NCLEX - National Council Licensure Examination NCLEX-RN 6 — Questions and Answers
Question 1: A nurse is caring for a patient who refuses a blood transfusion due to religious beliefs, despite the physician's recommendation. Which ethical principle is the nurse upholding by respecting the patient's decision?
- Beneficence
- Autonomy (Correct answer)
- Justice
- Fidelity
Correct answer: Autonomy
Autonomy is the patient's right to make informed decisions about their own care, even when those decisions conflict with medical advice. Respecting a patient's refusal of treatment based on personal or religious beliefs is a direct application of this principle.
Question 2: When performing a head-to-toe assessment, in which order should the nurse typically assess the abdomen?
- Inspection, palpation, percussion, auscultation
- Auscultation, percussion, palpation, inspection
- Inspection, auscultation, percussion, palpation (Correct answer)
- Palpation, inspection, auscultation, percussion
Correct answer: Inspection, auscultation, percussion, palpation
Abdominal assessment follows a unique sequence: inspection first, then auscultation before percussion and palpation, because palpation and percussion can alter bowel sounds and give inaccurate auscultation findings if performed first.
Question 3: A nurse administers the wrong medication to a patient. The patient experiences no adverse effects. What is the nurse's most appropriate first action?
- Document the incident and monitor the patient closely
- Notify the patient's physician and complete an incident report (Correct answer)
- Reassure the patient and continue with the scheduled medications
- Notify the charge nurse and withhold the correct medication
Correct answer: Notify the patient's physician and complete an incident report
Following a medication error, the priority is patient safety: the physician must be notified immediately so the patient can be assessed and treated if needed, and an incident report must be completed to support quality improvement and transparency.
Question 4: A client with heart failure is prescribed furosemide. 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 significant potassium loss in urine, placing patients at risk for hypokalemia. Hypokalemia can lead to dangerous cardiac dysrhythmias, making serum potassium the priority electrolyte to monitor.
Question 5: Which therapeutic communication technique is MOST appropriate when a patient states, 'I'm afraid I might not survive this surgery'?
- 'I'm sure you'll be fine — the surgeon is very experienced.'
- 'Many patients feel that way before surgery.'
- 'Tell me more about what you're feeling.' (Correct answer)
- 'You shouldn't think negatively about your outcome.'
Correct answer: 'Tell me more about what you're feeling.'
Encouraging the patient to elaborate ('Tell me more') is an open-ended response that validates the patient's feelings and promotes further expression. The other options offer false reassurance, minimize the patient's concern, or use non-therapeutic responses.
Question 6: A nurse is planning care for a postoperative patient who has returned from surgery. Which assessment finding requires the nurse's IMMEDIATE attention?
- Urine output of 35 mL over the past hour
- Pain rating of 6 out of 10 at the incision site
- Respiratory rate of 8 breaths per minute (Correct answer)
- Oral temperature of 37.8°C (100°F)
Correct answer: Respiratory rate of 8 breaths per minute
A respiratory rate of 8 breaths per minute indicates severe respiratory depression, which can be life-threatening — especially postoperatively when opioid analgesics may suppress respiration. This requires immediate intervention. The other findings warrant monitoring but are not immediately life-threatening.
NCLEX - National Council Licensure Examination NCLEX-RN 6
A nurse is caring for a patient who refuses a blood transfusion due to religious beliefs, despite the physician's recommendation.
Which ethical principle is the nurse upholding by respecting the patient's decision?