NCLEX-RN Nursing — All Questions

A client with metastatic cancer has a do-not-resuscitate order written by the provider. The client develops a temperature of 102.6 F (39.2 C) and reports pain rated 8 of 10. Which action should the nurse take?

• a.Give the prescribed antipyretic and analgesic and continue routine monitoring✓
• b.Limit care to hygiene and repositioning until the family can be contacted
• c.Ask the provider to rescind the order before treating the fever and pain
• d.Withhold the analgesic because comfort measures conflict with the written order

A do-not-resuscitate order directs staff not to perform cardiopulmonary resuscitation; every other prescribed treatment, including antipyretics, analgesia, and monitoring, continues unchanged. Treating fever and pain does not conflict with the order, so there is nothing to rescind.

A nurse posts on a personal social media account: “Long shift with my 32-year-old motorcycle crash guy in room 12 — three surgeries and he is still smiling.” No name appears in the post. How should this post be evaluated?

• a.It is acceptable, because the account is set to be seen by friends
• b.It is acceptable, because no name or medical record number appears
• c.It breaches confidentiality only if the client’s family reads the post
• d.It breaches confidentiality, because the details identify the client✓

Describing a client by room number, age, and circumstance still allows identification, so the post is a breach of confidentiality even though no name is used. Privacy settings and later deletion give no protection, because posted content can be copied and remains retrievable.

An alert, oriented client is in bed when an adult son arrives and asks the nurse for the results of the morning laboratory tests. Which action should the nurse take?

• a.Tell the son that laboratory results are released only by the provider
• b.Ask the client, in the son’s presence, whether the results may be shared✓
• c.Direct the son to submit a written request to the medical records department
• d.Give the results, because a son is a member of the immediate family

When the client is present and has capacity, information may be shared with a family member if the client agrees or is given a chance to object, so the client controls the disclosure. Being a close relative does not by itself authorize release of results.

A charge nurse is reviewing electronic health record access logs for the unit. Which finding requires the charge nurse to intervene?

• a.A nurse opened the chart of a neighbor on another unit✓
• b.A nurse reviewed the chart of a client assigned to her tonight
• c.A nurse read the surgical history of a client she is admitting
• d.A nurse opened a chart to check an order for a client she covers

Client information may be accessed only by team members actively involved in that client’s care, so opening a neighbor’s chart out of concern or curiosity is a privacy violation even if nothing is repeated to anyone. Reviewing charts of assigned or covered clients is a permitted use for treatment.

A charge nurse asks an RN who has not completed the facility’s chemotherapy certification to hang a vesicant chemotherapy infusion because the unit is short-staffed. Which response by the RN is appropriate?

• a.“I will hang it and document that I was directed to give it while short-staffed.”
• b.“I will hang it because the order is written and the pharmacy prepared it.”
• c.“I have not completed the chemotherapy competency, so I cannot hang that infusion.”✓
• d.“I will hang it if you stay in the room and observe me for the first hour.”

A nurse is personally accountable for practicing within their scope and demonstrated competence, and a staffing shortage, a valid order, or a note about who gave the direction does not transfer that accountability. Being watched by another nurse is not a substitute for the required competency.

A hospital policy permits RNs to perform a procedure that the state’s nurse practice act does not include within the RN scope of practice. Which understanding should guide the nurse?

• a.The hospital policy governs, because the employer accepts the legal liability
• b.The nurse practice act sets the limit, so the nurse should not perform it✓
• c.The procedure is allowed once the nurse is checked off by a unit educator
• d.The procedure is allowed if a provider writes an order authorizing it

The state’s nurse practice act and board of nursing define what a licensed nurse may legally do; employer policy, a provider’s order, and an in-house competency check cannot widen that legal scope. A nurse who practices beyond the act risks licensure discipline no matter who directed the act.

A nurse tells a client, “I will be back at 2 p.m. to walk with you in the hallway.” Despite a heavy assignment, the nurse returns at 2 p.m. as promised. Which ethical principle does this action demonstrate?

• a.Justice, which is the fair distribution of nursing care
• b.Fidelity, which is keeping promises made to the client✓
• c.Nonmaleficence, which is the duty to avoid causing harm
• d.Veracity, which is telling the client the truth

Fidelity is faithfulness to the commitments and promises a nurse makes to a client, which is exactly what returning at the promised time demonstrates. Veracity concerns truthfulness in what the nurse tells the client rather than following through on an agreement.

A nurse believes a dying client’s pain is undertreated but is directed by unit leadership to follow the current order and not contact the provider. The nurse continues to feel troubled about the client’s suffering. Which term best describes what the nurse is experiencing?

• a.Moral courage, acting on ethical values despite the personal risk involved
• b.Moral distress, knowing the right action but being blocked from taking it✓
• c.Ethical uncertainty, being unsure which ethical principles apply in the case
• d.Ethical dilemma, choosing between two options of equal ethical weight

Moral distress arises when the nurse has identified the ethically correct action but is blocked from carrying it out by organizational or other constraints. An ethical dilemma is different: there the nurse must choose between competing options rather than being prevented from acting on one already judged right.

A nurse caring for a 4-year-old notes bruises in several stages of healing across the child’s back, and the parent’s explanation does not match the pattern of injury. Which action should the nurse take?

• a.Ask the parent for written permission to report the injuries to the state
• b.Gather proof of abuse before making a report to an outside agency
• c.Report the suspicion to child protective services as a mandated reporter✓
• d.Wait for the provider to decide whether the injuries should be reported

Nurses are mandated reporters and must report a reasonable suspicion of abuse; proof, parental permission, and a provider’s agreement are not prerequisites, and federal privacy rules permit the disclosure to the authority receiving such reports. Waiting to build a case leaves the child in the setting where the injuries occurred.

