Most of the questions that Iâ ve encountered on the actual test were about assessme

nt, delegation and prioritization. I would like to help everyone pass the NCLEX
by developing their analytical thinking but not to the extent of over analyzing
the questions.
The key to develop oneâ s analytical thinking is to constantly answer NCLEX type qu
estions. Try to answer these questions and see how well you are in answering ass
essment, delegation and prioritization types of questions.
PART 1
Situation 1:
A nurse recently started working in a hospital that employs unlicensed assistant
personnel (UAP). Which of the following are essential to effective delegation?
Select All that Apply
a) make frequent walking rounds to assess clients
b) give the UAP written instructions for assignments
c) delegate tasks based on the experience of the UAP
d) take frequent mini-reports from the UAP
e) explain unexpected outcomes of delegated tasks to the UAP
f) have the UAP repeat instructions
Situation 2:
A nurse is teaching a class regarding lead poisoning in children to student nurs
es. The nursing students learn to target which priority group of children for sc
reening?
a) those children with sickle cell anemia
b) those children who live in homes built in the 1970â ²s
c) adolescents living in the inner city
d) those children who live in low-income families
Situation 3:
A nurse is attending an In-service training class on delegation. The nurse learn
s that proper delegation can involve which of the following? Select all that app
ly
a) delegating responsibility
b) delegating nursing process
c) giving authority
d) delegating accountability
e) delegating tasks
f) giving orders
Situation 4:
When developing the plan of care for a client with suicidal ideation, which of t
he following would the nurse anticipate as the priority?
a)Hygiene
b)Safety
c)Self-esteem
d)Sleep
Situation 5:
A client in early labor is receiving oxytocin. When observing late decelerations
in the fetal heart rate, the nurse should first:
a) Administer oxygen
b) Place her on her left side
c) Check the blood pressure
d) Discontinue the oxytocin infusion
"Answers to
NCLEX Practice Test 1"
From: JobForNursing.Com
Situation 1
ANSWERS: A, B, C, D, E, F
RATIONALE: All these aspects are essential for effective delegation.

Situation 2
ANSWER: D
RATIONALE: Lead poisoning is common in old houses (built in 1950's), and in plac
es with unsanitary conditions including soil, dust, vehicles using leaded gas. T
hese factors are common among low-income families.

Situation 3
ANSWERS: A, C, and E
RATIONALE: Proper delegation involves delegating responsibility, giving authorit
y, and delegating tasks. Nursing process, accountability and giving orders are t
o be done by the RN, and NOT to be delegated.

Situation 4
ANSWER: B
RATIONALE: For client with suicidal ideation, CLIENT SAFETY is the PRIORITY. The
nurse protects the client from self-harm or self-destruction. Although self-est
eem, sleep and hygiene are common areas that require intervention for a client w
ith suicidal ideation, ensuring the clientâ s safety is the MOST IMMEDIATE and SERI
OUS CONCERN.

Situation 5
ANSWER: D
RATIONALE: The infusion should be STOPPED because it is placing the fetus in DAN
GER.
----------------------------------------------

