1020 Practice Exam 2 PDF

Practice NCLEX Style MCQs for 1020 Exam 2: **Documentation:** 1. **Question**: A nurse is preparing to document a patient's pain level, which the patient rates as 10 out of 10. What is the nurse\'s priority action? - A\) Document the pain level in the patient\'s chart. - **B...

Practice NCLEX Style MCQs for 1020 Exam 2: **Documentation:** 1. **Question**: A nurse is preparing to document a patient's pain level, which the patient rates as 10 out of 10. What is the nurse\'s priority action? - A\) Document the pain level in the patient\'s chart. - **B) Notify the healthcare provider immediately.** - C\) Administer pain medication as ordered. - D\) Discuss pain management options with the patient. **Correct Answer**: B) Notify the healthcare provider immediately. **Rationale**: A pain level of 10 indicates severe discomfort and requires immediate intervention. 2. **Question**: When documenting in a patient's electronic health record (EHR), which of the following practices should a nurse follow to ensure accuracy? - A\) Documenting information at the end of the shift. - B\) Using vague terms to describe patient behaviors. - **C) Beginning each note with the date, time, and signature.** - D\) Charting for another nurse if they are unavailable. **Correct Answer**: C) Beginning each note with the date, time, and signature. **Rationale**: Proper documentation includes the date, time, and signature to ensure accountability and clarity. 3. **Question**: According to HIPAA regulations, what is a nurse required to do to maintain patient confidentiality? - A\) Share patient information freely with other healthcare workers. - **B) Limit access to patient records to only those involved in the patient\'s care.** - C\) Discuss patient information in public areas. - D\) Keep passwords visible for easy access. **Correct Answer**: B) Limit access to patient records to only those involved in the patient\'s care. **Rationale**: HIPAA mandates that patient information should be disclosed only to authorized personnel involved in the patient\'s care. 4. **Question**: Which statement about the legal guidelines for documentation is correct? - **A) \"If it's not documented, it was not done.\"** - B\) \"You can use personal opinions to describe patient behavior.\" - C\) \"Charting can be done by anyone in the healthcare team.\" - D\) \"It is acceptable to leave blank spaces in nursing notes.\" **Correct Answer**: A) \"If it's not documented, it was not done.\" **Rationale**: Accurate and complete documentation is crucial; failure to document can imply that care was not provided. 5. **Question**: A nurse is documenting a patient's statement regarding their health condition. How should the nurse accurately record the patient's words? - A\) Paraphrase the statement for clarity. - **B) Record the statement word-for-word in quotation marks.** - C\) Summarize the patient's feelings about their condition. - D\) Use medical terminology to describe the patient's comments. **Correct Answer**: B) Record the statement word-for-word in quotation marks. **Rationale**: Direct quotes should be documented verbatim to preserve the patient\'s exact words and intent. **Ethical/Legal:** 1. **Question**: A nurse enters a patient's room to find the patient unresponsive. The nurse does not perform CPR because the patient has a Do Not Resuscitate (DNR) order. Which ethical principle is the nurse upholding? - A\) Autonomy - B\) Beneficence - C\) Nonmaleficence - D\) Fidelity **Correct Answer**: A) Autonomy\ **Rationale**: Autonomy refers to respecting the patient\'s right to make their own decisions regarding their care, which includes honoring a DNR order. 2. **Question**: A nurse threatens to withhold pain medication if a patient does not stop yelling. This is an example of: - A\) Assault - B\) Battery - C\) Negligence - D\) Defamation **Correct Answer**: A) Assault\ **Rationale**: Assault refers to a threat or attempt to make bodily contact with another person without their consent, particularly when the individual fears harm. 3. **Question**: A nurse accidentally administers the wrong dose of medication, and the patient experiences a negative reaction. Which legal concept does this situation represent? - A\) Assault - B\) Battery - C\) Malpractice - D\) Defamation **Correct Answer**: C) Malpractice\ **Rationale**: Malpractice occurs when a healthcare professional fails to provide care that meets the accepted standards, resulting in harm to the patient. 4. **Question**: According to the American Nurses Association (ANA) Code of Ethics, which of the following actions demonstrates advocacy for the patient? - A\) Ignoring a patient's refusal of care because it is necessary. - B\) Supporting a patient's decision to refuse surgery despite the healthcare team's recommendations. - C\) Documenting incomplete information to avoid legal issues. - D\) Performing a procedure the patient does not want because it is best for their health. **Correct Answer**: B) Supporting a patient's decision to refuse surgery despite the healthcare team's recommendations\ **Rationale**: Advocacy involves supporting the patient's values and decisions, even when they may conflict with the healthcare team's recommendations. 