A client is newly diagnosed with active pulmonary tuberculosis and tells the nurse, “I do not want anyone outside this hospital to know about this.” Which action should the nurse take?

• a.Agree to keep the diagnosis inside the hospital as the client requests
• b.Obtain the client’s written authorization before the case is reported
• c.Explain that the case is reported to the public health department as the law requires✓
• d.Report the case directly to the federal agency that tracks the disease

Tuberculosis is a reportable condition, and privacy rules permit disclosure of protected health information to a public health authority without the client’s authorization. Case reports go to state or local public health officials, who then notify federal surveillance, so the nurse does not report federally.

During a resuscitation, a provider gives the nurse a verbal medication order. Which action by the nurse meets the standard for receiving a verbal order?

• a.Ask a second nurse to listen to the order and confirm what was said
• b.Enter the order into the record afterward and ask the provider to sign it
• c.Repeat the order aloud from memory and then carry it out immediately
• d.Write the order down and read it back to the provider for confirmation✓

The nurse receiving a verbal order writes it down and reads back what was written, which verifies both what was heard and what was transcribed; the prescriber then dates, times, and authenticates the order. Repeating from memory confirms only hearing, leaving a transcription error undetected.

A nurse reviews a newly written order that reads “digoxin .125 mg PO daily.” Which action should the nurse take?

• a.Have the prescriber rewrite the order with a leading zero✓
• b.Transcribe the order as 0.125 mg and give the dose without a call
• c.Ask another nurse to confirm the intended dose before giving it
• d.Give the dose as written, since the intent of the order is clear

A dose written without a leading zero reads as a whole number if the decimal point is missed, so “.125 mg” can be given as 125 mg; only the prescriber may correct their own order. A nurse rewriting the dose or getting a colleague’s opinion leaves the ambiguous original order in place.

A client is found on the floor beside the bed and is assessed as uninjured. After completing the facility’s occurrence report, what should the nurse document in the client’s medical record?

• a.A statement that an occurrence report was completed for this fall
• b.The nurse’s conclusion that the bed alarm had not been switched on
• c.The objective findings of the assessment and how the client was found✓
• d.A copy of the occurrence report filed behind the nursing progress notes

The chart carries the objective facts — how the client was found, the assessment, and what was done — while the occurrence report is a separate quality and risk-management document that is not included in the medical record and is not referenced in it. Charting a cause records an opinion rather than an observation.

A hospital convenes a root cause analysis after a client received a fatal dose of the wrong medication. Which statement describes the purpose of this process?

• a.To decide whether the event must be disclosed to the client’s family
• b.To find the system factors that allowed the error and change them✓
• c.To calculate the financial exposure the hospital faces from the event
• d.To identify the staff member at fault and apply corrective discipline

Root cause analysis repeatedly asks why an error reached the client in order to expose the process and system vulnerabilities behind it, then produces an action plan to correct them. It deliberately looks past the individuals involved, because disciplining one nurse leaves the same failure available to the next one.

A nurse is handwriting an entry on a paper medication administration record after giving a scheduled dose of insulin. Which entry uses approved terminology and abbreviations for the medical record?

• a.Regular insulin 6 units subcutaneously at 0730✓
• b.Regular insulin 6.0 units subcutaneously at 0730
• c.Regular insulin 6 U subcutaneously at 0730
• d.Regular insulin 6 IU subcutaneously at 0730

The Joint Commission's official 'Do Not Use' list governs every handwritten medication entry. Write 'unit' in full, because a handwritten 'U' is read as a zero, as a four, or as 'cc'. Write 'International Unit' in full, because 'IU' is read as 'IV' or as the number 10. And do not write a trailing zero after a decimal point, because 6.0 units is read as 60 units — a tenfold insulin overdose. Spelling out 'units' with no trailing zero is the entry that satisfies all three rules.

A client whose record lists the name “Robert” tells the nurse, “I go by Robin, and I use she and her.” Which action by the nurse is appropriate?

• a.Use the legal name on the record when other staff are present
• b.Ask the provider whether the client’s stated name may be used
• c.Use Robin and she and her, and record this in the client’s chart✓
• d.Use Robin with the client but Robert in the change of shift report

Nursing practice requires compassion and respect for the dignity and unique attributes of every person, so the nurse uses the name and pronouns the client states and passes them to the team through the record. Switching back to the legal name in front of staff tells the client that respect depends on who is listening.

Two nurses on a unit have argued repeatedly about who restocks the medication room, and the dispute is now disrupting handoff. Which approach by the nurse manager is most likely to resolve the conflict durably?

• a.Assign the restocking task to one nurse and end the discussion there
• b.Wait to see whether the two nurses settle the matter between themselves
• c.Ask each nurse to give up part of the task so both share the burden
• d.Bring both nurses together to build a plan that meets both their needs✓

Collaboration — surfacing what each party actually needs and building a shared solution — takes the most effort but produces the most durable resolution. Imposing a decision, splitting the difference, and waiting all leave the underlying interests unaddressed, so the conflict resurfaces.

At discharge a client tells the nurse, “That inhaler costs more than my share of the rent, so I will use it only when I feel really bad.” Which action should the nurse take first?

• a.Teach the client that skipping doses will worsen the breathing problem
• b.Document the client’s plan and reinforce the prescribed dosing schedule
• c.Give the client a list of pharmacies that may sell the inhaler for less
• d.Tell the provider that cost is blocking the client from taking it✓

Advocacy here means telling the prescriber that affordability is what is blocking adherence, so a therapeutically equivalent lower-cost drug or an assistance program can be considered before the client leaves. Repeating the teaching or listing pharmacies leaves the client holding a prescription they have already said they cannot afford.