Assessment/Delegation/Prioritization (Part 2)
So how did you do on the first 5 questions on delegation and prioritization? Hav
e you noticed the techniques that you have implemented in answering each questio
ns? By answering more questions using the techniques that you have learned, you
will get the correct answer.
As Iâ ve said, if you are unsure of the answer, try using the elimination technique
but you should understand the question first, right?
Now, I have prepared a new set of questions for you to answer. Try to answer eac
h questions and letâ s see how well you do. Make sure that this time you will answe
r each question in a maximum of 1 minute.
Situation 6: A nurse delegates administration of an enema to a nursing assistant
. The nurse should intervene if the nursing assistant:
a) advances the catheter 4 inches into the anal canal
b) positions the client on the right side with head slightly elevated
c) lubricates 4 to 5 inches of the catheter tip
d) hangs the enema bag 12 to 18 inches above the anus
Situation 7: The home care nurse has four phone calls to answer. Which phone cal
l should the home care nurse respond to first?
a) a client who received chemotherapy yesterday and is reporting nausea and vomi
ting
b) a client who was discharged two days ago with a urinary catheter after a tran
surethral prostactemomy and is reporting pink-tinged urine
c) a client with schizophrenia who says that the police has surrounded the house
d) the wife of a client with chronic heart disease who reports her husband is co
ughing frothy, white secretions and became confused during the night
Situation 8: A nurse is reviewing with a nursing assistant the care assignment f
or a client. Which of the following statements if made by the nurse regarding ca
re of a client with crutches is most appropriate?
a) the client needs to ambulate with crutches and a two-point gait
b) ambulate the client without weight bearing every 4 hours the length of the ha
ll and back
c) ask the client if she understands how to use a two-point gait, if not, please
explain it to the client
d) make sure the client does not bend the elbows when using the crutches
Situation 9: A nurse arrives on the scene of an apartment fire. Which of the fol
lowing clients does the nurse attend to first?
a) a 28-year old woman who has burns on the face and neck and reports difficulty
swallowing
b) a 48-year old male who has burns on both hands and reports severe pain
c) an 18-year old male who jumped from a second story window and is reporting se
vere arm pain
d) a 3-year old child who cannot find her parents and is reporting a headache
Situation 10: A female college student reports to the student health center very
distressed after waking up in a male studentâ s restroom and not remembering what
happened to the night before. The first action the nurse should take is:
a) obtain a rape kit
b) ask the client if she thinks she was raped
c) place the client in an examining room and leave her while she puts on a gown
d) provide a quiet, private area to use for initial assessment of the client
Situation 11: A nurse receives a 10-month old child with a fracture of the left
femur on the pediatric unit. Which action is important for the nurse to take fi
rst?
a) call for a social worker to meet with the family
b) speak with the parents about how the fracture occurred
c) administer pain medication
d) check the childâ s blood pressure, then pulse, respiration, and temperature
Situation 12: A nurse on the cardiac unit is caring for four clients and is prep
aring to do initial rounds. Which client should the nurse assess first?
a) a client scheduled for cardiac ultrasound this morning
b) a client with syncope being discharged today
c) a client with a diabetic foot ulcer that needs a dressing change
d) a client with chronic bronchitis on nasal oxygen
Situation 13: A nurse is working on the night shift with a nursing assistant. Th
e nursing assistant comes to the nurse stating that the other nurse working on t
he unit is not assessing a client with abdominal pain despite multiple requests.
Which of the following actions by the nurse is best?
a) ask the other nurse if she needs any help
b) assess the client, and let the other nurse know what should be done
c) ask the client if he is satisfied with his care
d) contact the nursing supervisor to address the situation
Situation 14: A nurse enters a room and finds lying face down on the floor, blee
ding from a gash in the head. Which action should the nurse perform first?
a) turn the client face up to assess
b) push the call button for help
c) determine level of consciousness
d) go out in the hall to get the nursing assistant to stay with the client while
the nurse calls the physician
Situation 15: The nurse is reviewing immunizations with the caregiver of a 72 ye
ar old client with a history of cerebral vascular disease. The caregiver learns
that which immunization is a priority for the client?
a) hepatitis A vaccine
b) lyme disease vaccine
c) hepatitis B vaccine
d) pneumococccal vaccine
Answers to
NCLEX Practice Test 1.1
6. ANSWER: B
RATIONALE: The appropriate position of the client during enema administration is
left lateral position to facilitate flow of solution by gravity. Therefore, the
action of the CNA in choices no. 4 needs to be corrected.

7. ANSWER: D
RATIONALE: The situation indicates development of pulmonary edema in the client
with chronic heart disease. This serious complication is a priority.
8. ANSWER: B
RATIONALE: When delegating task, the nurse should provide complete, concrete and
specific directions.
9. ANSWER: A
RATIONALE: Burns on the face and neck involves obstruction of airway due to smok
e inhalation. Airway is a priority.
10. ANSWER: D
RATIONALE: This situation indicates possible rape of the client. Providing psych
osocial support and ensuring privacy for initial assessment of the client is mos
t appropriate initial action.
11. ANSWER: B
RATIONALE: In case of injury especially among children, it is very important tha
t the nurse should first assess possible abuse. Abuse is one of the reporting re
sponsibilities of the nurse.
12. ANSWER: D
RATIONALE: A client with problem of the airway should be attended first. ABC is
a priority.
13. ANSWER: D
RATIONALE: the RN should use proper channel of communication. The nursing superv
isor is responsible for the actions of the different members of the nursing team
.
14. ANSWER: C
RATIONALE: assessing level of consciousness is the first action when dealing wit
h a situation where the client might have had a fall or when preparing to do CPR
(cardio-pulmonary resuscitation).
15. ANSWER: D
RATIONALE: Pneumococcal vaccine is a priority immunization for the elderly, espe
cially those with chronic illness. It is administered every 5 years.