NCLEX - National Council Licensure Examination NCLEX-RN 5

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?

Accepted Answer

Autonomy

Answer

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?

Accepted Answer

Neurological status and level of consciousness

Answer

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?

Accepted Answer

Replace the armband before administering the medication

Answer

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?

Accepted Answer

Serum potassium

Answer

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?

Accepted Answer

Asking a UAP to measure and record a stable patient's vital signs

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX - National Council Licensure Examination NCLEX-RN 5