Principles of Delegation NCLEX

1. A client with leukemia is being considered for a bone marrow transplant. The

healthcare team is discussing the risks and benefits of this treatment and other

possible treatments with the goal of inflicting the least possible harm on the

client. Which principle of healthcare ethics is the team practicing?

• nonmaleficence

2. Which action by the nurse represents the ethical principle of beneficence?

• The nurse administers an immunization to a child even though it may

cause discomfort

3. The nursing instructor asks a student to name an example of false imprisonment.

Which of the following situations reflects a violation of this client right?

• Tell the client that he or she may not leave the hospital

4. A nurse and a nursing assistant enter a client s room to provide care and find the

client lying on the floor. The nurse should first:\

• Check the client’s LOC and VS

5. Which of the following actions exemplifies the use of evidence-based practice in

the delivery of client care?

• Donning sterile gloves to change an abdominal wound dressing

6. The registered nurse has accepted a new position as case manager in a hospital.

Which of the following responsibilities are part of the nurse s new role? Select all that

apply.

• Evaluating and updating the plan of care as needed

• Assessing the client’s needs for home supplies and equipment

• Coordinating consultations and referrals to facilitate discharge

• Establishing a safe and cost-effective plan of care with the client

7. The nurse manager of a quality improvement program asks a nurse in the

neurological unit to conduct a retrospective audit. Which of the following actions should

the auditing nurse plan to perform in this type of audit?\

• Obtaining the assigned medical record from the hospital’s medical room to

review documentation made during a client’s hospital stay

8. A nurse preparing a client for a bronchoscopy notes that the client is wearing a

gold necklace. What should the nurse do to safeguard the client s necklace?

• Ask the client for permission to lock the necklace in the hospital safe

9. A nurse providing preoperative care to a client who is scheduled for a left

mastectomy and axillary lymph node dissection notes that the client is wearing a

wedding band on her left ring finger. The nurse should:

• Explain to the client why the wedding band must be removed

10. A nurse preparing a client to go to the radiology department for a chest x-ray

notes that the client is wearing a religious medal on a chain around the neck. The client,

a Catholic, expresses a concern about removing the medal. What is the most

appropriate action for the nurse to take?

• Assisting the client in pinning the medal and chain to the waistband of the

client's pajama bottoms

11. A physician writes a medication prescription in a client s record. While

transcribing the prescription, the nurse notes that the prescribed dose is three times

higher than the recommended dose. The nurse calls the physician, who states that this

is the dose that the client takes at home and that it is acceptable for this client s

condition. What is the appropriate action for the nurse to take?

• Contacting the nursing supervisor

12. A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid

in the water seal chamber. After further assessment, the nurse suspects that the client s

lung has reexpanded and notifies the physician. The physician verifies with the use of a

chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest

tube be removed. The nurse should first:

• Inform the physician that removal of a chest tube is not a nursing

procedure

13. A nurse calls a physician to report that a client with congestive heart failure

(CHF) is exhibiting dyspnea and worsening of wheezing. The physician, who is in a

hurry because of a situation in the emergency department, gives the nurse a telephone

prescription for furosemide (Lasix) but does not specify the route of administration.

What is the appropriate action on the part of the nurse?

• Calling the physician who gave the telephone prescription to clarify the

prescription

14. A nurse is assisting a physician in assessing a hospitalized client. During the

assessment, the physician is paged to report to the recovery room. The physician

leaves the client’s bedside after giving the nurse a verbal prescription to change the

solution and rate of the intravenous (IV) fluid being administered. What is the

appropriate nursing action in this situation?

• Asking the physician to write the prescription in the client's record before

leaving the nursing unit

15. A client scheduled for surgery tells the nurse that he signed an informed consent

for the surgical procedure but was never told about the risks of the surgery. The nurse

serves as the client’s advocate by:

• Calling the surgeon and asking that the risks be explained to the client

16. A nurse is planning to administer an oral antibiotic to a client with a

communicable disease. The client refuses the medication and tells the nurse that the

medication causes abdominal cramping. The nurse responds, “The medication is

needed to prevent the spread of infection, and if you don’t take it orally I will have to

give it to you in an intramuscular injection.” Which of the following statements accurately

describes the nurse’s response to the client?

• The nurse could be charged with assault.

17. A nurse discovers that another nurse has administered an enema to a client even

though the client told the nurse that he did not want one. The most appropriate action

for the nurse is to:

• Report the incident to the nursing supervisor

18. A nurse calls a physician to question a prescription written for a higher-thannormal dosage of morphine sulfate. The physician changes the prescription to a dosage

within the normal range, and the nurse documents the new telephone prescription in

accordance with the agency s guidelines in the client s record. Which other statement

does the nurse document in the nursing notes?

