NCLEX-RN PRACTICE
EXAM 2
High-Yield Qs & Answers with Rationales
ADVANCED CLINICAL
SCENARIOS
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
,SECTION A: MANAGEMENT OF CARE (QUESTION S 1-40)
QUESTION 1
Client Needs: Management of Care
A charge nurse on a medical-surgical unit receives report on four patients requiring
immediate attention: a
45-year-old with chest pain and diaphoresis, a 62-year-old post-operative patient with a
blood pressure of 82/45 mmHg, a 28-year-old with severe abdominal pain rated 9/10, and
a 71-year-old confused patient attempting to climb out of bed.
Which patient should the charge nurse assess first?
A. The 45-year-old with chest pain and diaphoresis B. The 62-year-old with hypotension C.
The 28-year-old with severe abdominal pain D. The 71-year-old confused patient trying to
get out of bed
Answer: B
Rationale: The 62-year-old with hypotension (82/45 mmHg) represents the most
immediately lifethreatening condition requiring urgent intervention. This blood pressure
indicates potential hypovolemic shock or cardiovascular compromise that could lead to
cardiac arrest. While chest pain (A) is serious, the vital signs indicate stable hemodynamic
status. Severe pain (C) requires attention but is not immediately lifethreatening. The
confused patient (D) needs safety measures but is not in immediate physiological danger.
QUESTION 2
Client Needs: Management of Care
The nursing supervisor must assign a float nurse from the pediatric ICU to the adult
emergency department during a staffing crisis. The float nurse has 8 years of pediatric
experience but no adult emergency experience.
Which assignments would be most appropriate for this float nurse? (Select all that apply)
,A. Triaging adult patients in the emergency department B. Administering medications to
stable adult patients C. Assisting with cardiac arrest resuscitation D. Performing wound
care on stable patients E. Documenting patient assessments and vital signs F. Providing
family education and support
Answer: B, D, E, F
Rationale: The float nurse should receive assignments within their competency level
and scope of practice. Administering medications (B), wound care (D), documentation (E),
and family support (F) are transferable skills from pediatric to adult care with appropriate
supervision. Triaging adults (A) requires specific adult emergency training and
assessment skills. Cardiac arrest resuscitation (C) in adults differs significantly from
pediatric protocols and should be handled by experienced adult emergency staff.
QUESTION 3
Client Needs: Management of Care
A 17-year-old patient requires emergency surgery for acute appendicitis. The parents are
out of the country and cannot be reached. The patient is conscious and requesting the
surgery.
What is the nurse's priority action?
A. Proceed with surgery based on the patient's consent B. Wait for parental consent before
proceeding C.
Contact the hospital's ethics committee D. Seek court authorization for emergency
treatment
Answer: A
Rationale: In life-threatening emergencies where parents cannot be contacted,
healthcare providers can proceed with necessary treatment to preserve life and health. The
17-year-old patient's consent for emergency surgery is legally acceptable when immediate
intervention is required. Waiting for parental consent (B) could result in perforation and
peritonitis. Ethics committee consultation (C) would cause dangerous delays in emergency
situations. Court authorization (D) is not required for emergency, life-saving procedures
when parents are unavailable.
QUESTION 4
Client Needs: Management of Care
, A charge nurse is developing assignments for the day shift. Available staff includes two
RNs, two LPNs, and three UAPs. The unit has 28 patients with varying acuity levels.
Which delegation decision demonstrates appropriate assignment based on scope of
practice?
A. LPN administering IV chemotherapy to an oncology patient B. UAP taking vital signs
on patients in stable condition C. LPN teaching discharge instructions to a diabetic patient
D. UAP performing sterile wound care on a post-surgical patient
Answer: B
Rationale: UAPs can safely take vital signs on stable patients as this falls within their
scope of practice and training. IV chemotherapy administration (A) requires RN-level
knowledge of oncology medications and monitoring for complications. Patient teaching
(C) is an RN responsibility that cannot be delegated to LPNs. Sterile wound care (D)
requires nursing judgment and sterile technique beyond UAP scope; this should be
performed by licensed nursing personnel.
QUESTION 5
Client Needs: Management of Care
A patient with end-stage cancer has a living will stating "no extraordinary measures" but
family members are demanding aggressive treatment including CPR and mechanical
ventilation. The patient is currently alert but weak.
What is the nurse's best action?
A. Follow the family's wishes for aggressive treatment B. Advocate for the patient's
documented wishes in the living will C. Seek a court order to determine the appropriate
course of action D. Refer the case to hospital administration for decision
Answer: B
Rationale: The nurse has a legal and ethical obligation to advocate for the patient's
autonomous decision as documented in the living will. Advanced directives represent the
patient's own values and wishes when they were competent to make decisions. Family
wishes (A) cannot override a valid living will. Court orders (C) and administrative
decisions (D) are not necessary when clear advance directives exist; the nurse should
advocate for the patient's documented preferences.
