NCLEX-RN Practice Test #12 3

Question 1

The RN is using clinical judgment to determine which of four clients to see first. Which framework provides the most systematic approach for prioritization?

Accepted Answer

Maslow's Hierarchy of Needs (physiological → safety → love/belonging → esteem → self-actualization) combined with ABC (Airway-Breathing-Circulation)

Answer

Combining Maslow's hierarchy with ABC provides a systematic two-level framework: (1) identify which clients have physiological threats, (2) within physiological threats, use ABC to determine who has airway (A) threats first, then breathing (B), then circulation (C). This is the standard NCLEX priority-setting framework used for triage, delegation, and care sequencing.

Question 2

The RN discovers a medication error was made by a nursing student under their supervision. Which action best reflects the RN's professional accountability?

Accepted Answer

Assess the client immediately, notify the provider, complete an incident report, and document the client's condition and actions taken — while providing the student with direct, private feedback

Answer

The RN who supervises a student is professionally accountable for safe client care. Following a medication error: (1) assess client safety immediately, (2) notify provider, (3) complete an incident report (safety tool — not punitive documentation), (4) document in the record objectively. The student receives immediate private feedback as a learning opportunity. Concealment jeopardizes client safety.

Question 3

The nurse manager notices that one nurse consistently documents assessments 3–4 hours before actually performing them. This practice is best described as:

Accepted Answer

Fraudulent documentation — a breach of professional and ethical standards that constitutes falsification of medical records

Answer

Documenting an assessment before it is performed is falsification of medical records. It is a serious professional and legal violation that misrepresents the client's care and endangers patient safety (clinical deterioration between the documented and actual assessment time would not be captured). It can result in license revocation, termination, and legal liability.

Question 4

The RN is caring for a client with terminal cancer who refuses all further treatment and asks about hospice care. The family is opposed to hospice because they believe it means "giving up." How should the nurse respond to the family?

Accepted Answer

"Hospice focuses on comfort, symptom management, and quality of life. It is not giving up — it is choosing to live as fully as possible in the remaining time. The medical team and social worker can discuss your concerns."

Answer

The therapeutic response acknowledges the family's emotional response while providing accurate information about hospice philosophy (comfort-focused care, not abandonment). It respects both the client's autonomy and the family's need for understanding. Dismissing family concerns ("you have no say") damages trust. Overriding a competent client's decision violates autonomy.

Question 5

The nurse is caring for a client who speaks no English. The client's adult child offers to interpret. Which response represents best practice?

Accepted Answer

Use the child as interpreter only for non-clinical, general communication; use a qualified medical interpreter for all clinical discussions, consents, and teaching

Answer

Using family members as medical interpreters for clinical discussions violates professional standards and puts clients at risk. Family members may omit, edit, or mistranslate information (intentionally or not). Federal law (Title VI of the Civil Rights Act) requires qualified medical interpreters for LEP (limited English proficiency) clients for all clinical interactions.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-RN Practice Test #12 3