• The nursing supervisor
• The nursing ethics committee
• he policy and procedure committee
• NonmaleficenceThe nurse observes a coworker diverting narcotics by administering normal saline

to a patient in pain. By not reporting this observation, the nurse is in violation of what ethical principle concerning the patients under the care of the impaired nurse?

• Autonomy
• Justice
• Nonmaleficence
• Veracity

• Withdrawing treatmentThe family of a patient who is receiving mechanical ventilation for respiratory

distress associated with an inoperable brain tumor asks that the patient be extubated to "allow natural death" to occur. This is an example of what situation?

• Withdrawing treatment
• Rationing care
• A criminal act
• Withholding treatment
• Moral distressA nurse has been having difficulty sleeping since the death of a patient who had a

stressful family situation involving a DNR (do not resuscitate) order. She is arguing with her husband and coworker and is complaining about working conditions. The nurse's symptoms could be signs of what problem?

• Moral distress
• Moral confusion
• Immoral distress
• Change fatigue
• Fourth intercostal space to the left of the sternum to

hear sounds from the tricuspid area.

• Second intercostal space to the right of the sternum to

hear sounds from the aortic valve area Where should a nurse place the stethoscope when auscultating heart sounds?Select all that apply

• First intercostal space left of the sternum to hear sounds from the pulmonic

valve area.

• Fourth intercostal space to the left of the sternum to hear sounds from the

tricuspid area.

• Second intercostal space to the right of the sternum to hear sounds from the

aortic valve area.

• Fifth intercostal space left side of sternum to hear sounds from the mitral area.
• Apex of the heart to hear the loudest 2nd heart sound (S2).
• Stop the feeding and assess gastric residual volume in 1

hour A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention?

• Stop the feeding and assess gastric residual volume in 1 hour.
• Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4

hours.

• Change the feeding schedule from continuous to intermittent delivery.
• Discard the 200 mL and continue the feedings at the same rate.
• You have some genuine concerns about the open

heart surgery, and you feel as if your children are not addressing your concerns.A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don’t know what to do." What is the best response for the nurse as client advocate?

• Your children are correct. The open heart surgery is the best thing for your

health.

• You feel as if your children are not addressing your concerns. You and your

family will need to resolve this before you go to surgery.

• I can contact your primary healthcare provider so that you can discuss your

concerns regarding open heart surgery.

• You have some genuine concerns about the open heart surgery, and you feel

as if your children are not addressing your concerns.

• Clarify the prescription with the primary healthcare

provider.The nurse is caring for a client with a fibula fracture. The primary healthcare provider makes rounds and writes prescriptions. What is the nurse's best action?

• Check the prescription prior to sending it to the pharmacy.
• Clarify the prescription with the primary healthcare provider.
• Notify the pharmacy that the prescription is needed immediately.
• Gather the supplies needed for an injection.
• Have client return to bed and utilize slide board to

transfer to litter.When the surgical transport team arrives to take a client to the operating room, the client is sitting in a chair in the room. What is the best way for the nurse to get the client onto the transport litter?

• Using a foot stool, assist client to step up and crawl onto litter.
• Have client return to bed and utilize slide board to transfer to litter.
• With feet placed apart, grasp client around waist and lift onto litter.
• Put Hoyer pad under client, using Lift to move client from chair to litter.
• Clean gloves while performing a heel stick on an infant. Which action by a nurse would indicate that this nurse is following standard

precautions?

• Clean gloves while performing a heel stick on an infant.
• Sterile gloves to empty a indwelling urinary catheter bag.
• Shoe covers when entering the room of a client with influenza.
• Clean gloves while inserting a urinary catheter.
• The consent form is signed.
• The most recent lab work is on the chart.
• Any preoperative medication is given as prescribed.
• Person performing the procedure has marked the site.

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed?Select all that apply

• The consent form is signed.
• The operative site is prepped with a razor.
• The most recent lab work is on the chart.
• Any preoperative medication is given as prescribed.
• Person performing the procedure has marked the site.
• Loud crying with pain.The nurse is caring for a Puerto Rican client. The client has several injuries from a

car accident and is experiencing pain. Which behavior is likely to be noted?

• Loud crying with pain.
• Enduring the pain in order to bring honor.
• Quiet and stoic responses to pain.
• Refusing pain medication because it is God's will.