NCLEX-RN (NCSBN) — clinical judgment practice for the exam that licenses a nurse

A nurse is delegating tasks. Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)?

1. Administering a scheduled oral medication during the routine morning pass
2. Assessing a postoperative wound and documenting its appearance
3. Assisting a stable patient with ambulation to the bathroom
4. Performing the initial patient teaching about a newly diagnosed condition

Answer: C — Assisting a stable patient with ambulation to the bathroom

The Five Rights of Delegation limit UAPs to tasks that are routine, predictable, and do not require nursing judgment. Ambulating a stable patient fits. Medications (A), assessment (B), and teaching (D) all require licensed nursing judgment and cannot be delegated.

A hospital is implementing a new electronic health record. Which action best reflects the PLAN phase of a PDSA quality improvement cycle for this rollout?

1. Go live with the new system across every hospital unit at once so no one is working from two records
2. Survey nurses about their satisfaction with the system after full implementation is complete
3. Pilot the new system on one unit and identify a specific goal and measurement plan before starting
4. Discontinue the EHR project after the first reported charting issue and return to paper

Answer: C — Pilot the new system on one unit and identify a specific goal and measurement plan before starting

C) Correct — the Plan phase involves defining the goal and measurement plan, often via a small-scale pilot before Do/Study/Act. A) Skips planning and piloting — high risk. B) Reflects the Study phase, done after implementation. D) Reactive and skips the structured cycle.

A charge nurse is evaluating whether to accept a new admission onto a unit that is at capacity. Which factor should be the PRIORITY consideration?

1. Whether the unit can safely staff and care for the new client without compromising care for existing clients
2. Whether the charge nurse can maintain a lighter personal assignment while covering the additional client
3. Whether the new client's insurance carrier will authorize an admission to this level of care and cover the anticipated stay
4. The time of day the admission arrives and whether it falls close to the change-of-shift report

Answer: A — Whether the unit can safely staff and care for the new client without compromising care for existing clients

A) Correct — patient safety and safe staffing capacity are the priority considerations for admission decisions. B) Personal preference isn't the clinical basis for the decision. C) Not an appropriate basis for admission decisions. D) Time of day alone doesn't address safety capacity.

Which is the correct priority for a nurse managing multiple casualties arriving simultaneously after a building collapse?

1. Treat victims strictly in the order they arrive so that no one waits longer than anyone else
2. Treat the least injured first to clear them quickly and free beds for the critical victims
3. Complete detailed documentation on each victim before initiating any treatment or transport
4. Triage first to identify and prioritize the most salvageable, critically injured victims

Answer: D — Triage first to identify and prioritize the most salvageable, critically injured victims

D) Correct — rapid triage to identify salvageable critical injuries directs limited resources to where they'll save the most lives. A) Arrival order doesn't reflect acuity/salvageability. C) Documentation is secondary to triage and treatment. B) The opposite of appropriate disaster triage prioritization.

A client is scheduled for surgery and reports a latex allergy. Which nursing action is a priority?

1. No special precautions are needed as long as the client has never had a reaction requiring treatment
2. Ensure the surgical team is aware and that a latex-free environment/supplies are used
3. Delay the surgery indefinitely regardless of urgency until formal allergy testing confirms the sensitivity
4. Inform only the surgeon, since the operating surgeon selects all of the supplies used in the case

Answer: B — Ensure the surgical team is aware and that a latex-free environment/supplies are used

B) Correct — communicating the allergy to the full team and ensuring latex-free supplies prevents a potentially severe allergic reaction during surgery. A) A latex allergy requires specific precautions. C) Elective precautions can typically be implemented without unnecessary surgical delay. D) The full perioperative team needs this safety-critical information.

A nurse manager is evaluating staff performance using a just culture framework after a medication error. Which question is MOST appropriate for the manager to ask?

1. "Who is to blame for this error, and what level of disciplinary action should be documented?"
2. "What system factors contributed to this error, and could this happen to anyone in this situation?"
3. "How can we discipline this nurse in a way that deters other staff from making similar medication errors?"
4. "Should we terminate this nurse immediately so the unit's error rate returns to baseline?"

Answer: B — "What system factors contributed to this error, and could this happen to anyone in this situation?"

B) Correct — a just culture framework focuses on system factors and whether the error reflects a systemic risk rather than individual blame. A), C), D) Reflect a punitive, blame-focused approach inconsistent with just culture principles.

A client tells the nurse, "There is smoke coming from the trash can in the bathroom!" What is the nurse's FIRST action?

