NCLEX-RN PRACTICE
EXAM 3
High-Yield Qs & Answers with Rationales
CRITICAL THINKING &
CLINICAL JUDGMENT
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
1
,Section A: Management of Care (Questions 1-40)
QUESTION 1
Client Needs: Management of Care
The charge nurse in the emergency department receives multiple trauma patients from a multi-
vehicle accident. Patient A has an open femur fracture with active bleeding and is conscious.
Patient B is unconscious with shallow respirations and no pulse. Patient C has minor lacerations
and is ambulatory but anxious. Patient D has chest pain and difficulty breathing but stable vital
signs.
Using START triage principles, which patient should receive the RED tag?
A. Patient A - open femur fracture with bleeding B. Patient B - unconscious with no pulse
C. Patient C - minor lacerations, ambulatory D. Patient D - chest pain and
dyspnea Answer: A
Rationale: In START triage, RED tags indicate immediate treatment needed for
survivable injuries.
Patient A has life-threatening bleeding but is conscious and salvageable with immediate
intervention. Patient
B would receive a BLACK tag (expectant/deceased) due to no pulse. Patient C gets GREEN (minor),
and Patient D gets YELLOW (delayed) as condition is concerning but stable.
QUESTION 2
Client Needs: Management of Care
A sentinel event occurred when a patient received the wrong blood type during transfusion,
resulting in a severe hemolytic reaction. The nurse manager is conducting a root cause analysis
meeting with the interprofessional team. The laboratory technician becomes defensive and
blames the nursing staff for not following proper verification procedures.
What is the nurse manager's priority action during this meeting?
2
,A. Document the technician's defensive behavior in the incident report B. Redirect focus from
individual blame to system process failures C. Remind all staff about blood transfusion verification
policies D. Schedule individual counseling sessions for involved staff
Answer: B
Rationale: Root cause analysis focuses on identifying system failures rather than
individual blame. The goal is to prevent future occurrences by examining processes,
communication gaps, and environmental factors. A blame-free environment encourages honest
reporting and participation. Individual accountability is addressed separately from the system
analysis process.
QUESTION 3
Client Needs: Management of Care
The ICU charge nurse is making patient assignments when the unit receives an admission for a
patient requiring continuous renal replacement therapy (CRRT). The available nurses have the
following qualifications: Nurse A (2 years ICU experience, CRRT certified), Nurse B (10 years ICU
experience, no CRRT certification), Nurse C (new graduate, 3 months ICU experience), and Nurse D
(float nurse from medical-surgical unit).
Which nurse should be assigned to the CRRT patient?
A. Nurse A - certified in CRRT despite less experience B. Nurse B - most experienced ICU nurse
available C.
Nurse C - new graduate needs challenging experiences
D. Nurse D - float nurse to provide learning opportunity
Answer: A
Rationale: CRRT requires specialized certification and competency validation due to
the complexity and potential complications of the therapy. Patient safety takes priority over years
of experience when specialized skills are required. Nurse A has both ICU experience and the
required certification. This assignment follows appropriate resource allocation principles and Joint
Commission competency requirements.
QUESTION 4
Client Needs: Management of Care
During shift report, the charge nurse learns that the unit is short-staffed with a nurse-to-patient
ratio of 1:8 on the medical-surgical unit, exceeding safe staffing guidelines. The nurse manager is
3
, unavailable, and no additional staff can be obtained. Two patients are scheduled for surgery, one
patient requires frequent neurological assessments, and several patients need medication
administration.
What is the charge nurse's priority action? Select all that apply.
A. Cancel the scheduled surgeries until adequate staffing is available B. Notify the nursing
supervisor about the unsafe staffing situation C. Document the staffing concerns and patient
acuity in writing D. Reassign the most stable patients to unlicensed assistive personnel E. Prioritize
direct patient care activities and defer documentation F. Contact the chief nursing officer about
the staffing shortage
Answer: B, C
Rationale: The charge nurse must immediately notify the supervisor about unsafe
conditions and document the situation for liability protection and quality assurance. Cancelling
surgeries requires physician orders and administrative approval. UAP cannot be assigned tasks
outside their scope. Deferring documentation compromises patient safety and legal requirements.
The supervisor should handle escalation to administration.
QUESTION 5
Client Needs: Management of Care
A 45-year-old patient from a Middle Eastern culture is admitted for emergency surgery. The
patient's husband states that he must make all medical decisions for his wife and refuses to allow
female nurses to provide direct care. The patient appears anxious but defers to her husband. The
charge nurse observes tension between the staff and family.
What is the most appropriate nursing action to ensure culturally competent care?
A. Explain that hospital policy requires patient consent for all treatments B. Arrange for a cultural
liaison to facilitate communication with the family C. Assign only male nurses to provide direct
patient care as requested D. Document the family's requests as potential barriers to care
Answer: B
Rationale: A cultural liaison can help bridge communication gaps, explain cultural
practices to staff, and find compromises that respect cultural values while maintaining safety
standards. This approach demonstrates cultural competence and facilitates collaborative care.
Simply explaining policies or documenting barriers doesn't address the underlying cultural needs
or resolve the conflict.