• The physician was called to clarify the prescription for morphine sulfate.

19. A charge nurse on the 11 pm–to–7 am shift is gathering the nursing staff together

to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member

has an odor of alcohol on her breath, slurred speech, and an unsteady gait and

suspects alcohol intoxication. The charge nurse would most appropriately:

• Send the staff member home

20. A client asks a nurse about the procedure for becoming an organ donor. The

nurse tells the client:

• That anatomical gifts must be made in writing and signed by the client

21. A nurse enters a client’s room to administer a medication that has been

prescribed by the physician. The client asks the nurse about the medication. Which

response by the nurse is appropriate?

• "It's called furosemide (Lasix), and it will promote urination and rid your

body of the excess fluid. It can cause an alteration in electrolyte levels, so

we'll need to increase the potassium in your diet."

22. A nursing student is assigned to care for a client who requires a total bed bath.

When the student explains to the client that she is going to gather supplies to administer

the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean

enough.” The student reports the client’s refusal to the nurse in charge. Which action by

the nurse in charge is appropriate?

• Telling the nursing student to allow the client to rest

23. A client with cancer is transported to the radiology department for a bone scan to

determine whether the cancer has metastasized to bone. While the client is in the

radiology department, the client’s wife arrives for a visit and asks what test is being

performed on the client. What should the nurse tell the wife?

• She will have to discuss the prescribed test with the client.

24. A married couple is attending a hospital program about in vitro fertilization.

During the program, a crew from a local television station arrives to film the proceedings

because the station is publicizing a series on hospital services. The nurse conducting

the program should:

• Explain to the television crew that videotaping is not allowed

25. A nurse is taking a morning break with the unit secretary in the nurses’ lounge.

The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has

gonorrhea.” How should the nurse respond to the secretary?

• "We can't discuss a client's medical condition."

26. A nurse on the night shift is making client rounds. When the nurse checks a client

who is 97 years old and has successfully been treated for heart failure, he notes that the

client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the

nurse should:

• Administer cardiopulmonary resuscitation (CPR)

27. A physician informs a nurse that the husband of an unconscious client with

terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The

physician tells the nurse to perform a slow code and let the client rest in peace if she

stops breathing. How should the nurse respond?

• Telling the physician that "slow codes" are not acceptable

28. A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig s disease) is

admitted to the hospital because his condition is deteriorating. The client tells the nurse

that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that:

• The DNR request should be discussed with the physician, who will write

the order

29. A man who is visiting his wife in a long-term care facility for people with

Alzheimer’s disease collapses and is transported to a hospital. The client remains

unconscious, and testing reveals that he has cancer that has metastasized to bone,

brain, and liver. The nursing staff at the wife’s care facility report to the hospital

physician that the client has no other family members and that his wife is mentally

incompetent. What information regarding do-not-resuscitate (DNR) orders does the

nurse remember?

• That a DNR order may be written by a client's physician

30. A client admitted to the hospital has a do-not-resuscitate (DNR) order in his

medical record. The nurse understands that:

• The DNR order requires frequent review as specified by state or agency

policy

31. A registered nurse (RN) is planning client assignments for the day. Which of the

following clients should the RN assign to the nursing assistant?

• A client who needs frequent ambulation with a walker

32. A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing

assistant on the nursing team is planning client assignments for the day. Which of the

following clients should the RN assign to the LPN?

• A client receiving oxygen who requires frequent pulse oximetry monitoring

and respiratory treatments

33. A registered nurse (RN) in charge of a long-term care facility who is working with

a nursing assistant on the night shift prepares to take her break. To ensure client safety

during her break, which of the following actions should the nurse take? Select all that

apply.

• Conducting client rounds before taking the break

• Taking the break in the staff lounge located on the nursing unit

34. A nurse is providing a change-of-shift report on his assigned clients, using an

audiotape. Which of the following pieces of information should the nurse include in the

report about each assigned client? Select all that apply.

• Client needs and priorities of care

• Current diagnosis and any secondary diagnoses

• Results of laboratory studies conducted that day

• Client response to treatments implemented that day

35. A nurse working the 7 am to 3 pm shift is reviewing the records of her assigned

clients. Which client should the nurse assess first?

• A client scheduled for hemodialysis at 10 am

36. A nurse has delegated several nursing tasks to staff members. The nurse’s

primary responsibility after delegation of the tasks is:

• Following up with each staff member regarding the performance of the

task and the outcomes related to implementation of the task.