1. Call the fire department and report the exact location of the smoke
2. Use the fire extinguisher on the trash can using the PASS technique
3. Rescue the client and any clients in immediate danger
4. Sound the fire alarm to alert staff on this unit and adjacent units

Answer: C — Rescue the client and any clients in immediate danger

C) Correct: RACE — Rescue is FIRST. Move clients in immediate danger to safety. A) Calling 911 is part of activating alarms but the priority is removing the client from danger. B) Extinguishing comes after rescue, alarm, contain. D) Alarm follows rescue. The trap is choosing Alarm because it feels procedural — the framework explicitly puts Rescue first.

Which statement reflects the epidemiological triangle model of disease causation?

1. Disease occurs from agent, host, and environment interacting
2. Disease is caused solely by environmental exposures acting on a population
3. Disease is caused solely by inherited host genetics and individual susceptibility
4. Disease arises randomly, with no identifiable causative factors that can be studied

Answer: A — Disease occurs from agent, host, and environment interacting

A) Correct — the epidemiological triangle describes the interaction of agent, host, and environment in disease causation. B) Incomplete — ignores agent/host factors. C) Incomplete — ignores agent/environment factors. D) Contradicts the entire premise of epidemiology.

A child with a cyanotic congenital heart defect suddenly becomes more cyanotic, agitated, and assumes a squatting position. What is this finding known as, and what does squatting accomplish?

1. A "tet spell"; squatting increases systemic vascular resistance, improving pulmonary blood flow
2. A normal daily variation in a child with a cyanotic defect; squatting reflects fatigue and needs no assessment
3. A sign of improving oxygenation; squatting increases venous return and raises the systemic oxygen saturation
4. An unrelated musculoskeletal finding; squatting relieves the hip and knee discomfort common at this age

Answer: A — A "tet spell"; squatting increases systemic vascular resistance, improving pulmonary blood flow

A) Correct — this describes a hypercyanotic "tet" spell (classically in tetralogy of Fallot); squatting increases systemic vascular resistance, which paradoxically improves pulmonary blood flow and oxygenation. B) This is an acute event requiring prompt assessment. C) The child is experiencing worsening oxygenation before the compensatory squatting response. D) It is a cardiac compensatory mechanism, not musculoskeletal.

A toddler swallowed an unknown quantity of a liquid medication and is alert. What should the caregiver do FIRST?

1. Induce vomiting immediately at home
2. Give the child milk to dilute the substance
3. Call Poison Control immediately for guidance
4. Wait to see if symptoms develop before acting

Answer: C — Call Poison Control immediately for guidance

C) Correct — Poison Control provides substance-specific guidance immediately; management varies drastically by ingested agent. A) Inducing vomiting is no longer routinely recommended and can be harmful for some substances. B) Diluting without knowing the substance can worsen some ingestions. D) Delaying care in a poisoning is unsafe.

A patient says, 'I just want this to be over.' The most therapeutic nursing response is:

1. 'Don't think that way — there's always hope.'
2. 'You should talk to the chaplain.'
3. 'I'll come back when you feel better.'
4. 'Tell me more about what you're feeling.'

Answer: D — 'Tell me more about what you're feeling.'

Therapeutic communication uses open-ended exploration to draw out feelings — particularly important to assess for suicidal ideation when a statement like this is made. (A) is a 'false reassurance' blocker. (C) abandons the patient. (B) prematurely refers without first assessing.

A client with major depressive disorder is started on an SSRI. Which teaching point about the FDA boxed warning is important?

1. There is an increased risk of suicidal thoughts, especially in children, adolescents, and young adults, particularly early in treatment
2. The medication cures depression permanently after one completed course, so it can safely be stopped at that point
3. No follow-up visits or symptom monitoring are needed once the medication has been started and the dose is stable
4. The medication should be stopped abruptly if any side effect occurs, without first contacting the prescribing provider or pharmacist

Answer: A — There is an increased risk of suicidal thoughts, especially in children, adolescents, and young adults, particularly early in treatment

A) Correct — this reflects the actual boxed warning; monitoring is especially important in the first weeks. B) Overstates the effect; depression management is often ongoing. C) Close monitoring, especially early, is essential. D) Abrupt discontinuation can cause discontinuation syndrome; changes should be discussed with the provider.

Which intervention is MOST appropriate to prevent pressure injuries in an immobile older adult?

1. Repositioning every 2 hours and using pressure-redistributing surfaces
2. Repositioning once per shift and documenting skin condition at that time
3. Vigorous massage over bony prominences to stimulate local blood flow
4. Leaving the head of the bed elevated above 30 degrees at all times for comfort

Answer: A — Repositioning every 2 hours and using pressure-redistributing surfaces

A) Correct — regular repositioning and pressure-redistributing surfaces are core evidence-based prevention strategies. B) Insufficient frequency. C) Vigorous massage over bony prominences can cause tissue damage. D) Prolonged elevation above 30 degrees increases shear force risk on the sacrum.

