NCLEX Practice Questions — Set 18
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
Which task would be most appropriate for the psychiatric nurse to delegate to the mental health worker (MHW)?
Show answer and rationale
Correct answer: A. Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal.
Having someone stay with the client after a meal will prevent the client from inducing vomiting and could be delegated to an MHW. The client diagnosed with bulimia needs someone there to prevent vomiting, which is a sign of this mental health problem.
The psychiatric charge nurse is making shift assignments for the admission unit. The staff includes one registered nurse (RN), two licensed practical nurses (LPNs), four mental health workers (MHWs), and a unit secretary. Which task would be most appropriate to assign to the LPNs?
Show answer and rationale
Correct answer: B. Administer routine medications to the clients.
The LPNs’ scope of practice allows the administration of medication. This is an appropriate assignment.
The mental health worker (MHW) has tried to calm down the client on the psychiatric unit who is angry and attempting to fight with another client. The nurse observes the MHW "taking down" the client to the floor. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: D. Assist the MHW with the "take down" of the client.
All psychiatric staff members are taught how to "take down" a client physically if the client is a danger to him- or herself or to others. The nurse should assist the MHW in subduing the client so that no one is injured.
The mental health worker (MHW) reports to the psychiatric nurse that two clients were kissing each other while watching the movie in the lobby area. Which action should the nurse implement?
Show answer and rationale
Correct answer: B. Talk to the clients about kissing each other in the lobby area.
The nurse needs to talk to the clients to determine whether the kissing was consensual or under duress. Either way, the behavior is inappropriate, and the clients should be told there is no kissing or sexual activity allowed between clients while they are hospitalized on the psychiatric unit.
The nurse is caring for clients in the psychiatric unit. Which task would be most appropriate for the nurse to delegate to the mental health worker (MHW)?
Show answer and rationale
Correct answer: C. Instruct the MHW to walk with the client who is agitated and anxious.
The MHW could walk with the client who is agitated. This may help decrease the client’s agitation and anxiety.
Which behavior by the mental health worker (MHW) is an example of assault requiring immediate intervention by the psychiatric nurse?
Show answer and rationale
Correct answer: A. The MHW threatened to forcibly remove the client who is refusing to get out of the bed.
This is an example of assault, which is an act that results in a person’s genuine fear and apprehension that he or she will be touched without consent.
The charge nurse has assigned the licensed practical nurse (LPN) to administer medications to the clients on an inpatient psychiatric unit. Which client should the LPN force to take the prescribed medications?
Show answer and rationale
Correct answer: C. The client with bipolar disorder who has been declared incompetent in a court of law.
When an individual is declared incompetent in a court, a guardian makes decisions for the client. The client loses the right to refuse medication.
Which client should the psychiatric charge nurse assign to the nurse from the surgical unit who was assigned to the psychiatric unit for the shift?
Show answer and rationale
Correct answer: B. The client who is diagnosed with chronic depression and will not talk to anyone.
The client who is chronically depressed should be assigned to the surgical nurse who is being floated to the psychiatric unit. The client is not identified as suicidal in the option.
The psychiatric nurse assigned the mental health worker (MHW) to stay with a client 1-to-1 due to high risk for suicide. Which behavior by the MHW warrants intervention by the nurse?
Show answer and rationale
Correct answer: A. The MHW watches the client walking outside from the porch area.
The MHW should be beside the client (within arm’s length), not observing the client from the porch.
Which statement by the mental health worker (MHW) warrants intervention by the psychiatric nurse?
Show answer and rationale
Correct answer: A. "I gave the client with heart burn some Maalox."
The MHW cannot administer medication; therefore, this comment warrants intervention.
The nurse on the substance abuse unit is administering medications. For which client would the nurse question administering the medication?
Show answer and rationale
Correct answer: B. The client admitted for opioid withdrawal who is receiving clonidine (Catapres) and has a blood pressure (BP) of 88/60.
Clonidine is administered primarily to treat hypertension but is also used to reduce the symptoms of withdrawal from opioids, nicotine, and alcohol. The nurse would question administering this medication because of the client’s low blood pressure, no matter why it is being prescribed.
The psychiatric nurse overhears a mental health worker (MHW) telling a client diagnosed with schizophrenia, "You cannot use the phone while you are here on the unit." Which action should the psychiatric nurse take?
Show answer and rationale
Correct answer: A. Explain to the MHW that the client does not lose any rights.