37. A case manager is reviewing progress notes in a client s medical record. Which

notation indicates the need for follow-up?

• Client 2

Heart Failure

Crackles were heard in the lower lung lobes bilaterally on auscultation.

38. The nurse reviewing a client s record sees that the following medications are

prescribed. Which medication should the nurse plan to administer first?

• Levothyroxine (Synthroid) 137mg orally

39. A nurse manager has announced a change to computerized documentation of

nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is

not taking an active part in facilitating implementation of the new procedure. Which of

the following strategies would be the best approach to dealing with the conflict?

• Confronting the LPN and encouraging him to express his feelings

regarding the change

40. A registered nurse (RN) is planning client assignments for the day. Which clients

should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select

all that apply.

• A client who requires transport to the radiology department in a wheelchair

• A client with a Foley catheter for whom a 24-hour urine collection is in

progress

41. A registered nurse (RN) is planning assignments for five clients on the nursing

unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which

clients should the nurse assign to the LPN? Select all that apply.

• A client with a colostomy who requires reinforcement regarding the

procedure for irrigation

• A client with diabetes mellitus who requires the administration of regular

insulin in accordance with a sliding dosage scale every 4 hours

42. A registered nurse (RN) has received the assignment for the day shift. Once the

RN has made initial rounds and checked all of the assigned clients, which client will she

plan to care for first?

• A client who is scheduled for surgery at 1 pm

43. A case manager is reviewing the records of the clients in the nursing unit. Which

note(s) in a client s record indicate an unexpected outcome and the need for follow-up?

Select all that apply.

• A client with a central venous catheter has a temperature of 100.6° F.

44. A case manager is serving on a community task force on violence in schools.

The members of the task force are planning to develop interventions to help prevent

violence. According to the nursing process, the first activity that the nurse would

suggest to the task force is:

• Conducting a community survey to assess community perceptions regarding

school violence

45. A nurse planning care for her assigned clients understands that the purpose of

the hospital’s standards of care is to:

• Provide direction for the practice of nursing

46. A registered nurse (RN) is supervising a nursing assistant ambulating a client

with right-sided weakness. The RN would conclude that the nursing assistant is

performing the procedure incorrectly after observing that the nursing assistant:

• Stands behind the client

47. A registered nurse (RN) is watching as a new licensed practical nurse (LPN)

administer an intramuscular (IM) injection in a client s deltoid muscle. The RN

determines that the LPN is performing the procedure correctly if the LPN:

• Administers the injection 2 inches below the acromion process

48. A graduate nurse hired to work in a medical unit of a hospital is attending an

orientation session. The nurse educator, discussing care maps, asks the graduate

nurse whether she understands how a care map is used. Which response indicates

understanding?

• "The care map outlines the day-to-day expected outcomes of care and the

outcomes anticipated at discharge."

49. The nurse is preparing client assignments for the day. Which client should the

nurse assign to a nursing assistant?

• An unconscious client who requires oral care

50. A nurse manager tells the nursing staff that they will need to comply with the

mandatory overtime policy that the hospital has implemented. Later that day, the nurse

manager overhears a nurse complaining about the policy and telling other nurses that

she will not work the overtime if she has made other plans after her regular shift. What

is the best approach for the nurse manager to use in dealing with the conflict?

• Confronting the nurse regarding her behavior regarding the overtime

policy

51. A nurse manager is planning client assignments for the day. Which of the

following clients should the nurse assign to the nursing assistant (unlicensed assistive

personnel)?

• A client with renal calculi whose urine must be strained

52. A registered nurse (RN) must determine how best to assign co-workers (another

RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which

of the following is the best assignment?

• The RN is assigned to care for a woman with newly diagnosed leukemia

who has a newborn at home.

53. A client who had a stroke has left-side weakness and is having difficulty holding

utensils while eating. To which of these services does the nurse suggest a referral?

• Occupational therapy

54. A case manager is reviewing notations made in clients’ records. Which note

indicates an unexpected outcome and the need for immediate follow-up?

• A client exhibits signs of increased intracranial pressure after a

craniotomy.

55. A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard

time drawing the insulin into a syringe because he has difficulty seeing the markings on

the syringe. To which of the following services does the nurse suggest a referral?

• Home care

56. A nurse is planning client assignments for the day. Which of the following

assignments is the least appropriate for the nursing assistant?

• Assisting a client with dysphagia in eating

57. A nurse is assigned to care for four clients. Which client should the nurse assess

first?