4
EXAM 3
High-Yield Qs & Answers with Rationales
CRITICAL THINKING &
CLINICAL JUDGMENT
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
1
,Section A: Management of Care (Questions 1-40)
QUESTION 1
Client Needs: Management of Care
The charge nurse in the emergency department receives multiple trauma patients from a multi-
vehicle accident. Patient A has an open femur fracture with active bleeding and is conscious.
Patient B is unconscious with shallow respirations and no pulse. Patient C has minor lacerations
and is ambulatory but anxious. Patient D has chest pain and difficulty breathing but stable vital
signs.
Using START triage principles, which patient should receive the RED tag?
A. Patient A - open femur fracture with bleeding B. Patient B - unconscious with no pulse
C. Patient C - minor lacerations, ambulatory D. Patient D - chest pain and
dyspnea Answer: A
Rationale: In START triage, RED tags indicate immediate treatment needed for
survivable injuries.
Patient A has life-threatening bleeding but is conscious and salvageable with immediate
intervention. Patient
B would receive a BLACK tag (expectant/deceased) due to no pulse. Patient C gets GREEN (minor),
and Patient D gets YELLOW (delayed) as condition is concerning but stable.
QUESTION 2
Client Needs: Management of Care
A sentinel event occurred when a patient received the wrong blood type during transfusion,
resulting in a severe hemolytic reaction. The nurse manager is conducting a root cause analysis
meeting with the interprofessional team. The laboratory technician becomes defensive and
blames the nursing staff for not following proper verification procedures.
What is the nurse manager's priority action during this meeting?
2
,A. Document the technician's defensive behavior in the incident report B. Redirect focus from
individual blame to system process failures C. Remind all staff about blood transfusion verification
policies D. Schedule individual counseling sessions for involved staff
Answer: B
Rationale: Root cause analysis focuses on identifying system failures rather than
individual blame. The goal is to prevent future occurrences by examining processes,
communication gaps, and environmental factors. A blame-free environment encourages honest
reporting and participation. Individual accountability is addressed separately from the system
analysis process.
QUESTION 3
Client Needs: Management of Care
The ICU charge nurse is making patient assignments when the unit receives an admission for a
patient requiring continuous renal replacement therapy (CRRT). The available nurses have the
following qualifications: Nurse A (2 years ICU experience, CRRT certified), Nurse B (10 years ICU
experience, no CRRT certification), Nurse C (new graduate, 3 months ICU experience), and Nurse D
(float nurse from medical-surgical unit).
Which nurse should be assigned to the CRRT patient?
A. Nurse A - certified in CRRT despite less experience B. Nurse B - most experienced ICU nurse
available C.
Nurse C - new graduate needs challenging experiences
D. Nurse D - float nurse to provide learning opportunity
Answer: A
Rationale: CRRT requires specialized certification and competency validation due to
the complexity and potential complications of the therapy. Patient safety takes priority over years
of experience when specialized skills are required. Nurse A has both ICU experience and the
required certification. This assignment follows appropriate resource allocation principles and Joint
Commission competency requirements.
QUESTION 4
Client Needs: Management of Care
During shift report, the charge nurse learns that the unit is short-staffed with a nurse-to-patient
ratio of 1:8 on the medical-surgical unit, exceeding safe staffing guidelines. The nurse manager is
3
, unavailable, and no additional staff can be obtained. Two patients are scheduled for surgery, one
patient requires frequent neurological assessments, and several patients need medication
administration.
What is the charge nurse's priority action? Select all that apply.
A. Cancel the scheduled surgeries until adequate staffing is available B. Notify the nursing
supervisor about the unsafe staffing situation C. Document the staffing concerns and patient
acuity in writing D. Reassign the most stable patients to unlicensed assistive personnel E. Prioritize
direct patient care activities and defer documentation F. Contact the chief nursing officer about
the staffing shortage
Answer: B, C
Rationale: The charge nurse must immediately notify the supervisor about unsafe
conditions and document the situation for liability protection and quality assurance. Cancelling
surgeries requires physician orders and administrative approval. UAP cannot be assigned tasks
outside their scope. Deferring documentation compromises patient safety and legal requirements.
The supervisor should handle escalation to administration.
QUESTION 5
Client Needs: Management of Care
A 45-year-old patient from a Middle Eastern culture is admitted for emergency surgery. The
patient's husband states that he must make all medical decisions for his wife and refuses to allow
female nurses to provide direct care. The patient appears anxious but defers to her husband. The
charge nurse observes tension between the staff and family.
What is the most appropriate nursing action to ensure culturally competent care?
A. Explain that hospital policy requires patient consent for all treatments B. Arrange for a cultural
liaison to facilitate communication with the family C. Assign only male nurses to provide direct
patient care as requested D. Document the family's requests as potential barriers to care
Answer: B
Rationale: A cultural liaison can help bridge communication gaps, explain cultural
practices to staff, and find compromises that respect cultural values while maintaining safety
standards. This approach demonstrates cultural competence and facilitates collaborative care.
Simply explaining policies or documenting barriers doesn't address the underlying cultural needs
or resolve the conflict.
4
