t
ne
tz
sh
NCLEX-RN EXAM 2020 EXAM
ne
la
The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the
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Sp
client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the
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health care provider of the incident, and completes an incident report. Which statement should the nurse
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document on the incident report?
tz
sh
Sp
The client was found lying on the floor.
ne
la
A client is brought to the emergency department by emergency medical services (EMS) after being hit by
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sh
Sp
a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple
fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the
ne
la
surgical procedure, which is the best action?
tz
Transport the victim to the operating room for surgery.
sh
Sp
ne
la
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have
tz
assessed the client and have determined that the client is not injured. After completing the incident
sh
Sp
report, the nurse should implement which action next?
ne
Reassess the client. la
tz
sh
Sp
ne
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because
la
the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked
in the ICU. The nurse should take which best action?
tz
sh
Sp
Clarify with the team leader to make a safe ICU client assignment.
ne
a
The nurse who works on the night shift enters the medication room and finds a co-worker with a
l
tourniquet wrapped around the upper arm. The co- worker is about to insert a needle, attached to a
tz
sh
Sp
syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the
ne
nurse?
la
Call the nursing supervisor.
tz
sh
Sp
ne
la
A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer
will be bringing the document to the hospital today for witness signatures. The client asks the nurse for
tz
sh
Sp
assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
ne
l a
tz
sh
Sp
"I will call the nursing supervisor to seek assistance regarding your request."
ne
la
The nurse has made an error in a narrative documentation of an assessment finding on a client and
obtains the client's record to correct the error. The nurse should take which actions to correct the error?
sh
Sp
Select all that apply.
la
, t
ne
tz
sh
Document the correct information and end with the nurse's signature and title.
ne
Draw 1 line through the error, initialing and dating it.
la
tz
sh
Sp
Which identifies accurate nursing documentation notations? Select all that apply.
ne
la
tz
The client slept through the night.
sh
Sp
Abdominal wound dressing is dry and intact without drainage.
ne
la
The client's left lower medial leg wound is 3 cm in length without redness, drainage, or
tz
edema.
sh
Sp
ne
la
A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a
tz
nursing student to identify a situation that represents an example of invasion of client privacy. Which
sh
Sp
situation, if identified by the student, indicates an understanding of a violation of this client right?
ne
la
Observing care provided to the client without the client's permission
tz
sh
Sp
ne
Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive
personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency
syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the
la
tz
sh
Sp
disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP
that making this accusation has violated which legal tort?
ne
la
Slander
tz
sh
Sp
ne
An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On
a
physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and
l
tz
sh
Sp
asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in
confidence that her son frequently hits her if supper is not prepared on time when he arrives home from
ne
work. Which is the most appropriate nursing response?
la
tz
sh
Sp
"As a nurse, I am legally bound to report abuse. I will stay with you while you give the
ne
la
report and help find a safe place for you to stay."
tz
sh
Sp
ne
The nurse calls the heath care provider (HCP) regarding a new medication prescription because the
a
dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and
l
the medication is due to be administered. Which action should the nurse take?
tz
sh
Sp
Contact the nursing supervisor.
ne
la
sh
Sp
la
, t
ne
tz
sh
24) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile
(fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually
ne
oriented photograph. Which is the most appropriate initial nursing action?
la
Call the nursing supervisor and report the incident.
tz
sh
Sp
ne
la
The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary
modifications. During the teaching session, the client continuously turns away from the nurse. The nurse
tz
sh
Sp
should implement which best action?
ne
la
tz
Answers-Continue with the instructions, verifying client understanding.
sh
Sp
ne
la
A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly
tz
believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions
sh
Sp
by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)
ne
la
Answers-Ensures that a close relative stays with the client
tz
sh
Makes a referral for a Catholic priest to visit the client
Sp
ne
Offers to provide a means for praying the rosary if the client wishes.
la
tz
sh
Sp
Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5)
Latino American Man
ne
la
Native American man
tz
sh
Sp
Hispanic American man
ne
a
African American woman
l
tz
sh
Sp
ne
The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The
la
nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which
tz
client statement is made?
sh
Sp
"I cannot have any food containing or prepared with blood."
ne
la
tz
sh
Sp
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who
ne
is scheduled for surgery the following week. During the discussion, the client continually smiles and nods
a
the head. How should the nurse interpret this nonverbal behavior?