5. **Question**: Which of the following is a legal requirement for a nurse who suspects elder abuse? - A\) Report the suspicion only if there is evidence. - B\) Report the suspicion immediately to the authorities. - C\) Wait for the patient\'s family to report the incident. - D\) Notify the physician but not law enforcement. **Correct Answer**: B) Report the suspicion immediately to the authorities\ **Rationale**: Nurses are mandated reporters, which means they are legally required to report any suspected abuse to the appropriate authorities. 6. **Question**: A nurse charts that a patient was "uncooperative and rude" during a dressing change. What documentation error does this represent? - A\) Failing to use military time. - B\) Not documenting the intervention. - C\) Using personal opinions. - D\) Not signing the documentation. **Correct Answer**: C) Using personal opinions\ **Rationale**: Documentation should be objective and free from personal opinions. The nurse should document only observable facts. **Delegation:** 1. **Question**: A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN). Which of the following tasks is the RN permitted to delegate? - A\) Administering IV push medications - B\) Teaching a patient about managing their diabetes - C\) Administering an oral medication to a stable patient - D\) Performing a comprehensive health assessment **Correct Answer**: C) Administering an oral medication to a stable patient\ **Rationale**: LPNs can administer oral medications to stable patients, but tasks such as IV push medications and patient teaching remain within the scope of RNs. 2. **Question**: Which of the following is a component of effective delegation according to the Five Rights of Delegation? - A\) Delegating the task to a nurse who is too busy - B\) Assigning an unlicensed assistive personnel (UAP) to assess a patient's condition - C\) Ensuring the person being delegated the task understands the expected outcome - D\) Allowing the UAP to work independently without supervision **Correct Answer**: C) Ensuring the person being delegated the task understands the expected outcome\ **Rationale**: The Five Rights of Delegation include giving the right direction and communication to ensure the delegate understands the expected outcome. 3. **Question**: An RN is working with a UAP on a busy unit. Which of the following tasks can the RN delegate to the UAP? - A\) Changing a sterile wound dressing - B\) Feeding a stable patient who requires assistance - C\) Administering a pain medication - D\) Evaluating the effectiveness of a care plan **Correct Answer**: B) Feeding a stable patient who requires assistance\ **Rationale**: The RN can delegate non-invasive tasks such as feeding, while sterile procedures and medication administration must be done by licensed personnel. 4. **Question**: The RN is hesitant to delegate tasks due to insecurity and fear of liability. Which of the following would help the RN overcome delegation insecurity? - A\) Delegating only to experienced staff members - B\) Providing clear directions and setting specific time frames for task completion - C\) Delegating complex tasks to unlicensed assistive personnel - D\) Avoiding delegation and completing all tasks independently **Correct Answer**: B) Providing clear directions and setting specific time frames for task completion\ **Rationale**: To overcome delegation insecurity, the RN should ensure clear communication and appropriate supervision, thus maintaining accountability. 5. **Question**: When delegating tasks, which patient should the RN assign to the unlicensed assistive personnel (UAP)? - A\) A patient with unstable vital signs requiring frequent monitoring - B\) A post-operative patient needing a blood transfusion - C\) A patient needing assistance with bathing and hygiene - D\) A patient requiring education on newly prescribed medications **Correct Answer**: C) A patient needing assistance with bathing and hygiene\ **Rationale**: The UAP can perform basic care tasks, such as bathing and hygiene, while tasks involving monitoring and education are outside their scope of practice. 6. **Question**: The RN is responsible for delegating tasks to a UAP. According to the scope of practice, which of the following statements is true regarding delegation? - A\) The RN can delegate tasks such as assessment and health counseling. - B\) The UAP can assess a patient's pain level and report directly to the physician. - C\) The RN must provide feedback on the completion of tasks delegated to the UAP. - D\) The UAP can administer medications and perform invasive procedures under RN supervision. **Correct Answer**: C) The RN must provide feedback on the completion of tasks delegated to the UAP\ **Rationale**: The RN must provide feedback and maintain accountability for the outcome of the tasks delegated to the UAP, but cannot delegate tasks like assessment or invasive procedures. **Evaluation:** 1. **Question**: A nurse is evaluating a patient\'s response to an intervention. Which of the following is the best action for the nurse to take when a goal has not been fully achieved? - A\) Discontinue the plan of care. - B\) Document the goal as achieved and move on to the next issue. - C\) Modify the plan of care to better address the patient\'s needs. - D\) Ignore the unmet goal and focus on other aspects of care. **Correct Answer**: C) Modify the plan of care to better address the patient\'s needs.