EXAM 2
High-Yield Qs & Answers with Rationales
ADVANCED CLINICAL
SCENARIOS
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
,SECTION A: MANAGEMENT OF CARE (QUESTION S 1-40)
QUESTION 1
Client Needs: Management of Care
A charge nurse on a medical-surgical unit receives report on four patients requiring
immediate attention: a
45-year-old with chest pain and diaphoresis, a 62-year-old post-operative patient with a
blood pressure of 82/45 mmHg, a 28-year-old with severe abdominal pain rated 9/10, and
a 71-year-old confused patient attempting to climb out of bed.
Which patient should the charge nurse assess first?
A. The 45-year-old with chest pain and diaphoresis B. The 62-year-old with hypotension C.
The 28-year-old with severe abdominal pain D. The 71-year-old confused patient trying to
get out of bed
Answer: B
Rationale: The 62-year-old with hypotension (82/45 mmHg) represents the most
immediately lifethreatening condition requiring urgent intervention. This blood pressure
indicates potential hypovolemic shock or cardiovascular compromise that could lead to
cardiac arrest. While chest pain (A) is serious, the vital signs indicate stable hemodynamic
status. Severe pain (C) requires attention but is not immediately lifethreatening. The
confused patient (D) needs safety measures but is not in immediate physiological danger.
QUESTION 2
Client Needs: Management of Care
The nursing supervisor must assign a float nurse from the pediatric ICU to the adult
emergency department during a staffing crisis. The float nurse has 8 years of pediatric
experience but no adult emergency experience.
Which assignments would be most appropriate for this float nurse? (Select all that apply)
,A. Triaging adult patients in the emergency department B. Administering medications to
stable adult patients C. Assisting with cardiac arrest resuscitation D. Performing wound
care on stable patients E. Documenting patient assessments and vital signs F. Providing
family education and support
Answer: B, D, E, F
Rationale: The float nurse should receive assignments within their competency level
and scope of practice. Administering medications (B), wound care (D), documentation (E),
and family support (F) are transferable skills from pediatric to adult care with appropriate
supervision. Triaging adults (A) requires specific adult emergency training and
assessment skills. Cardiac arrest resuscitation (C) in adults differs significantly from
pediatric protocols and should be handled by experienced adult emergency staff.
QUESTION 3
Client Needs: Management of Care
A 17-year-old patient requires emergency surgery for acute appendicitis. The parents are
out of the country and cannot be reached. The patient is conscious and requesting the
surgery.
What is the nurse's priority action?
A. Proceed with surgery based on the patient's consent B. Wait for parental consent before
proceeding C.
Contact the hospital's ethics committee D. Seek court authorization for emergency
treatment
Answer: A
Rationale: In life-threatening emergencies where parents cannot be contacted,
healthcare providers can proceed with necessary treatment to preserve life and health. The
17-year-old patient's consent for emergency surgery is legally acceptable when immediate
intervention is required. Waiting for parental consent (B) could result in perforation and
peritonitis. Ethics committee consultation (C) would cause dangerous delays in emergency
situations. Court authorization (D) is not required for emergency, life-saving procedures
when parents are unavailable.
QUESTION 4
Client Needs: Management of Care
, A charge nurse is developing assignments for the day shift. Available staff includes two
RNs, two LPNs, and three UAPs. The unit has 28 patients with varying acuity levels.
Which delegation decision demonstrates appropriate assignment based on scope of
practice?
A. LPN administering IV chemotherapy to an oncology patient B. UAP taking vital signs
on patients in stable condition C. LPN teaching discharge instructions to a diabetic patient
D. UAP performing sterile wound care on a post-surgical patient
Answer: B
Rationale: UAPs can safely take vital signs on stable patients as this falls within their
scope of practice and training. IV chemotherapy administration (A) requires RN-level
knowledge of oncology medications and monitoring for complications. Patient teaching
(C) is an RN responsibility that cannot be delegated to LPNs. Sterile wound care (D)
requires nursing judgment and sterile technique beyond UAP scope; this should be
performed by licensed nursing personnel.
QUESTION 5
Client Needs: Management of Care
A patient with end-stage cancer has a living will stating "no extraordinary measures" but
family members are demanding aggressive treatment including CPR and mechanical
ventilation. The patient is currently alert but weak.
What is the nurse's best action?
A. Follow the family's wishes for aggressive treatment B. Advocate for the patient's
documented wishes in the living will C. Seek a court order to determine the appropriate
course of action D. Refer the case to hospital administration for decision
Answer: B
Rationale: The nurse has a legal and ethical obligation to advocate for the patient's
autonomous decision as documented in the living will. Advanced directives represent the
patient's own values and wishes when they were competent to make decisions. Family
wishes (A) cannot override a valid living will. Court orders (C) and administrative
decisions (D) are not necessary when clear advance directives exist; the nurse should
advocate for the patient's documented preferences.