The nurse should explain to the MHW that the mental health client retains all of the civil rights afforded to all persons, except the right to leave the hospital in the case of involuntary commitments. The client may have phone calls restricted if that is included in the care plan-for example, if the client is calling and threatening the president.
The client diagnosed with bipolar disorder is admitted to the psychiatric unit in an acute manic state. The nurse needs to complete the admission assessment, but the client is restless, very energetic, and agitated. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: A. Ask questions while walking and pacing with the client.
Walking or pacing with the client will allow the client to work off energy and may decrease restlessness and agitation. The nurse should implement this intervention to obtain information for the admission assessment.
The client in the psychiatric setting tells the nurse, "There were so many people at the team meeting; I am not sure what the psychiatric social worker is supposed to do for me." Which statement is the psychiatric nurse’s best response?
Show answer and rationale
Correct answer: C. "This person works with your family and community and makes referrals if needed."
According to the NSCBN referrals area content on the NCLEX-RN� test blueprint, the psychiatric social worker may conduct therapy and often has the primary responsibility for working with families, for community support, and for referrals.
The male client diagnosed with paranoid schizophrenia is yelling, talking to himself, and blocking the view of the television. The other clients in the day room are becoming angry. Which action should the nurse take first?
Show answer and rationale
Correct answer: B. Approach the client calmly along with two mental health workers (MHWs).
The first intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not approach the agitated client alone, but should be accompanied by other personnel.
A young child, Joey, was admitted to the pediatric unit with a fractured jaw, bruises, and multiple cigarette burns to the arms. The mother reported the father hurt the child. A man comes to the nurse’s station saying, "I am Joey’s father; can you tell me how he is doing?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: B. "I am sorry I cannot give you any information about your son."
The Health Insurance Portability and Accountability Act (HIPAA) considers parents the "personal representative" of the minor child with the right to information. However, there are exceptions to this rule, including when the provider reasonably believes that the minor may be a victim of abuse or neglect by the parents/guardians. This statement is the nurse’s best response.
The psychiatric nurse is caring for clients on a closed unit. Which client would warrant immediate intervention by the nurse?
Show answer and rationale
Correct answer: D. The client who is nauseated and has vomited twice.
This client who is nauseated and has vomited has a physiological problem that should be assessed by the nurse immediately. This client warrants immediate intervention.
The clinical manager wants to reward the staff on the psychiatric unit for having no tardies or absences for 1 month. Which action would be most appropriate for the clinical manager?
Show answer and rationale
Correct answer: C. Provide pizza, drinks, and dessert for all the shifts.
Because the clinical manager wants to reward the unit for no absences or tardies, the manager must reward all shifts, so providing a thank you meal to all shifts would be most appropriate. This allows all the staff members to celebrate the unit accomplishment.
The nurse is working in an outpatient psychiatric clinic. The male client tells the nurse, "I am going to kill my wife if she files for divorce. I know I can’t live without her." Which action should the nurse implement?
Show answer and rationale
Correct answer: D. Inform the client’s psychiatric healthcare provider (HCP) of the comment.
Mental health clinicians have a duty to warn identifiable third parties of threats made by a person even if these threats were discussed during a therapy session (Tarasoff v. Regents of the University of California, 1976). The nurse should notify the client’s psychiatric HCP so that the wife can be notified of the threat.
Which interventions should the inpatient psychiatric nurse implement for the client experiencing sleepwalking? Select all that apply.
Show answer and rationale
Correct answer: D. Instruct to client to drink decaffeinated beverages.
Caffeinated beverages are stimulants; therefore, this is an appropriate intervention.
The nurse is in the middle/working phase of the nurse/client relationship. Which statement is a task in the orientation phase?
Show answer and rationale
Correct answer: A. Help the client identify problem-solving techniques.
Identifying problem-solving techniques is part of the working phase.
Which situation requires priority intervention on an inpatient psychiatric unit?
Show answer and rationale
Correct answer: D. A client sitting in a chair is delusional and hallucinating.
Safety is priority over a client who is exhibiting behavior common to an inpatient psychiatric unit.
The client with long-term alcoholism asks the nurse, "How does Alcoholics Anonymous help me quit drinking?" Which statements are the nurse’s best responses? Select all that apply.
Show answer and rationale
Correct answer: C. "AA is a support group of alcoholics who have successfully quit drinking."
AA is a support group made up of recovering alcoholics who help others to stop drinking based on the 12-step approach.
