Sample NCLEX Style Questions: LVN - RN Transition Midterm

What would be the respiratory rate in two-year-old child? A. 20 B. 30 C. 40 D. 50

B. 30 (Rationale: The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.)

How many rights of delegation are there in the nursing practice? Record your answer using a whole number. _______________

5 (Rationale: There are five rights of delegation in nursing practice. They are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.)

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted? A. These actions can be construed as assault and battery. B. The problem was resolved with forethought and accountability. C. Skin must be protected, and the actions taken were by a reasonably prudent nurse. D. The nurse had tried to reason with the toddler and expected understanding and cooperation.

A. These actions can be construed as assault and battery. (Rationale: Assault is a threat or an attempt to do violence to another, and battery means touching an individual in an offensive manner or actually injuring another person. The nurse's behavior demonstrates anger and does not take into account the growth and developmental needs of children in this age group. Although the behavior (scratching) needs to be decreased, this can be done with mittens, not immobilization. A 3-year-old child does not have the capacity to understand cause (scratching) and effect (bleeding).)

The student nurse is reviewing the electronic health record for clients in a health care facility. Which action by the student nurse may inhibit clients from disclosing personal information? A. Use of clients' data for nursing research B. Use of client data for Medicaid payment C. Discussing a client's illness with the client D. Sharing clients' data with family members

D. Sharing clients' data with family members (Rationale: Clients may not want their health information shared with others and may want to maintain their privacy. If the nurse retrieves client data from the electronic health records and shares it with family members, it may lead to clients not sharing information. The nurse can use client data for research without mentioning a client's personal details. The nurse can use client data for filing insurance to receive Medicaid payments. The nurse can discuss the client's illness with the client; doing so helps to understand the client's perspective and to provide effective care)

C. Diabetic acidosis (Rationale: A client with diabetic acidosis has a sweet, fruity odor to the breath. Gum disease is marked by halitosis. A stale urine smell indicates uremic acidosis. An infection inside a cast is accompanied by a musty odor of the casted body part.)

A client's breath has a sweet, fruity odor. Which condition is likely affecting this client? A. Gum disease B. Uremic acidosis C. Diabetic acidosis D. Infection inside a cast

A nurse educates a client about the role played by an individual in taking responsibility for health and wellness and its impact. What instructions should the nurse give? Select all that apply. A. "An individual should use passive strategies for health promotion." B. "An individual should know that lifestyle choices affect his or her quality of life and well-being." C. "An individual should take responsibility of health and wellness by making proper lifestyle choices." D. "An individual should realize that illness prevention has a positive economic impact on his or her life." E. "An individual should understand that it is enough to make positive lifestyle choices in order to prevent illness."

B, C, D (Rationale: A client should understand that making appropriate lifestyle choices can affect his or her quality of life and well-being. An individual should take responsibility for his or her health and wellness by making proper lifestyle choices. The client should also realize that illness prevention has a positive economic impact by decreasing health care costs. Passive health promotion strategies enable people to benefit from the activities of others. These strategies do not require the involvement of the clients. The client should understand that making positive lifestyle choices and discarding negative lifestyle choices contribute to illness prevention.)

How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? A. It is a willful act violating a client's rights. B. It is a civil wrong made against a person or property. C. It is an act that lacks intent but involves volitional action. D. It is an unintentional act that includes negligence and malpractice

C. It is an act that lacks intent but involves volitional action. (Rationale: A quasi-intentional tort lacks intent but involves volitional actions such as invasion of privacy and defamation of character. An intentional tort is a willful act that violates another's rights. This includes assault, battery, and false imprisonment. A tort is a civil wrong made against a person or property. An unintentional tort involves negligence and malpractice.)

What does a nurse understand by the quality improvement competency, according to Quality and Safety Education (QSEN)? A. Using information and technology to communicate, manage knowledge, mitigate errors, and support decision-making B. Integrating best current evidence with clinical expertise along with client and family preferences and values for the delivery of quality healthcare C. Functioning effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care D. Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

D. Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems (Rationale: The quality improvement competency states that a nurse should use data to monitor the outcomes of healthcare processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems. According to the competency called informatics, a nurse should use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. As per the competency called evidence-based practice, a nurse should integrate best current evidence with clinical expertise and client and family preferences and values for the delivery of quality healthcare. According to the competency called teamwork and collaboration, a nurse should function effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision making to achieve quality client care.)