\ **Rationale**: When a goal is unmet or partially achieved, the nurse should modify the care plan to improve patient outcomes. 2. **Question**: A nurse is assessing a patient's response to pain medication 45 minutes after administration. Which phase of the nursing process is the nurse engaging in? - A\) Assessment - B\) Implementation - C\) Evaluation - D\) Planning **Correct Answer**: C) Evaluation\ **Rationale**: Evaluation involves assessing the patient\'s response to interventions and determining if the desired outcomes have been achieved. 3. **Question**: When evaluating patient outcomes, which of the following criteria is most important for the nurse to use? - A\) Patient's emotional responses to care - B\) Measurable, criterion-based standards - C\) Family's perception of care provided - D\) Nurse's personal judgment about care effectiveness **Correct Answer**: B) Measurable, criterion-based standards\ **Rationale**: The use of measurable, criterion-based standards ensures an objective evaluation of the patient\'s outcomes. 4. **Question**: After revising a patient's care plan, the nurse determines that additional time is needed for the patient to meet the revised goals. Which step should the nurse take next? - A\) Discharge the patient and follow up later. - B\) Set a new future date to evaluate the patient\'s progress toward the goals. - C\) Continue with the original care plan without changes. - D\) Assign the task to another healthcare team member. **Correct Answer**: B) Set a new future date to evaluate the patient\'s progress toward the goals.\ **Rationale**: If more time is required to meet the goal, the nurse should set a new date to evaluate the patient's progress toward achieving the revised goals. 5. **Question**: During evaluation, the nurse collaborates with the patient and family to determine if the patient has met the set goals. Which of the following is a key benefit of this collaboration? - A\) It allows the nurse to modify the plan of care without the patient\'s input. - B\) It ensures the patient\'s goals are met according to organizational standards. - C\) It provides opportunities to assess the patient\'s preferences and adjust care accordingly. - D\) It gives the family full control of the patient\'s care decisions. **Correct Answer**: C) It provides opportunities to assess the patient\'s preferences and adjust care accordingly.\ **Rationale**: Collaborating with the patient and family allows the nurse to incorporate the patient's preferences and values into the care plan, improving care effectiveness. 6. **Question**: A nurse is reviewing a patient's progress and finds that the patient has not demonstrated the ability to change a wound dressing due to severe arthritis. What is the nurse\'s best course of action? - A\) Continue encouraging the patient to practice. - B\) Modify the plan of care to include a referral for home health services. - C\) Discharge the patient and instruct them to seek outside help. - D\) Reassess the patient in one week to see if their arthritis improves. **Correct Answer**: B) Modify the plan of care to include a referral for home health services.\ **Rationale**: Since the patient is unable to perform the task due to a physical limitation, the nurse should revise the plan to include alternative resources, such as home health services. **Planning:** 1. **Question**: A nurse is setting goals for a patient who is recovering from surgery. Which of the following characteristics must these goals have to be effective? - A\) They must be long-term and vague. - B\) They must be patient-centered, specific, and time-limited. - C\) They should focus primarily on the nurse's role in care. - D\) They must be dependent on physician-initiated interventions. **Correct Answer**: B) They must be patient-centered, specific, and time-limited.\ **Rationale**: Goals should be patient-centered, specific, measurable, and time-limited to provide clear direction for interventions and to facilitate evaluation. 2. **Question**: The nurse is setting a short-term goal for a patient. Which of the following is the best example of a short-term goal? - A\) The patient will return to work within 6 months. - B\) The patient will demonstrate proper wound care before discharge. - C\) The patient will lose 10 pounds within the next 6 months. - D\) The patient will stop smoking within the next year. **Correct Answer**: B) The patient will demonstrate proper wound care before discharge.