The client diagnosed with bipolar disorder and who is prescribed lithium, an antimania medication, is admitted to the psychiatric unit in an acute manic state. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Assess and treat the client’s physiological needs.
The nurse should first assess the client’s physiological needs because the client in the manic state may not have slept, bathed, or had anything to eat for days. The client’s physiological needs are priority.
The psychiatric unit staff is upset about the new female charge nurse who just sits in her office all day. One of the staff members informs the clinical manager about the situation. Which statement by the clinical manager indicates a laissez-faire leadership style?
Show answer and rationale
Correct answer: C. "You and the staff really should take care of this situation on your own."
This statement is that of a laissez-faire manager who maintains a permissive climate with little direction or control. Instructing the staff to handle the situation on their own does not support the staff.
The mental health worker (MHW) reports that one of the nurses threatened to forcefeed the male client diagnosed with schizophrenia if the client did not eat the meal on the lunch tray. Which action should the charge nurse take first?
Show answer and rationale
Correct answer: D. Request the nurse to come to the office and discuss the MHW’s allegation.
This is client abuse, and the charge nurse must investigate the allegation immediately with the nurse. If the allegations are true, they should be documented in writing and reported to the client abuse committee.
The psychiatric nurse overhears a mental health worker (MHW) arguing with a client diagnosed with paranoid schizophrenia. Which action should the nurse implement?
Show answer and rationale
Correct answer: A. Ask the MHW to go to the nurse’s station.
The nurse should first separate the MHW from the client; therefore, asking the MHW to go to the nurse’s station would be the first intervention.
Which client should the psychiatric nurse working in a mental health clinic refer to the psychiatric social worker?
Show answer and rationale
Correct answer: D. The client who is unable to buy the prescribed antipsychotic medications.
The psychiatric social worker can assist with financial arrangements, referrals, and nonphysiological concerns.
The psychiatric nurse has taken 15 minutes extra for the lunch break two times in the last week. Which action should the female clinical manager implement?
Show answer and rationale
Correct answer: D. Talk to the nurse informally about taking 45 minutes for lunch.
The clinical manager should talk to the nurse informally and find out what is going on. This behavior cannot continue, but it is not behavior that requires anything more than informally finding out why the nurse has been late.
The client diagnosed with Alzheimer’s disease is on a special unit for clients with cognitive disorders. Which assessment data would warrant immediate intervention by the psychiatric nurse?
Show answer and rationale
Correct answer: D. The client is difficult to arouse from sleep.
The client diagnosed with Alzheimer’s disease should not be difficult to arouse from sleep. This is not a typical symptom of this disease and would warrant immediate intervention from the nurse.
The mother of a client recently diagnosed with schizophrenia says to the nurse, "I was afraid of my son. Will he be all right?" Which response by the psychiatric nurse supports the ethical principal of veracity?
Show answer and rationale
Correct answer: D. "If your son takes medication, the symptoms can be controlled."
Veracity is the ethical principle "to tell the truth." The truth is that schizophrenia is a thought disorder caused by a chemical imbalance of the brain. Antipsychotic medication can control the client’s hallucinations and delusions.
The nurse is caring for clients in an outpatient psychiatric clinic. Which client would the nurse discuss with the healthcare provider?
Show answer and rationale
Correct answer: B. The client diagnosed with schizophrenia who reports taking the antacid Maalox daily for heartburn.
Antacids neutralize gastric acid and may reduce the effects of antipsychotic medications and lead to medication failure. The client diagnosed with schizophrenia would be on an antipsychotic medication; therefore, the nurse should discuss this client with the psychiatric HCP.
The client in the psychiatric unit tells the nurse, "Someone just put a bomb under the couch in the lobby." Which action should the nurse implement first?
Show answer and rationale
Correct answer: C. Look under the couch for a bomb.
The nurse must know the bomb scare policy of the facility, and in many cases the nurse looks for the bomb but does not touch it if it is found. In some instances, the nurse should not attempt to look for a bomb, but because the client is on a psychiatric unit, the nurse should look for a suspicious-looking object before notifying the bomb squad and evacuating the clients.
The new nurse on the psychiatric unit tells the charge nurse, "I don’t like how the shift report is given." Which statement is the charge nurse’s best response?
Show answer and rationale
Correct answer: B. "I would be happy to listen to any ideas you have on how to give the shift report."
The best response is to allow the new nurse to share any new ideas with the charge nurse. The charge nurse could then talk to the other staff members and take the change to the clinical manager to determine whether the change should be instituted.
