NCLEX - National Council Licensure Examination NCLEX-RN 5 — Questions and Answers
Question 1: A nurse is caring for a patient who refuses a blood transfusion due to religious beliefs, even though the physician considers it medically necessary. Which ethical principle is the nurse upholding by supporting the patient's decision?
- Beneficence
- Autonomy (Correct answer)
- Justice
- Nonmaleficence
Correct answer: Autonomy
Autonomy refers to an individual's right to make decisions about their own healthcare, including the right to refuse treatment. By respecting the patient's refusal, the nurse is upholding the principle of autonomy, even when it conflicts with what medical staff believe is in the patient's best interest.
Question 2: When performing a head-to-toe physical assessment, which area should the nurse assess FIRST?
- Abdomen
- Extremities
- Neurological status and level of consciousness (Correct answer)
- Integumentary system
Correct answer: Neurological status and level of consciousness
Assessment follows a systematic head-to-toe approach beginning with neurological status and level of consciousness, as changes in mental status can indicate life-threatening conditions that require immediate intervention. Establishing baseline neurological function guides the remainder of the assessment.
Question 3: A nurse is preparing to administer a medication and discovers the patient's armband is missing. What is the most appropriate action?
- Ask the patient to state their name and proceed with administration
- Check the patient's chart and administer the medication if the room number matches
- Replace the armband before administering the medication (Correct answer)
- Administer the medication and document the missing armband afterward
Correct answer: Replace the armband before administering the medication
Patient identification is a critical safety step. The armband must be replaced and verified before administering any medication. Simply asking the patient their name or relying on room numbers does not meet the two-identifier verification standard required for safe medication administration.
Question 4: A client with heart failure is prescribed furosemide (Lasix). Which laboratory value should the nurse monitor most closely?
- Serum sodium
- Serum potassium (Correct answer)
- Serum calcium
- Serum magnesium
Correct answer: Serum potassium
Furosemide is a loop diuretic that causes the kidneys to excrete potassium along with water. Hypokalemia is the most common and clinically significant electrolyte imbalance associated with furosemide use and can lead to dangerous cardiac dysrhythmias, making serum potassium the priority lab value to monitor.
Question 5: Which of the following actions by a graduate nurse demonstrates understanding of the concept of delegation?
- Delegating a complex wound dressing change to an unlicensed assistive personnel (UAP)
- Asking a UAP to measure and record a stable patient's vital signs (Correct answer)
- Having a UAP administer oral medications to alert and oriented patients
- Delegating the assessment of a newly admitted patient to a UAP
Correct answer: Asking a UAP to measure and record a stable patient's vital signs
Measuring and recording vital signs on a stable patient is within the scope of practice for UAPs and is appropriate for delegation. Assessment, medication administration, and complex wound care require nursing judgment and clinical knowledge and cannot be delegated to UAPs.
Question 6: A nurse is caring for a post-operative patient who reports pain of 8/10 and has an order for morphine sulfate. Before administering the medication, which assessment is the priority?
- Blood pressure
- Temperature
- Respiratory rate (Correct answer)
- Heart rate
Correct answer: Respiratory rate
Morphine is an opioid analgesic that causes central nervous system and respiratory depression. Assessing respiratory rate before administration is the priority because administering morphine to a patient with already compromised respirations can cause respiratory arrest. A respiratory rate below 12 breaths per minute typically contraindicates opioid administration.
NCLEX - National Council Licensure Examination NCLEX-RN 5
A nurse is caring for a patient who refuses a blood transfusion due to religious beliefs, even though the physician considers it medically necessary.
Which ethical principle is the nurse upholding by supporting the patient's decision?