l
tz
sh
Sp
ne
Reflecting a cultural value
la
sh
Sp
la
ne
tz
sh
NCLEX-RN EXAM 2020 EXAM
ne
la
The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the
tz
sh
Sp
client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the
ne
health care provider of the incident, and completes an incident report. Which statement should the nurse
la
document on the incident report?
tz
sh
Sp
The client was found lying on the floor.
ne
la
A client is brought to the emergency department by emergency medical services (EMS) after being hit by
tz
sh
Sp
a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple
fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the
ne
la
surgical procedure, which is the best action?
tz
Transport the victim to the operating room for surgery.
sh
Sp
ne
la
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have
tz
assessed the client and have determined that the client is not injured. After completing the incident
sh
Sp
report, the nurse should implement which action next?
ne
Reassess the client. la
tz
sh
Sp
ne
The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because
la
the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked
in the ICU. The nurse should take which best action?
tz
sh
Sp
Clarify with the team leader to make a safe ICU client assignment.
ne
a
The nurse who works on the night shift enters the medication room and finds a co-worker with a
l
tourniquet wrapped around the upper arm. The co- worker is about to insert a needle, attached to a
tz
sh
Sp
syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the
ne
nurse?
la
Call the nursing supervisor.
tz
sh
Sp
ne
la
A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer
will be bringing the document to the hospital today for witness signatures. The client asks the nurse for
tz
sh
Sp
assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
ne
l a
tz
sh
Sp
"I will call the nursing supervisor to seek assistance regarding your request."
ne
la
The nurse has made an error in a narrative documentation of an assessment finding on a client and
obtains the client's record to correct the error. The nurse should take which actions to correct the error?
sh
Sp
Select all that apply.
la
, t
ne
tz
sh
Document the correct information and end with the nurse's signature and title.
ne
Draw 1 line through the error, initialing and dating it.
la
tz
sh
Sp
Which identifies accurate nursing documentation notations? Select all that apply.
ne
la
tz
The client slept through the night.
sh
Sp
Abdominal wound dressing is dry and intact without drainage.
ne
la
The client's left lower medial leg wound is 3 cm in length without redness, drainage, or
tz
edema.
sh
Sp
ne
la
A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a
tz
nursing student to identify a situation that represents an example of invasion of client privacy. Which
sh
Sp
situation, if identified by the student, indicates an understanding of a violation of this client right?
ne
la
Observing care provided to the client without the client's permission
tz
sh
Sp
ne
Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive
personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency
syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the
la
tz
sh
Sp
disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP
that making this accusation has violated which legal tort?
ne
la
Slander
tz
sh
Sp
ne
An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On
a
physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and
l
tz
sh
Sp
asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in
confidence that her son frequently hits her if supper is not prepared on time when he arrives home from
ne
work. Which is the most appropriate nursing response?
la
tz
sh
Sp
"As a nurse, I am legally bound to report abuse. I will stay with you while you give the
ne
la
report and help find a safe place for you to stay."
tz
sh
Sp
ne
The nurse calls the heath care provider (HCP) regarding a new medication prescription because the
a
dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and
l
the medication is due to be administered. Which action should the nurse take?
tz
sh
Sp
Contact the nursing supervisor.
ne
la
sh
Sp
la
, t
ne
tz
sh
24) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile
(fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually
ne
oriented photograph. Which is the most appropriate initial nursing action?
la
Call the nursing supervisor and report the incident.
tz
sh
Sp
ne
la
The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary
modifications. During the teaching session, the client continuously turns away from the nurse. The nurse
tz
sh
Sp
should implement which best action?
ne
la
tz
Answers-Continue with the instructions, verifying client understanding.
sh
Sp
ne
la
A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly
tz
believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions
sh
Sp
by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)
ne
la
Answers-Ensures that a close relative stays with the client
tz
sh
Makes a referral for a Catholic priest to visit the client
Sp
ne
Offers to provide a means for praying the rosary if the client wishes.
la
tz
sh
Sp
Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5)
Latino American Man
ne
la
Native American man
tz
sh
Sp
Hispanic American man
ne
a
African American woman
l
tz
sh
Sp
ne
The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The
la
nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which
tz
client statement is made?
sh
Sp
"I cannot have any food containing or prepared with blood."
ne
la
tz
sh
Sp
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who
ne
is scheduled for surgery the following week. During the discussion, the client continually smiles and nods
a
the head. How should the nurse interpret this nonverbal behavior?
l
tz
sh
Sp
ne
Reflecting a cultural value
la
sh
Sp
la