The client on the psychiatric unit tells the nurse, "I am so bored. I hate just sitting on the unit doing nothing." Which intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Notify the psychiatric recreational therapist about the client’s concerns.
According to the NCLEX-RN� test blueprint, the nurse must be knowledgeable of the multidisciplinary team. The recreational therapist helps the client to balance work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time.
The head nurse in a psychiatric unit in the county emergency department is assigning clients to the staff nurses. Which client should be assigned to the most experienced nurse?
Show answer and rationale
Correct answer: C. The client who was found wandering the streets in a daze.
The client who was found wandering in a daze has no diagnosis and requires an indepth assessment. This client should be assigned to the most experienced nurse.
The client diagnosed with anorexia is refusing to eat and is less than 20% of ideal body weight (IBW) for her height and structure. The client has not eaten anything since admission 2 days ago. Which action should the nurse implement?
Show answer and rationale
Correct answer: B. Notify the psychiatrist to request a court order to feed the client.
When a person is admitted to a psychiatric unit, the client does not lose any rights. The client has a right to refuse treatment, but if the client is a danger to herself, then the psychiatric team must go to court and obtain an order to forcefeed the client. This could be with nasogastric tube feedings or total parenteral nutrition.
The client on a psychiatric involuntary admission is threatening to run away from the unit. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Place the unit on high alert for unauthorized departure.
The nurse’s first intervention is to place the unit on high alert, which includes putting signs on the exit doors warning all people coming in and out that there is a client threatening to leave the unit.
The nurse answers the client’s phone in the lobby area and the person asks, "May I speak to Mr. Jones?" Which action should the nurse implement?
Show answer and rationale
Correct answer: B. Find Mr. Jones and tell him he has a phone call.
The nurse should find Mr. Jones and tell him he has a phone call. The client cannot have rights restricted unless it is a part of the client’s individualized care plan. For example, the client may not be able to use the phone if he or she is calling 911 and making false reports.
The client seeing the psychiatric nurse in the mental health clinic tells the nurse, "If I tell you something very important, will you promise not to tell anyone?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: C. "If it affects your care I will have to tell someone who can help."
This is the nurse’s best response. The nurse is being honest with the client but will keep the information confidential if it does not affect the client’s care.
Which situation would warrant immediate intervention by the charge nurse on the psychiatric unit after receiving the a.m. shift report?
Show answer and rationale
Correct answer: D. The male mental health worker (MHW) reports losing his unit key and identification card.
The loss of a unit key is priority because the nurse must determine when the MHWlast had the key and determine whether it may be lost on the psychiatric unit. If a client finds the key, then the unit is no longer secure.
The client enters a mental health clinic with a gun and is threatening to kill the nurse who told his wife to leave him. Which action should the nurse implement first?
Show answer and rationale
Correct answer: D. Calmly and firmly ask the man to put the gun down on the floor.
The nurse should first try to talk to the client and diffuse the situation. This action is attempting to ensure the safety of the man, the other clients, and the staff.
The charge nurse of the psychiatric unit is making assignments. Which clients should be assigned to the medical-surgical nurse who is working in the psychiatric unit for the day? Select all that apply.
Show answer and rationale
Correct answer: B. The client diagnosed with bipolar disease who has diabetes and requires blood glucose monitoring.
The client with diabetes can be monitored by the medical-surgical nurse. The option does not state that any unusual situations are occurring with the client’s diagnosed illness. The client wishes to remain in bed and the medications have not had enough time in the client’s body to make him or her a suicide risk.
The outpatient clinic psychiatric nurse is preparing to assist the healthcare provider to perform electroconvulsive therapy. Rank in order of performance the nursing interventions to be implemented.
Show answer and rationale
Correct answer: D. Check the client’s name and date of birth against the chart/orders.
Part of the National Patient Safety Goals is implementing two identifiers when the client is to receive a procedure. The nurse must do this to determine that it is the correct client and the correct procedure.
Mr. Allan is triaging and returning phone calls. Which client should Mr. Allan call first?
Show answer and rationale
Correct answer: B. The client with schizophrenia who is hearing voices telling him to hurt his wife.
The nurse should contact this client first because the client realizes the voices are telling him to hurt his wife. The nurse should inform this client to come to the clinic immediately, and he should be admitted to a psychiatric unit.
Ms. Belinda is working in at the triage desk. Which client should Ms. Belinda intervene with first?
Show answer and rationale
Correct answer: C. The client who told the receptionist he wants to kill himself and has a gun in the car.