Which nursing action best supports functional independence for a frail older adult during a hospital stay?

1. Keep the client in bed with an indwelling Foley catheter in place to reduce fall and incontinence risk
2. Restrict visitors to reduce overstimulation and protect uninterrupted rest periods
3. Perform all ADLs for the client to conserve energy for physical therapy sessions
4. Encourage early, supervised mobility and minimize unnecessary tethers (lines, catheters)

Answer: D — Encourage early, supervised mobility and minimize unnecessary tethers (lines, catheters)

D) Correct — early mobility and minimizing unnecessary tethers reduce hospital-acquired deconditioning, delirium, and functional decline. A) Immobility and unnecessary catheters increase deconditioning, infection, and delirium risk. C) Performing all ADLs promotes dependence. B) Social engagement/family presence actually helps reduce delirium risk.

Which teaching point is appropriate for a client planning to breastfeed regarding nipple soreness in the first week?

1. "Soreness that worsens or nipple cracking usually means the latch needs correcting"
2. "You should switch to formula feeding if you have any nipple soreness at all"
3. "Soreness in the first week means you have an infection that needs antibiotics"
4. "Feed the baby less frequently for a few days to let your nipples heal"

Answer: A — "Soreness that worsens or nipple cracking usually means the latch needs correcting"

A) Correct — poor latch is the most common cause of worsening soreness/cracking; correcting positioning resolves it. B) An overreaction — most soreness improves with latch correction. C) Soreness alone doesn't indicate infection (mastitis presents with fever/redness/flu-like symptoms). D) Reducing frequency risks engorgement and reduced supply.

A patient with cirrhosis has worsening confusion. Lab shows elevated ammonia. The MOST appropriate medication is:

1. Sliding-scale insulin (corrects the hyperglycemia driving the confusion)
2. Lactulose (lowers blood ammonia by trapping NH4+ in the bowel)
3. Acetaminophen (for comfort while the ammonia clears on its own)
4. Ibuprofen (reduces the inflammation worsening the confusion)

Answer: B — Lactulose (lowers blood ammonia by trapping NH4+ in the bowel)

Hepatic encephalopathy treatment: lactulose (acidifies colon, converts NH3 to NH4+, increases excretion). Rifaximin may also be added. Acetaminophen and NSAIDs are hepatotoxic/nephrotoxic and contraindicated.

A child requires a medication with a safe pediatric dose range of 20-40 mg/kg/day. The child weighs 15 kg, and the order is for 900 mg/day. Is this order safe?

1. Yes, the order falls within the calculated safe range for this child's weight and may be given as written
2. No, it exceeds the maximum safe dose and the nurse should clarify with the provider before administering
3. No, the ordered dose falls below the minimum safe daily dose, and the nurse should request an increased dose
4. There is not enough information to determine safety without knowing the child's age and body surface area

Answer: B — No, it exceeds the maximum safe dose and the nurse should clarify with the provider before administering

B) Correct — the safe range is 300-600 mg/day (20 × 15 to 40 × 15); 900 mg/day exceeds the maximum and requires provider clarification. A) Miscalculates the safe range. C) The order exceeds the maximum, not falls below the minimum. D) Sufficient information exists to calculate this.

A client is to receive 2 L of normal saline over 24 hours via an infusion pump programmed in mL/hr. What rate should the nurse set?

1. 42 mL/hr
2. 125 mL/hr
3. 83 mL/hr
4. 200 mL/hr

Answer: C — 83 mL/hr

C) Correct — 2,000 mL ÷ 24 hr ≈ 83 mL/hr. A) Reflects a calculation error. B) This would be the rate for 2 L over 16 hours, not 24. D) This would infuse 2 L in 10 hours, far too fast.

A client with a central line develops a fever, and blood cultures are pending. Which nursing action reflects appropriate central line-associated bloodstream infection (CLABSI) prevention while awaiting results?

1. Continue the routine dressing and flushing schedule without inspecting the site or changing technique, since the pending cultures will identify any infection
2. Assess the insertion site for redness/drainage, maintain strict aseptic technique for all line access, and follow facility CLABSI bundle protocols
3. Remove the central line immediately without further assessment, since any fever in a client with a central line confirms the line is the source
4. Increase the frequency of line access to draw additional specimens and check patency, so that more data are available when the provider is notified

Answer: B — Assess the insertion site for redness/drainage, maintain strict aseptic technique for all line access, and follow facility CLABSI bundle protocols

B) Correct — thorough site assessment and strict aseptic technique per CLABSI bundle protocols are appropriate ongoing prevention/evaluation steps. A) A fever with a central line present warrants increased vigilance. C) Removal decisions should follow clinical assessment/culture results and provider judgment. D) Minimizing unnecessary access reduces infection risk.