A. Exploring (Rationale: Exploring is a technique used to obtain more information to better understand the nature of the client's statement. Reflecting is a technique used to either reiterate the content or the feeling message. In content reflection (paraphrasing), the nurse repeats basically the same statement; in feeling reflection, the nurse verbalizes what seems to be implied about feelings in the comment. Refocusing is bringing the client back to a previous point; there is no information that this was discussed previously. Acknowledging is providing recognition for a change in behavior, an effort a client has made, or a contribution to a discussion.)

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? A. Exploring B. Reflecting C. Refocusing D. Acknowledging

D. Accountability (Rationale: The concept of accountability is of high priority in nursing practice. As a licensed professional, the nurse is always accountable, which means liable and answerable for his or her actions. Dedication means to be committed, and assertiveness means to be confident. These are desired characteristics in a nurse but not legal defenses. Certification relates to achieving a higher level of knowledge or proficiency in one's area of specialization and is also not a legal defense.)

Which of the following legal defenses are the most important for a nurse to develop? A. Dedication B. Certification C. Assertiveness D. Accountability

A registered nurse is educating a nursing student on the various classifications of torts. What acts are classified as intentional torts in nursing practice? Select all that apply. A. Battery B. Assault C. Negligence D. Malpractice E. False Imprisonment

A, B, E (A. Battery, B. Assault, E. False Imprisonment)

A nursing student is recalling the definition of Nurse Practice Acts. What do the Nurse Practice Acts do? A. Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. B. Nurse Practice Acts reflect the knowledge and skills possessed by nurses practicing in their profession. C. Nurse Practice Acts are legal requirements that describe the minimum acceptable nursing care. D. Nurse Practice Acts protect individuals from losing their health insurance when changing jobs by providing portability.

A. Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. (Rationale: The Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. They help to distinguish between nursing and medical practice and establish education and licensure requirements for nurses. Standards of care reflect the knowledge and skills possessed by nurses who are active practitioners in their profession. Standards of care are legal requirements that define the minimum acceptable nursing care. The Health Insurance Portability and Accountability Act (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.)

According to Quality and Safety Education (QSEN), what is patient-centered care? A. Understanding that the client is the source of control when providing care B. Functioning effectively within nursing and interprofessional teams to deliver quality care C. Using data to evaluate outcomes of care processes and designing methods to improve health care D. Minimizing the risk of harm to clients and health care workers through improved professional performance

A. Understanding that the client is the source of control when providing care

In what order should a nurse follow steps of risk management to identify potential hazards and to eliminate them before harm occurs? A. Analyzing the possible risks Incorrect B. Identifying possible risks Correct C. Evaluating the steps taken Incorrect D. Acting to reduce the risks

B, A, D, C (Rationale: To eliminate potential hazards before harm occurs, the nurse should first identify the possible risks. After this, the nurse should analyze the possible risks. Then the nurse should act to reduce risks. Finally, the nurse should evaluate the steps that have been taken.)

A nurse who promotes freedom of choice for clients in decision-making best supports which principle? A. Justice B. Autonomy C. Beneficence D. Paternalism

B. Autonomy (Rationale: The principle of AUTONOMY relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others. Justice means to be righteous, equitable, and to act or treat fairly. -Beneficence relates to the state or act of doing good and being kind and charitable. It also includes promotion of well-being and abstaining from injuring others. -Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs without infringing on their rights or responsibilities.)

B. Autonomy (Rationale: Autonomy refers to the commitment to include clients in decisions about all aspects of care as a way of acknowledging and protecting their independence. In the given situation, the nurse ensures that the client has thoroughly understood the new treatment plan before gaining written consent. This ensures that the client is involved in the decision-making process appropriately. Justice refers to fairness. The given situation does not deal with fairness. Beneficence refers to taking positive actions to help others. This involves keeping the interests of the client before self-interest. Nonmaleficence is the avoidance of harm or hurt. Weighing the pros and cons of the new treatment plan would involve nonmaleficence.)

A primary healthcare provider notes that all conventional treatment procedures have proved to be ineffective in managing a client's disorder. The primary healthcare provider decides to try an experimental treatment. The nurse ensures that the client has understood the implications of the new treatment plan thoroughly and then signs the client's consent form as a witness. Which basic healthcare ethic does the nurse follow in this situation? A. Justice B. Autonomy C. Beneficence D. Nonmaleficence

A registered nurse is teaching a nursing student about the standards of nursing practice. How would the nursing student define assessment? A. Assessment is the process of coordinating care delivery. B. Assessment is the process of analyzing assessment data to determine diagnoses or issues. C. Assessment is the process of collecting comprehensive data pertinent to the client's health and/or situation. D. Assessment is the process where a registered nurse provides consultation to influence an identified plan, enhances the abilities of other caregivers, and effects change.

