NCLEX-RN Practice
Exam 5
High-Yield Qs & Answers with Rationales
COMPREHENSIVE FINAL REVIEW
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
,Section A: Management of Care (Questions 1-40)
Question 1
Client Needs: Management of Care
A charge nurse on a medical-surgical unit receives report on four patients during
shift change. Patient A has chest pain with ST elevation, Patient B needs pre-op
teaching for surgery at 0800, Patient C requires discharge teaching, and Patient
D has a new onset fever of 101.8°F with productive cough. The unit is
shortstaffed with two RNs and one LPN available for the 12-bed unit.
Which patient should the charge nurse assign to the LPN?
A. Patient A with chest pain and ST elevation B. Patient B requiring pre-operative
teaching C. Patient C needing discharge teaching
D. Patient D with new onset fever and cough
Answer: C
Rationale: Patient C requiring discharge teaching has the most stable
condition and involves a routine task within the LPN's scope of practice. Patient A
requires immediate assessment and interventions for a potential MI, Patient D
needs assessment for possible pneumonia, and Patient B requires complex
teaching that should be performed by an RN. The LPN can provide routine
discharge instructions under RN supervision.
Question 2
Client Needs: Management of Care
During a mass casualty event, a triage nurse is evaluating four victims who have
just arrived at the emergency department. Victim 1 has severe burns over 60% of
body surface area and is unconscious, Victim 2 has an open femur fracture with
controllable bleeding, Victim 3 has minor lacerations and is ambulatory, and
Victim 4 has a pneumothorax with severe respiratory distress.
,Using disaster triage protocols, which victim should receive immediate priority
care?
A. Victim 1 with severe burns over 60% of body surface area B. Victim 2 with
open femur fracture and controllable bleeding C. Victim 3 with minor lacerations
who is ambulatory D. Victim 4 with pneumothorax and severe respiratory
distress
Answer: D
Rationale: In disaster triage, Victim 4 with pneumothorax and severe
respiratory distress falls into the
"immediate" category (red tag) because they have life-threatening injuries that are
survivable with immediate intervention. Victim 1 with 60% burns would likely be
categorized as "expectant" (black tag) due to poor prognosis with limited resources.
Victim 2 is "delayed" (yellow tag) and Victim 3 is "minor" (green tag).
Question 3
Client Needs: Management of Care
A nurse manager is implementing a new fall prevention protocol on the medical
unit. The protocol includes hourly rounding, bed alarms for high-risk patients,
and standardized fall risk assessments. After three months, the fall rate has
decreased from 4.2 falls per 1,000 patient days to 2.8 falls per 1,000 patient
days. This quality improvement initiative demonstrates which aspect of evidence-
based practice?
A. Clinical expertise guiding patient care decisions B. Integration of research
evidence with clinical practice
C. Patient preferences driving care modifications D. Cost-effectiveness analysis of
interventions
Answer: B
Rationale: This scenario demonstrates the integration of research evidence
(fall prevention protocols) with clinical practice to achieve measurable quality
outcomes. The manager implemented evidence-based interventions and measured
their effectiveness through data collection. While clinical expertise was involved,
the primary focus is on applying research evidence to improve patient outcomes
through systematic quality improvement processes.
, Question 4
Client Needs: Management of Care
A 78-year-old patient with end-stage pancreatic cancer and multiple organ failure
has been on mechanical ventilation for two weeks. The family is requesting that
"everything possible" be done to keep their loved one alive, while the healthcare
team believes continued aggressive care is medically futile. The patient has no
advance directives.
Which action by the nurse best addresses this ethical dilemma?
A. Support the family's wishes to continue all aggressive treatments B. Advocate
for immediate withdrawal of life support measures C. Facilitate a
multidisciplinary ethics consultation for the family D. Document the patient's
poor prognosis in the medical record
Answer: C
Rationale: Facilitating an ethics consultation provides a structured approach
to address conflicts between family wishes and medical futility determinations.
The ethics committee can help mediate discussions, clarify values, explore
alternatives, and work toward a consensus that respects both the patient's best
interests and family concerns. This approach honors the principle of beneficence
while addressing autonomy and justice considerations in end-of-life care.
Question 5
Client Needs: Management of Care
A staff nurse witnesses a colleague removing controlled substances from the
medication dispenser frequently without documenting administration to assigned
patients. The colleague's behavior has become increasingly erratic, and patients
have complained about inadequate pain management.
What is the nurse's primary ethical and legal obligation in this situation?