• A client with a tracheostomy who is receiving humidified oxygen by way of

a tracheostomy mask

58. A nurse is planning the client assignments for the shift. Which client should the

nurse assign to the nursing assistant?

• A client with diarrhea on whom contact precautions have been imposed

59. A nurse is assisting a new nursing graduate with organizational skills in delivering

client care. The nurse determines that the new nursing graduate needs assistance with

time management if he:

• Documents task completion and client information at the end of the day

60. A new nurse employed at a community hospital is reading the organization’s

mission statement. The new nurse understands that this statement:

• Outlines what the organization plans to accomplish

61. A nurse, newly employed by a home health agency, is told that the organization’s

decision-making process is centralized. The nurse determines that this means that the

authority to make decisions is vested in:

• A few individuals, such as the board of directors

62. A nurse employed in a community hospital as a nurse manager understands that

in this position, the term authority most appropriately refers to:

• The official power to see that an organizational decision is enforced

63. A nursing instructor asks a nursing student to describe accountability. Which

statement(s) by the student indicate(s) an accurate description of accountability? Select

all that apply.

• "You are responsible for your own actions."

• "It carries legal implications for task performance."

• "You must answer for the care that you ask others to complete."

• "It refers to the process of answering or being responsible for what

occurs."

64. A registered nurse is in charge of the emergency department (ED) during the

night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has

never cared for anyone who has been raped. To determine the necessary actions in

regard to this client’s injury, the nurse should:

• Check the unit policy for the protocol for the care of clients who have been

sexually assaulted

65. A nurse educator describes the standards of care formulated by the American

Nurses Association to a group of new nursing graduates hired by the hospital. Which of

the following options are accurate descriptions of these standards of care? Select all

that apply.

• Define professional practice

• Have some similarity to policies and procedures

• Are authoritative statements that describe a common or acceptable level

of client care or performance

66. In which situation is the nurse upholding the ethical principle of fidelity?

• Contacting the physician about the client's request to incorporate

complementary therapies for pain into the treatment plan

67. Which of the following situations is an example of the use of evidence-based

practice in the delivery of client care?

• Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing

into a plastic-lined waste receptacle before pouring the solution into a

sterile basin

68. A nurse is preparing for the admission of a client with pulmonary tuberculosis.

Which of the following actions reflects the use of evidence-based practice in the care of

the client?

• Keeping the door to the client's room closed

69. A nurse manager asks a nurse to work overtime because of a short-staffing

problem. The nurse has made plans to do her Christmas shopping after work and does

not want to work overtime. What is the most assertive response by the nurse to her

nurse manager?

• "I have plans after work and will not be able to work overtime."

70. A nurse manager arrives at work and is immediately faced with several activities

that require his attention. Which activity will the nurse manager attend to first?

• Client assignments for the day

71. A nurse who has been employed in a hospital for 8 weeks is consistently taking

extended lunch breaks. The nurse’s behavior has caused problems with client care

during lunch hours. What is the appropriate way for the nurse manager to deal with this

situation?

• Confronting the nurse to discuss the behavior and initiate problem-solving

measures

72. A physician repeatedly asks a nurse to write his verbal prescriptions in his clients

charts after he makes his rounds. The nurse is uncomfortable with writing the

prescriptions and explains this to the physician, but the physician tells the nurse that

she will be reported if she does not write the prescriptions. How should the nurse

manage this conflict?

• Discussing the situation with the nurse manager

73. A nurse manager notes that an employee is constantly calling in sick. Which

action should the nurse manager take initially to handle this problem?

• Reminding the employee of the employment standards of the agency

74. A nursing staff member approaches a nurse manager and announces that

another nurse is not using alcohol swabs to clean the intravenous port when

administering intravenous push medications. What is the appropriate way for the nurse

manager to handle this situation?

• Reviewing the skills checklist of the nurse who is not using aseptic

technique to determine whether the nurse has ever performed this skill

and had her technique validated

75. A nurse is preparing the client assignments for the day. One of the registered

nurses on the team has just learned that she is pregnant. Which client does the nurse

refrain from assigning to the pregnant team member?

• A client with a solid sealed cervical radiation implant

76. A client has signed the informed consent for mastectomy of the left breast. On

the morning of the surgical procedure, the client asks the nurse several questions about

the procedure that make it obvious that she has does not have an adequate

comprehension of the procedure. What is the most appropriate response by the nurse?

• Contacting the surgeon and requesting that she visit the client to answer

her questions

77. A nurse sees another nurse changing an intravenous (IV) solution because the

wrong solution is infusing into the client. The nurse who changed the IV solution does

not report the error. What should the nurse who observed the error do first?