This client who is suicidal and has a gun in the car should be assessed first to see whether he has a plan to use the gun. This client needs to be assessed first.
Mr. Allan is reviewing laboratory data for clients seen in the clinic. Which of the following client data warrants notifying the psychiatric healthcare provider?
Show answer and rationale
Correct answer: B. The client on lithium (Eskalith) whose serum lithium level is 2.0 mEq/L.
The therapeutic serum level for lithium is 0.6 to 1.5 mEq/L. Because the client’s level is 2.0 mEq/L, Mr. Allan should notify the client’s psychiatric healthcare provider.
Mr. Allan is working in the mental health clinic and returns a telephone call to a male client who says that "voices are telling me to hurt myself, now." Which intervention should Mr. Allan implement first?
Show answer and rationale
Correct answer: A. Call 911 and tell the paramedics the client is a danger to himself and/or others.
The client is a risk to himself and the EMS should be notified to go to the client and make sure that no harm comes to the client. The client is not in the outpatient clinic with the nurse; therefore, the EMS should be notified to go to the client before the client harms himself.
The client diagnosed with a panic attack disorder in the clinic waiting room becomes anxious, starts to hyperventilate and tremble, and is diaphoretic. After removing the client from the day room which intervention should Ms. Marguerite implement next?
Show answer and rationale
Correct answer: D. Encourage to the client to take slow, deep breaths.
The first intervention is to address the client’s physical discomfort, which is hyperventilating; therefore, encouraging the client to take slow, deep breaths is the next intervention for Ms. Marguerite.
Which client would be most appropriate for Mr. Allan to assign to Mr. Benjamin, the LPN, in the psychiatric clinic?
Show answer and rationale
Correct answer: C. The client diagnosed with dementia who is confused and disoriented.
The client diagnosed with dementia would be expected to have confusion and disorientation; therefore, the LVN could be assigned this client. This client is not experiencing any potentially life-threatening complication of dementia.
Which task is inappropriate for Mr. Allan to delegate to the MHW?
Show answer and rationale
Correct answer: A. Request the MHW to draw blood for a serum lithium level.
The MHW does not draw blood, and this would be an inappropriate task to delegate. The laboratory technician draws the client’s blood work.
The client diagnosed with paranoid schizophrenia is yelling, talking to himself, and blocking the view of the television. The other clients in the waiting room are becoming angry. Which action should Mr. Allan implement first?
Show answer and rationale
Correct answer: C. Approach the client calmly along with Mr. Benjamin.
The first intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not approach the agitated client alone, but should be accompanied by other personnel.
Mr. Allan observes Ms. Brenda, the MHW, arguing with a client in the waiting room. Mr. Allan requests Ms. Brenda to go to his office immediately. Which action should Mr. Allan implement first?
Show answer and rationale
Correct answer: A. Discuss the behavior with Ms. Brenda.
Mr. Allan should discuss the behavior with Ms. Brenda, then take appropriate disciplinary action. Psychiatric staff members cannot argue with clients.
Ms. Belinda has been late to work three times in the last week. Mr. Allan talks to Ms. Belinda and finds out Ms. Belinda has to take the bus to work until her car is fixed, which should be completed in 1 week. Which action should Mr. Allan implement?
Show answer and rationale
Correct answer: D. Do not take any action at this time since Ms. Belinda has an excellent attendance record.
Mr. Allan needs to work with the employees, and being understanding of situations is an attribute of an effective clinical manager. Ms. Belinda has a valid reason for being late and since she has an excellent attendance record. Mr. Allan should be understanding and work with Ms. Belinda.
The nurse on the psychiatric unit observes one client shove another client. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Approach the client with another staff member.
The nurse should intervene to stop the behavior first before one of the clients is injured. Approaching the client with another staff member shows strength and provides the nurse with the ability to perform a safe "take down."
The primary nurse informs the shift manager one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first?
Show answer and rationale
Correct answer: B. Take the assigned client’s vital signs and compare with the UAP’s results.
The shift manager should have objective data prior to confronting the UAP about the allegation of falsifying vital signs; therefore, the shift manager should take the client’s vital signs and compare them with the UAP’s results before taking any other action.
The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: A. Request the UAP to prepare the client for a wound debridement at the bedside.
The client will need to be pre-medicated for a wound debridement; therefore, this task cannot be delegated to the UAP.
The clinic manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis?
Show answer and rationale
Correct answer: B. Obtain a bone density evaluation test on a female client older than 50.