\ **Rationale**: Short-term goals are typically achievable within hours to a week, such as demonstrating proper wound care before discharge. 3. **Question**: Which of the following is an example of a SMART goal for a patient with hypertension? - A\) The patient will understand the importance of medication. - B\) The patient's blood pressure will decrease to 120/80 mmHg within two weeks. - C\) The nurse will educate the patient on blood pressure management. - D\) The patient will express understanding of the need for a low-sodium diet. **Correct Answer**: B) The patient's blood pressure will decrease to 120/80 mmHg within two weeks.\ **Rationale**: A SMART goal is specific, measurable, attainable, relevant, and time-limited. The goal regarding blood pressure is measurable and time-bound. 4. **Question**: A nurse is planning interventions for a patient with diabetes. Which of the following is an example of a nurse-initiated (independent) intervention? - A\) Administering insulin as prescribed. - B\) Instructing the patient on how to perform glucose monitoring at home. - C\) Scheduling an appointment with a dietician. - D\) Ordering a hemoglobin A1c test. **Correct Answer**: B) Instructing the patient on how to perform glucose monitoring at home.\ **Rationale**: Nurse-initiated interventions are those that the nurse can perform independently, such as teaching the patient how to monitor glucose. 5. **Question**: When prioritizing a patient's nursing diagnoses, which of the following should the nurse address first? - A\) The patient's anxiety about the upcoming surgery. - B\) The patient's risk for impaired skin integrity. - C\) The patient's airway obstruction. - D\) The patient's knowledge deficit about medication side effects. **Correct Answer**: C) The patient's airway obstruction.\ **Rationale**: According to Maslow's hierarchy of needs, physiological issues such as airway obstruction take priority over other concerns like anxiety or knowledge deficits. 6. **Question**: The nurse is collaborating with other healthcare professionals to develop a discharge plan for a patient. Which of the following is an essential component of discharge planning? - A\) Establishing long-term goals that the patient can work toward independently. - B\) Ensuring the patient will not need follow-up care after discharge. - C\) Developing a plan that begins at the time of admission. - D\) Waiting until the day of discharge to begin planning. **Correct Answer**: C) Developing a plan that begins at the time of admission.\ **Rationale**: Discharge planning should begin at the time of admission to ensure continuity of care and adequate preparation for the patient's transition. **Implementation:** 1. **Question**: A nurse is implementing a care plan for a patient. Which of the following is an example of a direct care intervention? - A\) Arranging for physical therapy. - B\) Administering a medication to relieve pain. - C\) Reviewing the patient's lab results. - D\) Documenting the patient's response to treatment. **Correct Answer**: B) Administering a medication to relieve pain.\ **Rationale**: Direct care interventions involve interactions with the patient, such as administering medications. 2. **Question**: When performing nursing interventions, which of the following is an example of a nurse-initiated (independent) intervention? - A\) Starting an IV infusion based on physician orders. - B\) Instructing a patient on relaxation techniques to reduce anxiety. - C\) Administering a prescribed pain medication. - D\) Changing a patient's wound dressing as ordered by a physician. **Correct Answer**: B) Instructing a patient on relaxation techniques to reduce anxiety.\ **Rationale**: Nurse-initiated interventions are those that nurses perform independently, such as patient education. 3. **Question**: During the implementation phase of the nursing process, the nurse is primarily focused on: - A\) Developing goals for the patient's care plan. - B\) Evaluating the outcomes of patient interventions. - C\) Carrying out the interventions to meet patient goals. - D\) Diagnosing the patient's health condition. **Correct Answer**: C) Carrying out the interventions to meet patient goals.\ **Rationale**: The implementation phase involves taking action to carry out the interventions that were planned to achieve patient outcomes. 4. **Question**: The nurse is about to perform an indirect intervention. Which of the following is an example of an indirect intervention? - A\) Educating the patient about diabetes management. - B\) Preparing a sterile field for a procedure. - C\) Calling the physician to report a change in the patient's condition. - D\) Assisting the patient with ambulation. **Correct Answer**: C) Calling the physician to report a change in the patient's condition.\ **Rationale**: Indirect interventions are those performed away from the patient but on behalf of the patient, such as reporting to the physician. 