NCLEX RN High-Yield Questions
Question 1 of 5.
The nurse is planning to complete the following assessments during the last half hour of the shift. Which of the following assessments has the highest priority and should be accomplished first?
A. A postpartum couplet with the infant who has had transient assignment (TTN) at birth and now has a respiratory rate of 60 breaths/minute.
B. A newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours.
C. A mother who had a cesarean section and is 6 hours post delivery with the baby in special care nursery; the mother has not yet seen her baby.
D. A couplet that delivered at 36 weeks' gestation: the 5 lb infant had initial blood glucose of 35 mg/dL and when taken to the room had a glucose of 46 mg/dL.
Explanation: The infant with transient tachypnea of the newborn (TTN) and a respiratory rate of 60 breaths/minute indicates potential respiratory distress, which is a life-threatening condition requiring immediate assessment.
Question 2 of 5.
Select the law that is accurately paired with its description in terms of client rights.
A. The Patient Self Determination Act: The client's right to choose the level of care
B. The Patient Self Determination Act: The clients' right to healthcare insurance coverage for mental health disorders
C. The Mental Health Parity Act: The privacy and security of technological psychiatric information
D. The Health Insurance Portability and Accountability Act (HIPAA): The privacy and security of technological medical information
Explanation: HIPAA ensures the privacy and security of technological medical information. The PSDA relates to advance directives, not choosing the level of care or mental health coverage . The Mental Health Parity Act addresses insurance coverage, not privacy .
Question 3 of 5.
You are the Nurse Manager for the trauma unit. Which of these staff comments or statements indicate the need for you to provide an educational activity relating to confidentiality and information security?
A. A computer in the hallway was left unattended and a client's medical record was visible to me.'
B. I just saw a nursing student looking at the medical record for a client that they are NOT caring for during this clinical experience.'
C. As I was walking past the nursing station, I saw a dietician reading the progress notes written by members of the laboratory department in addition to other dieticians' progress notes.'
D. I refused the nursing supervisor's request to share my electronic password for the new nurse on the unit.'
Explanation: Statements A, B, and C indicate breaches of confidentiality: an unattended computer with visible records , a student accessing unauthorized records , and a dietician accessing irrelevant notes . These require education on information security. Refusing to share a password is correct and does not indicate a need for education.
Question 4 of 5.
One of the roles of the registered nurse in terms of informed consent is to:
A. Serve as the witness to the client's signature on an informed consent.
B. Get and witness the client's signature on an informed consent.
C. Get and witness the durable power of attorney for health care decisions' signature on an informed consent.
D. None of the above
Explanation: The nurse's role in informed consent includes serving as a witness to the client's signature , confirming that the client signed voluntarily after being informed. The nurse does not obtain the consent or involve the durable power of attorney in signing .
Question 5 of 5.
The primary purpose of root cause analysis is to:
A. Discover a process flaw
B. Determine who erred
C. Discover environmental hazards
D. Determine basic client needs
Explanation: Root cause analysis aims to identify underlying process flaws that contributed to an adverse event to prevent recurrence, rather than focusing on individual blame .
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