A secondary nursing intervention includes screening for early detection. The bone density evaluation will determine the density of the bone and is diagnostic for osteoporosis.
The female home health (HH) aide calls the office and reports pain after feeling a pulling in her back when she was transferring the client from the bed to the wheelchair. Which priority action should the HH nurse tell the HH aide?
Show answer and rationale
Correct answer: C. Recommend that she apply an ice pack to the back.
The HH aide is in pain, and applying ice to the back will help decrease pain and inflammation. The HH nurse should be concerned about a coworker’s pain. Remember: Ice for acute pain and heat for chronic pain.
The home health (HH) nurse is discussing the care of a client with the female HH aide. Which task should the HH nurse delegate to the HH aide?
Show answer and rationale
Correct answer: B. Instruct her to assist the client with a shower.
The HH aide’s responsibility is to care for the client’s personal needs, which includes assisting with a.m. care.
The client in the operating room states, "I don’t think I will have this surgery after all." Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Immediately stop the surgical procedure.
Stopping the surgical procedure is the first intervention for the nurse to implement.
The new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the nurse is the best method to evaluate whether delegated care is being provided?
Show answer and rationale
Correct answer: B. Make rounds to see that the clients are being turned.
The nurse retains responsibility for the care. Making rounds to see that the care has been provided is the best method to evaluate the care.
The home health (HH) nurse notes the 88-year-old female client is unable to cook for herself and mainly eats frozen foods and sandwiches. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Contact the community’s Meals on Wheels.
Meals on Wheels delivers a hot, nutritionally balanced meal once a day on weekdays, usually at noon for older people who do not have assistance in the home for food preparation. This intervention would be most helpful to the client.
The charge nurse of a critical care unit is making assignments for the night shift. Which client should be assigned to the graduate nurse who has just completed an internship?
Show answer and rationale
Correct answer: A. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose Glasgow Coma Scale score is 13.
The Glasgow Coma Scale ranges from 0 to 15, with 15 indicating the client’s neurological status is intact. A Glasgow Coma Scale score of 13 indicates the client is stable and would be the most appropriate client to assign to the graduate nurse.
The surgical unit has a low census and is overstaffed. Which staff member should the house supervisor notify first and request to stay home?
Show answer and rationale
Correct answer: A. The nurse who requested to be off.
This nurse wants to take time off. Therefore, it is the best option to let the nurse desiring to be off from work to take time off if all other situations are equal.
The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP?
Show answer and rationale
Correct answer: C. Document the amount of food the residents ate after a meal.
The UAP can check to see the amount of food the residents consumed and document the information.
The director of nurses in a long-term care facility observes the licensed practical nurse (LPN) charge nurse explaining to an unlicensed assistive personnel (UAP) how to calculate the amount of food a resident has eaten from the food tray. Which action should the director of nurses implement?
Show answer and rationale
Correct answer: D. Encourage the nurse to continue to work with the UAP.
The director of nurses should encourage responsible behavior on the part of all staff. The charge nurse is performing a part of the responsibility of the charge nurse and should be encouraged to work with the UAP.
The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP?
Show answer and rationale
Correct answer: D. Apply the wound debriding paste to the wound.
Wound debriding formulations are medications, and a UAP cannot administer medications.
The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Move the client to a room near the station.
Moving the client near the nursing station where the staff can closely observe the client is one of the first measures in most fall prevention policies.
The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, "I am having problems getting in and out of my bathtub." Which intervention should the clinic nurse implement first?
Show answer and rationale
Correct answer: D. Determine whether the client has grab bars in the bathroom.
The first intervention is for the nurse to ensure the client is safe in the home. Assessing for grab bars in the bathroom is addressing the safety of the client.
The employee health nurse has cared for six clients who have similar complaints. The clients have a fever, nausea, vomiting, and diarrhea. Which action should the nurse implement first after assessing the clients?
Show answer and rationale
Correct answer: B. Notify the public health department immediately.
The employee health nurse should be aware that six clients with the same signs/ symptoms indicate a potential deliberate or accidental dispersal of toxic or infectious agents. The nurse must notify the public health department so that an investigation of the cause can be instituted and appropriate action to contain the cause can be taken.
The clinic nurse is caring for clients in a pediatric clinic. Which client should the nurse assess first?
Show answer and rationale
Correct answer: A. The 3-year-old child who is drooling and does not want to swallow.