5. **Question**: A nurse is working with a patient to achieve the care plan\'s outcomes. Which of the following must the nurse do during the implementation of care? - A\) Wait until the patient is ready to take all actions independently. - B\) Involve the patient and family in carrying out the recommended care and treatments. - C\) Focus only on the nurse's role in achieving patient goals. - D\) Document patient adherence after discharge only. **Correct Answer**: B) Involve the patient and family in carrying out the recommended care and treatments.\ **Rationale**: Involving the patient and family in care is critical for ensuring adherence to the care plan and achieving patient goals. 6. **Question**: Which of the following should the nurse consider while implementing interventions for a patient? - A\) Focus only on the intervention itself without considering potential complications. - B\) Reassess the patient's condition before, during, and after the intervention. - C\) Avoid making any changes to the care plan once it has been initiated. - D\) Implement the intervention without explaining it to the patient. **Correct Answer**: B) Reassess the patient's condition before, during, and after the intervention.\ **Rationale**: Continuous reassessment during the implementation of interventions ensures the patient's response is monitored and adjustments can be made if necessary. **Documentation Do's and Don'ts:** 1. **Question**: A nurse is documenting a patient's condition. Which of the following should the nurse include in the patient's chart? - A\) The nurse's personal opinions about the patient's behavior. - B\) A description of the patient as a \"complainer.\" - C\) The patient's actual words in quotation marks. - D\) A summary of another nurse\'s assessment. **Correct Answer**: C) The patient's actual words in quotation marks.\ **Rationale**: Documenting the patient's actual words using quotation marks ensures accuracy and objectivity. Personal opinions and assumptions should never be recorded. 2. **Question**: Which action by the nurse violates documentation standards? - A\) Correcting a documentation error according to agency policy. - B\) Charting patient care immediately after providing the care. - C\) Documenting in advance before an event occurs. - D\) Including the patient's response to interventions in the chart. **Correct Answer**: C) Documenting in advance before an event occurs.\ **Rationale**: It is never appropriate to document care or actions that have not yet occurred, as this compromises the accuracy and integrity of the patient's medical record. 3. **Question**: A nurse is charting in a patient's medical record. Which of the following is an appropriate documentation practice? - A\) Using vague terms such as "appears" or "seems." - B\) Using the patient's name instead of referring to them as "patient." - C\) Altering the record at the request of a physician. - D\) Recording only the nurse's perspective of the care provided. **Correct Answer**: B) Using the patient's name instead of referring to them as "patient."\ **Rationale**: The patient's name should be used to avoid confusion. Vague terms and alterations of the record are not permitted, and documentation should be objective and accurate. 4. **Question**: A physician asks a nurse to change a patient's chart entry from yesterday. What is the best response by the nurse? - A\) Comply with the physician's request. - B\) Decline and report the request to the nurse manager. - C\) Make the change but not inform anyone. - D\) Delete the previous entry and add the new information. **Correct Answer**: B) Decline and report the request to the nurse manager.\ **Rationale**: Nurses should not alter patient records at the request of others. Any requests to do so should be reported to the nurse manager or appropriate authority. 5. **Question**: A nurse realizes that an entry in the patient's chart is incorrect. What is the best action for the nurse to take? - A\) Erase the mistake and re-enter the correct information. - B\) Cross out the error, write \"error,\" and sign with initials and date. - C\) Ignore the error and leave it as it is. - D\) Delete the incorrect information from the electronic record. **Correct Answer**: B) Cross out the error, write \"error,\" and sign with initials and date.\ **Rationale**: When a charting error occurs, it should be corrected according to the agency's policy. Errors should not be erased or deleted. 6. **Question**: Which of the following actions is a **don't** in documentation practices? - A\) Charting changes in the patient's condition. - B\) Using specific factual descriptions in the chart. - C\) Charting for another nurse who is busy with another patient. - D\) Recording the patient's response to nursing interventions. **Correct Answer**: C) Charting for another nurse who is busy with another patient.\ **Rationale**: Nurses should only chart their own actions and assessments. Documenting for another nurse is inappropriate and could lead to inaccurate records.