A. Confront the colleague directly about the suspicious behavior B. Monitor the
colleague's behavior for additional evidence C. Report the observations to the
nurse manager immediately D. Discuss concerns with other staff members to
gather support
Answer: C
Rationale: The nurse has a legal and ethical obligation to report suspected
substance abuse or diversion to protect patient safety and ensure appropriate
pain management. Professional nursing standards require reporting suspected
Exam 5
High-Yield Qs & Answers with Rationales
COMPREHENSIVE FINAL REVIEW
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
,Section A: Management of Care (Questions 1-40)
Question 1
Client Needs: Management of Care
A charge nurse on a medical-surgical unit receives report on four patients during
shift change. Patient A has chest pain with ST elevation, Patient B needs pre-op
teaching for surgery at 0800, Patient C requires discharge teaching, and Patient
D has a new onset fever of 101.8°F with productive cough. The unit is
shortstaffed with two RNs and one LPN available for the 12-bed unit.
Which patient should the charge nurse assign to the LPN?
A. Patient A with chest pain and ST elevation B. Patient B requiring pre-operative
teaching C. Patient C needing discharge teaching
D. Patient D with new onset fever and cough
Answer: C
Rationale: Patient C requiring discharge teaching has the most stable
condition and involves a routine task within the LPN's scope of practice. Patient A
requires immediate assessment and interventions for a potential MI, Patient D
needs assessment for possible pneumonia, and Patient B requires complex
teaching that should be performed by an RN. The LPN can provide routine
discharge instructions under RN supervision.
Question 2
Client Needs: Management of Care
During a mass casualty event, a triage nurse is evaluating four victims who have
just arrived at the emergency department. Victim 1 has severe burns over 60% of
body surface area and is unconscious, Victim 2 has an open femur fracture with
controllable bleeding, Victim 3 has minor lacerations and is ambulatory, and
Victim 4 has a pneumothorax with severe respiratory distress.
,Using disaster triage protocols, which victim should receive immediate priority
care?
A. Victim 1 with severe burns over 60% of body surface area B. Victim 2 with
open femur fracture and controllable bleeding C. Victim 3 with minor lacerations
who is ambulatory D. Victim 4 with pneumothorax and severe respiratory
distress
Answer: D
Rationale: In disaster triage, Victim 4 with pneumothorax and severe
respiratory distress falls into the
"immediate" category (red tag) because they have life-threatening injuries that are
survivable with immediate intervention. Victim 1 with 60% burns would likely be
categorized as "expectant" (black tag) due to poor prognosis with limited resources.
Victim 2 is "delayed" (yellow tag) and Victim 3 is "minor" (green tag).
Question 3
Client Needs: Management of Care
A nurse manager is implementing a new fall prevention protocol on the medical
unit. The protocol includes hourly rounding, bed alarms for high-risk patients,
and standardized fall risk assessments. After three months, the fall rate has
decreased from 4.2 falls per 1,000 patient days to 2.8 falls per 1,000 patient
days. This quality improvement initiative demonstrates which aspect of evidence-
based practice?
A. Clinical expertise guiding patient care decisions B. Integration of research
evidence with clinical practice
C. Patient preferences driving care modifications D. Cost-effectiveness analysis of
interventions
Answer: B
Rationale: This scenario demonstrates the integration of research evidence
(fall prevention protocols) with clinical practice to achieve measurable quality
outcomes. The manager implemented evidence-based interventions and measured
their effectiveness through data collection. While clinical expertise was involved,
the primary focus is on applying research evidence to improve patient outcomes
through systematic quality improvement processes.
, Question 4
Client Needs: Management of Care
A 78-year-old patient with end-stage pancreatic cancer and multiple organ failure
has been on mechanical ventilation for two weeks. The family is requesting that
"everything possible" be done to keep their loved one alive, while the healthcare
team believes continued aggressive care is medically futile. The patient has no
advance directives.
Which action by the nurse best addresses this ethical dilemma?
A. Support the family's wishes to continue all aggressive treatments B. Advocate
for immediate withdrawal of life support measures C. Facilitate a
multidisciplinary ethics consultation for the family D. Document the patient's
poor prognosis in the medical record
Answer: C
Rationale: Facilitating an ethics consultation provides a structured approach
to address conflicts between family wishes and medical futility determinations.
The ethics committee can help mediate discussions, clarify values, explore
alternatives, and work toward a consensus that respects both the patient's best
interests and family concerns. This approach honors the principle of beneficence
while addressing autonomy and justice considerations in end-of-life care.
Question 5
Client Needs: Management of Care
A staff nurse witnesses a colleague removing controlled substances from the
medication dispenser frequently without documenting administration to assigned
patients. The colleague's behavior has become increasingly erratic, and patients
have complained about inadequate pain management.
What is the nurse's primary ethical and legal obligation in this situation?
A. Confront the colleague directly about the suspicious behavior B. Monitor the
colleague's behavior for additional evidence C. Report the observations to the
nurse manager immediately D. Discuss concerns with other staff members to
gather support
Answer: C
Rationale: The nurse has a legal and ethical obligation to report suspected
substance abuse or diversion to protect patient safety and ensure appropriate
pain management. Professional nursing standards require reporting suspected