Drooling and not wanting to swallow are the cardinal signs of epiglottitis, which is potentially life threatening. This child should be assessed first. The nurse should not attempt to visualize the throat area and should allow the HCP to do this in case an emergency tracheostomy is required.
The home health (HH) agency director of nursing is making assignments for the nurses. Which client should be assigned to the HH nurse new to HH nursing?
Show answer and rationale
Correct answer: C. The client complaining of pain who is diagnosed with diabetic neuropathy.
The client diagnosed with diabetic neuropathy would be expected to have pain; therefore, this client could be assigned to a nurse new to home health nursing. The client is not exhibiting a complication or an unexpected sign/symptom.
The home health (HH) nurse along with an HH aide is caring for a client who is 3 weeks postoperative for open reduction and internal fixation of a right hip fracture. Which task would be appropriate for the nurse to delegate to the aide?
Show answer and rationale
Correct answer: B. Tell the HH aide to elevate the right leg on two pillows.
The HH aide can place the right leg on two pillows. This task does not require assessment, teaching, or evaluating, and the client is stable.
Which client would most benefit from acupuncture, a traditional Chinese medicine considered complementary alternative medicine?
Show answer and rationale
Correct answer: A. The client diagnosed with osteoarthritis.
Acupuncture, the most common com – plementary therapy recommended by healthcare providers, would benefit a client with osteoarthritis.
Which data indicates therapy has been effective for the client diagnosed with bipolar disorder?
Show answer and rationale
Correct answer: A. The client goes to work every day for 9 months.
The ability to hold a job for 9 months indicates the client is responding to therapy.
Which legal intervention should the nurse implement on the initial visit when admitting a client to the home healthcare agency?
Show answer and rationale
Correct answer: C. Provide the client with a copy of the NAHC Bill of Rights.
Home healthcare agencies are required by law to address the concepts in the National Association for Home Care (NAHC) Bill of Rights with all home health clients on the initial visit. The agencies may also make additions to the NAHC’s original Bill of Rights.
The unlicensed assistive personnel (UAP) accidentally pulled the client’s chest tube out while assisting the client to the bedside commode (BSC). Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Securely tape petroleum gauze over the insertion site.
Taping petroleum gauze over the chest tube insertion site will prevent air from entering the pleural space. This is the first intervention.
The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a pediatric unit. Which nursing task should be assigned to the LPN?
Show answer and rationale
Correct answer: C. Administer PO medications to a client diagnosed with gastroenteritis.
The LPN can administer routine medications.
The hospital will be implementing a new medication administration record (MAR) for documenting medication administration. Which action should the clinical manager take first when implementing the new MAR?
Show answer and rationale
Correct answer: D. Schedule meetings on all shifts to discuss the new MAR.
The first intervention should be to arrange meetings to explain the new MAR and allow nurses to ask questions to clarify the new policy.
Which assessment data warrants immediate intervention by the nurse for the client diagnosed with chronic kidney disease (CKD) who is on peritoneal dialysis?
Show answer and rationale
Correct answer: D. The dialysate being removed from the abdomen is cloudy.
The dialysate return should be colorless or straw colored but should never be cloudy, which indicates an infection; therefore, the data warrant immediate intervention.
The nurse is taking a history on a client in a women’s clinic when the client tells the nurse, "I have been trying to get pregnant for 3 years." Which question is the nurse’s best response?
Show answer and rationale
Correct answer: B. "What have you tried to help you get pregnant?"
This is the best question to assess the client. The nurse would not want to suggest an intervention that has been futile.
The nurse working at the county hospital is admitting a client who is Rh-negative to the labor and delivery unit. The client is gravida 2, para 0. Which assessment data is most important for the nurse to assess?
Show answer and rationale
Correct answer: A. If the mother received a Rhogam injection after the last pregnancy.
The important information to assess is whether the client received the Rhogam injection within 72 hours of the loss of the first pregnancy. If the client did not receive the injection, the fetus is at risk for erythroblastosis fetalis (blue baby).
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a pediatric unit. Which task should the nurse delegate to the UAP?
Show answer and rationale
Correct answer: C. Weigh the diaper of the 6-month-old client who is on intake and output (I&O).
The UAP is capable of completing intake and output on clients. Weighing a diaper is the method of obtaining the output in an infant.
The home health nurse is planning his rounds for the day. Which client should the nurse plan to see first?
Show answer and rationale
Correct answer: D. The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough.
This client may be developing a complication of immobility, one of which is pneumonia. The nurse should assess this client first.