A client recovering from surgery has not voided 8 hours after Foley removal. Which assessment finding BEST indicates urinary retention requiring intervention?

1. Reports a feeling of urgency without ability to void; bladder scan shows 500 mL
2. Reports drinking about 200 mL of water in the past hour and feels no bladder discomfort
3. Has a soft, non-distended abdomen with active bowel sounds in all quadrants
4. Blood pressure 118/76 with a heart rate of 72 and no reported suprapubic pain

Answer: A — Reports a feeling of urgency without ability to void; bladder scan shows 500 mL

A) Correct: a bladder volume of ≥300-500 mL with inability to void is diagnostic of acute retention requiring intermittent catheterization. B) Intake alone does not confirm retention. C) Non-distended abdomen does not rule out retention; bladder scan is definitive. D) Stable vital signs are reassuring but not diagnostic.

A public health nurse is investigating a foodborne illness outbreak at a community event. Which action is the PRIORITY first step?

1. Close all restaurants in the area immediately, before any exposure information has been gathered
2. Withhold all investigative action until every laboratory specimen result has been finalized
3. Interview affected individuals to identify common food exposures and establish a case definition
4. Report the most likely pathogen based on reported symptoms alone, without interviewing those affected

Answer: C — Interview affected individuals to identify common food exposures and establish a case definition

C) Correct — establishing a case definition and identifying common exposures through interviews is the foundational first step of an outbreak investigation. A) Premature without identifying the actual source. B) Delaying action for full lab confirmation can allow ongoing exposure. D) Assumptions without investigation risk missing the true source.

Using the primary survey (ABCDE) in trauma assessment, which finding takes priority?

1. A closed, non-displaced wrist fracture with intact distal pulses
2. A 2 cm scalp laceration with minimal bleeding controlled by pressure
3. Stridor and inability to speak in a client with facial trauma
4. Bruising over the flank with tenderness reported on palpation

Answer: C — Stridor and inability to speak in a client with facial trauma

C) Correct — airway compromise is first in the primary survey and immediately life-threatening. A) A lower priority, addressed later. B) Minor bleeding is not immediately life-threatening. D) Requires assessment but isn't immediate.

A patient is admitted with COPD exacerbation and pH 7.30, PaCO₂ 60, HCO₃ 30. This represents:

1. Metabolic acidosis with respiratory compensation
2. Respiratory acidosis with partial compensation
3. Respiratory alkalosis with metabolic compensation
4. Mixed metabolic and respiratory disturbance

Answer: B — Respiratory acidosis with partial compensation

pH < 7.35 = acidosis. PaCO₂ > 45 = respiratory cause. HCO₃ > 26 = renal compensation kicking in. This is respiratory acidosis with partial metabolic compensation, classic for chronic CO₂ retention in COPD.

The nurse receives report on four clients. Which client requires the MOST IMMEDIATE intervention?

1. A client with a potassium of 2.9 mEq/L on telemetry showing frequent PVCs
2. A client with a sodium of 128 mEq/L who is alert, oriented, and without headache
3. A client with a hemoglobin of 8.2 g/dL who is asymptomatic and hemodynamically stable
4. A client with a fasting glucose of 188 mg/dL who is awaiting the morning insulin dose

Answer: A — A client with a potassium of 2.9 mEq/L on telemetry showing frequent PVCs

A) Correct: hypokalemia + PVCs is pre-arrest — potassium must be repleted urgently and the rhythm watched. B) Mild hyponatremia without neurologic symptoms is not immediately life-threatening. C) Mild anemia without symptoms can be addressed without urgency. D) Hyperglycemia at this level is not an emergency.

Carbamazepine?

Monitor CBC (agranulocytosis, aplastic anemia); can cause Stevens-Johnson syndrome; induces liver enzymes, many drug interactions.

Pediatric vital signs vary?

Yes — younger = faster HR, RR. Lower BP. Adjust by age.

UTI — lower vs upper symptoms?

Lower (cystitis): dysuria, frequency, urgency. Upper (pyelonephritis): plus fever, flank pain, CVA tenderness, nausea — more serious.

Bulimia nervosa?

Binge eating plus compensatory behavior (purging, laxatives, excessive exercise). Often normal weight — watch for dental erosion, hypokalemia from vomiting.

Tetanus prophylaxis after a wound?

Booster needed if >5 years since last dose for a dirty/contaminated wound (10 years for a clean wound); Tdap preferred once in adulthood.

When 'first' or 'initial' action?

Assess BEFORE intervening. Unless emergency (then act).