C. Assessment is the process of collecting comprehensive data pertinent to the client's health and/or situation. (Rationale: Assessment is the process of collection of comprehensive data pertinent to the client's health and/or situation. Coordination of care refers to delivering care to the client. Diagnosis refers to analyzing the assessment data to determine the diagnoses or issues. Consultation is the process where a registered nurse discusses with other healthcare providers to influence the identified plan, enhance the abilities of other caregivers, and effect change.)

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect? A. Hypoventilation B. Biot's respiration C. Kussmaul's respiration D. Cheyne-Stokes respiration

C. Kussmaul's respiration (Rationale: Kussmaul's respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot's respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.)

Which nursing action is not likely to cause legal issues? A. Using restraints on a non-cooperative client B. Refraining from reporting suspected child abuse C. Refraining from leaving the client during a staffing shortage D. Allowing nursing assistive personnel (NAP) to administer medications

C. Refraining from leaving the client during a staffing shortage (Rationale: The nurse should not abandon clients if there is a staffing shortage. This action helps to avoid legal complications. Using restraints without the order of the primary healthcare provider may lead to battery and false imprisonment charges. The nurse should always report cases of suspected child abuse. A nurse should never allow nursing assistive personnel (NAP) to administer medications because this action may lead to malpractice charges.)

The nurse is providing care in a multi-specialty hospital. Which nursing action is indicative of a failure to provide equitable care to patients? A. The nurse treats all males and female patients alike. B. The nurse maintains direct eye contact while talking to patients. C. The nurse provides preferential treatment to patients from low economic status. D. The nurse asks a female nurse to attend to the patient according to the patient's wishes.

C. The nurse provides preferential treatment to patients from low economic status. (Rationale: Equitable care refers to providing care without any bias in terms of religion, ethnicity, or socioeconomic status. The nurse believes in providing treatment first to people from low socioeconomic background. This indicates that the nurse is biased toward poor people and has failed to provide equitable health care. Treating both males and females alike indicates that the nurse is providing equitable care. Maintaining firm eye contact indicates that the nurse is exhibiting therapeutic communication with all patients. The nurse asks another female nurse to attend to the patient according to the patient's wishes. This indicates that the nurse respects the patient's decision and tries to implement it.)

What does the nurse understand by the word felony? A. A felony is a less serious crime that has a penalty of a fine or imprisonment for less than one year. B. A felony is the publication of false statements that occurs when one speaks falsely about another. C. A felony is the publication of false statements that occurs when false entries are made in a medical record. D. A felony is a crime of a serious nature that has a penalty of imprisonment for longer than one year or even death.

D. A felony is a crime of a serious nature that has a penalty of imprisonment for longer than one year or even death. (Rationale: A felony is a crime of a serious nature that has a penalty of imprisonment for longer than 1 year or even death. A misdemeanor is a less serious crime that has a penalty of a fine or imprisonment for less than 1 year. Slander is the publication of false statements that occurs when one speaks falsely about another. Libel is the publication of false statements that occurs when false entries are made in the medical record.)

An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next? A. Diagnosis B. Evaluation C. Assessment D. Implementation

D. Implementation (Rationale: The nurse will administer the tetanus as per the doctor's regime. The American Nurses Association identifies this standard of nursing practice as implementation. Diagnosis refers to analysis of the client's biological and psychosocial data to find out the relevant issues and problems. Evaluation is the procedure of assessing the desired outcomes of treatment. Assessment is done at the very beginning when the nurse collects the data about the client to make an accurate diagnosis.)

What is the professional nurse's legal responsibility regarding child abuse? A. Honor the request of the parents not to report the suspected abuse. B. Report any suspected abuse to local law enforcement authorities. C. Return the child to the legal parent even if he or she is suspected of abuse. D. Provide the parents with a copy of the child's medical record.

B. Report any suspected abuse to local law enforcement authorities. (Rationale: Nurses and primary healthcare providers are legally responsible for reporting suspected or actual abuse. Child protective services may obtain a court order to grant temporary guardianship if it is found that the child is in immediate danger. The other answer options do not fulfill the nurse's duty to report suspected child abuse.)