The nurse is preparing to perform a sterile dressing change on a client with full-thickness burns on the right leg. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Pre-medicate the client with a narcotic analgesic.
The nurse should first medicate the client since this procedure is very painful for the client.
The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: D. Check to make sure the client has been offered the use of the bathroom.
The client should be ready to work on therapy when the physical therapist arrives. The UAP should make sure the client has used the bathroom or has not been incontinent before the therapist arrives, thus making the most efficient use of the therapist’s time.
The volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client’s condition. Which information should the nurse discuss with the volunteer?
Show answer and rationale
Correct answer: C. Explain that client information is on a need-to-know basis only.
The nurse should remind the volunteer of the HIPAA and confidentiality rules that govern any information concerning clients in a healthcare setting.
The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system?
Show answer and rationale
Correct answer: B. It involves staff nurses in the decision-making process of the unit.
Shared governance is an organizational framework in which the nurse has autonomy over his or her own practice. The nurse is given direct input into the working of the unit.
The visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse’s best initial response?
Show answer and rationale
Correct answer: D. "I hear that you are frustrated. Can we discuss the issues calmly?"
The nurse should remain calm and try to allow the client to vent his frustrations in a more acceptable manner. The nurse should repeat calmly in a low voice any instructions given to the client.
The experienced nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue?
Show answer and rationale
Correct answer: D. Discuss the situation with the manager who interviewed him.
The nurse should give the manager a chance to discuss the situation before quitting. A temporary problem, such as illness, may be affecting staffing.
The nurse is preparing to administer the client’s first intravenous antibiotic. Prioritize the nurse’s actions from first (1) to last (5).
Show answer and rationale
Correct answer: A. Check the healthcare provider’s order in the chart.
This is the first intervention the nurse should implement. Checking the HCP’s order is priority.
A major disaster has been called, and the charge nurse on a medical unit must recommend to the medical discharge officer on rounds which clients to discharge. Which client should not be discharged?
Show answer and rationale
Correct answer: D. The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection.
Because resistant infections are very difficult to treat, this client should remain in the hospital for the required IVPB medication.
The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Review the client’s chart.
The nurse should be familiar with the chart and the situation so that details can be remembered. This should be the nurse’s first action.
The nurse has accepted the position of clinical manager for a medical-surgical unit. Which role is an important aspect of this management position?
Show answer and rationale
Correct answer: D. Evaluate the job performance of the staff.
One of the many jobs of a manager is to see that performance evaluations are completed on the staff.
The charge nurse notices that one of the staff takes frequent breaks, has unpredictable mood swings, and often volunteers to care for clients who require narcotics. Which priority action should the charge nurse implement regarding this employee?
Show answer and rationale
Correct answer: D. Discuss the nurse’s actions with the unit manager.
Usually, the charge nurse should attempt to settle a conflict at the lowest level possible, in this case, confronting the nurse. However, the charge nurse does not have the authority to require a drug screen, which is the intervention needed in this situation. The nurse should notify the unit manager.
A male HCP frequently tells jokes with sexual overtones at the nursing station. Which action should the female charge nurse implement?
Show answer and rationale
Correct answer: B. Tell the HCP that the jokes are inappropriate and offensive.
Telling jokes with sexual innuendos creates a "hostile work environment" and should be addressed with the HCP. This is a courtesy to the HCP to allow him to correct the behavior without being embarrassed.
The night shift nurse is caring for clients on the surgical unit. Which client situation would warrant immediate notification of the surgeon?
Show answer and rationale
Correct answer: A. The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a "pop" and then her pain went away.
Feeling a "pop" after an abdominal hysterectomy may indicate possible wound dehiscence, which is a surgical emergency and requires the nurse to notify the surgeon via telephone.
Which client should the nurse in the post-anesthesia care unit (PACU) assess first?
Show answer and rationale
Correct answer: A. The client who had right knee surgery and has a pulse oximeter reading of 90%.
A pulse oximeter reading of less than 93% indicates an oxygenation problem; therefore, this client should be assessed first.
The client with a below-the-knee amputation (BKA) has a large amount of bright red blood on the residual limb dressing and the nurse suspects an arterial bleed. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Apply a tourniquet above the amputation.
The nurse should keep a large tourniquet at the client’s bedside and should apply it when suspecting arterial bleeding; this is the nurse’s first intervention.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
More NCLEX practice and review
Everything on this site tagged NCLEX lives in the NCLEX category.
Sources