• Ask the nurse whether she intends to report the error

78. A nurse leader in a medical-surgical unit overhears the nursing staff openly

discussing a client and stating that the client is uncooperative and a real pain to care

for. The nurse leader would most appropriately manage this issue by:

• Discouraging the judgmental comments

79. A client receives cefazolin sodium (Ancef) by way of the intravenous route.

During the infusion, the client begins exhibiting signs of an allergic reaction. The client

states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a

red rash on the arms, chest, and back. The nurse immediately discontinues the

medication, further assesses the client, contacts the physician, and begins to document

the reaction in an incident report. The nurse most accurately documents which of the

following?

• During an infusion of cefazolin sodium, the client complained that his skin

was itchy. The client's skin was warm and flushed, with a red rash on the

arms, chest, and back. The physician was notified.

80. A nurse who works in a medical care unit is told that she must float to the

intensive care unit because of a short-staffing problem on that unit. The nurse reports to

the unit and is assigned to three clients. The nurse is angry with the assignment

because she believes that the assignment is more difficult than the assignment

delegated to other nurses on the unit and because the intensive care unit nurses are

each assigned only one client. The nurse should most appropriately:

• Ask the nurse manager of the intensive care unit to discuss the

assignment

81. A client with a left arm fracture complains of severe diffuse pain that is unrelieved

by pain medication. On further assessment, the nurse notes that the client experiences

increased pain during passive motion, compared with active motion, of the left arm. On

the basis of these assessment findings, which action should the nurse take first?

• Contacting the physician

82. A client with terminal cancer is receiving a continuous intravenous infusion of

morphine sulfate. On assessment of the client, what does the nurse check first?

• Respiratory status

83. A nurse is preparing to administer medications to a client by way of a nasogastric

(NG) tube. Before administering the medication, the nurse must first:

• Check the placement of the tube

84. An emergency department nurse is performing an assessment of a client who

has sustained circumferential burns of both legs. What should the nurse assess first?

• Peripheral pulses

85. A nurse employed at a hospital is asked by a nurse manager to review the

organizational chart. The nurse reviews the chart so that he will:

• Be familiar with the organization's line of authority

86. A physician asks the nurse who is caring for a client with a new colostomy to ask

the hospital’s stoma nurse to visit the client and assist the client with care of the

colostomy. The nurse initiates the consultation, understanding that the stoma nurse will

be able to influence the client because of his:

• Expert power

87. A nurse manager discusses staff empowerment with the nursing team. The nurse

manager explains that staff empowerment:

• Fosters the growth of others so that they are less dependent on the leader

88. A client who has undergone a total hip replacement is told that she will need to

go to an extended care rehabilitation facility for therapy before going home. Which

member of the healthcare team does the nurse ask to plan the discharge and transition

from the hospital to the rehabilitation facility?

• Social worker

89. The nurse notes that a physician has documented the following prescription in a

client s record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?

• Contacting the physician

90. A 17-year-old client arrives at the clinic and asks to be examined because she

believes that she has contracted a sexually transmitted infection. In regard to informed

consent, the nurse tells the client that:

• She will need to sign an informed consent form

91. An 18-year-old client is brought to the emergency department (ED) by

emergency medical services after sustaining life-threatening injuries in an automobile

accident. The client is unconscious and requires an emergency splenectomy. A nurse in

the ED assists in quickly preparing the client for surgery and tries to contact the client’s

parents but is unsuccessful. In regard to informed consent for the surgery:

• The nurse understands that consent is not needed

92. A nurse is supervising a new nursing graduate in various procedures. Which of

the following actions by the new nursing graduate constitutes a negligent act?

• Using clean gloves to change a gastrostomy tube dressing

93. A nurse is reviewing the notes written by a nurse on a previous shift. Which note

in the client’s record reflects the correct use of guidelines for documentation?

• The client's intake was 360 mL

94. A nurse is reading the nurse practice act for the state in which she is employed.

The nurse uses the information in this act to:

• Be aware of the role of the professional nurse

95. A client whose right leg is in skeletal traction complains of pain in the leg. Which

action should the nurse take first?

• Realigning the client

96. A nurse is performing suctioning through an adult client’s tracheostomy tube. The

nurse notes that the client’s oxygen saturation is 89% and terminates the procedure.

Which action would the nurse take next?

• Oxygenating the client with 100% oxygen

97. A nurse is assisting a client with a closed chest tube drainage system in bathing.

As the nurse is turning the client onto his side, the chest tube is disconnected. What

should the nurse do first?

• Submerge the end of the chest tube in a bottle of sterile water