Assignment 1: Objective Tests: Design and Considerations

Whitney Hyde

Dr. Digger

NURs 603
 NCLEX Question on Issues in Nursing
Culture Awareness
1. While the nurse is discussing preoperative procedures with a Japanese American patient,
the patient continues to smile and nod his head. How should the nurse interpret this
nonverbal behavior?
1. Reflecting a cultural value
2. An acceptance of the treatment
3. Client agreement to require procedures
4. Client understanding the preoperative procedures
Level of Cognitive Ability: Comprehension
This question is comprehension level because the learner has to demonstrate an understanding of
what is being communicated in the question (Bastable, 2014). The learner needs to understand
that the question is asking about the cultural values of the patient’s nonverbal behaviors.
Client Needs: Psychosocial Integrity

2. The nurse identifies low-risk therapies to a patient and should include which therapy(s) in
the discussion? Select all that apply.
1. Herbs
2. Prayer
3. Touch
4. Massage
5. Relaxation
6. Acupuncture
Level of Cognitive Ability: Analysis
This question is an analysis level because the learner needs to recognize what the question is
asking and break down the information into parts and identify relationships (Bastable, 2014).
The learner needs to identify the relationship between prayer, touch, massage, and relaxation
being low-risk therapies to a patient.
Client Needs: Physiological Integrity: Basic care and comfort
Rationale: Low risk therapies have no adverse effects when implemented. Low risk therapies
include meditation, relaxation techniques, imagery, music therapy, massage, touch, spiritual
measures, and laughter. Herbs and acupuncture may have adverse effects to the patient if
implemented.

3. Which patient(s) has a high risk of obesity and diabetes mellitus? Select all that apply.
1. A 40-year-old Latino American man
 2. A 45-year-old Native American man
3. A 23-year-old Asian American woman
4. A 35-year-old Hispanic American man
5. A 40-year-old African American woman
Level of Cognitive Ability: Analysis
This is an analysis level question because the learner needs to be able to have the knowledge of
health and dietary practices of different ethnicities and then understand how those dietary
practices increase their risk of obesity and diabetes mellitus. The learner had to identify and
analyze the relationship between the age and ethnicities and how those factors would increase the
patients risks for obesity and diabetes.
Client Needs: Health Promotion and Maintenance
4. The nurse is preparing a plan of care for a patient who is a Jehovah’s Witness. The
patient has been told that surgery is necessary. The nurse considers the religious beliefs
of the patient in developing the plan of care and should document which information?
1. The patient believes the souls lives on after death.
2. Medication administration in not allowed.
3. Surgery is prohibited in this religious group.
4. The administration of blood and blood products is not allowed.
Level of Cognitive Ability: Application
This is an application level question because the learner needs to use the knowledge they have on
Jehovah Witnesses religious preferences, demonstrate an understanding of how their religious
preferences may impact their plan of care, and then apply the knowledge and understanding to
this situation to identify the most appropriate answer (Bastable, 2014).
Client Needs: Psychosocial Integrity

5. An antihypertensive medication has been prescribed for a patient with hypertension. The
patient tells the nurse that they would like to use herbal substances to help lower their
blood pressure. What action should the nurse take?
1. Tell the patient that herbal substances are not safe and should never be used.
2. Teach the patient how to take their blood pressure so it can be monitored closely.
3. Encourage the patient to discuss the use of herbal substances with her
healthcare provider.
4. Tell the patient that if they take the herbal substances, they will need to have their
blood pressure checked frequently.
Level of Cognitive Ability: Application
This is an application level question because the learner needs to use their knowledge and
understand how to best advise the patient on herbal substances for treating medical problems.
The learner needs to apply their understanding of herbal substances and conventional medication
therapy to answer this question correctly.
Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Rationale: Herbal substances with similar pharmacological effects as conventional medication
should be cautioned in patients because they can result in an unknown reaction or adverse effect
(Silvestri, 2014). The nurse should advise the patient to discuss the use of herbal substances with
their primary care provider to see if the herbal substance is safe. Therefore options 1,2, and 4 are
inappropriate actions.

Ethics
1. The nurse hears a patient calling out for help and finds the patient lying on the floor. The
nurse performs an assessment, assist the patient back to bed, notifies the healthcare team,
and completes an incident report. Which statement should the nurse document in the
incident report?
1. The patient fell out of bed.
2. The patient climbed over the side rails.
3. The patient was found lying on the floor.
4. The client became restless and tried to get out of bed.
Level of Cognitive Ability: Knowledge
This is a knowledge level question because the learner needs to recall the rules and instruction
for how to appropriately document an incident report (Bastable, 2014). The learner should recall
the knowledge that only facts should be documented during an incident report.
Client Needs: Safe and Effective Care Environment: Safety and Infection Control

2. A patient is brought to the emergency room by emergency medical services (EMS)

after being hit by a car. The name of the patient is unknown and the patient has
sustained a severe head injury, multiple fractures, and is unconscious. An emergency
craniotomy is required. Regarding the informed consent for the surgical procedure,
which is the best action?
1. Obtain a court order for the surgical consent.
2. Ask the EMS team to sign the informed consent.
3. Transport the victim to the operating room for surgery.
4. Call the police to identify the client and locate the family.
Level of Cognitive Ability: Application
This question is an application level because the learner needs to have knowledge about
informed consent, be able to comprehend the emergent situation, and apply their knowledge and
understanding of the situation to correctly answer the question (Bastable, 2014).
Client Needs: Safe and Effective Care Environment: Management of Care
Rationale: Informed consent of an adult client is not required in an emergency when delaying
treatment for the purpose of obtaining informed consent would result in injury or death to the
patient and if the patient waives the right to give informed consent (Silvestri, 2014). Option 1
would cause a delay in emergency treatment, option 2 is inappropriate, and option 4 may be
pursued if the situation was not an emergency.
3. The nurse arrives to work and is told to report (float) to the intensive care unit (ICU)
for the day because the ICU is short staffed. The nurse has never worked in the ICU,
which action should the nurse take first?
1. Call the hospital lawyer.
2. Refuse to float to the ICU.
3. Call the nursing supervisor.
4. Identify tasks that can be performed safety in the ICU.
Level of Cognitive Ability: Application
This question is at the application level because the learner needs have knowledge about floating
practices and understand that the focus of the question is on patient safety (Bastable, 2014). The
learner needs to be able to apply knowledge and understanding about legal practices and patient
safety.
Client Needs: Safe and Effective Care Environment: Management of Care
Rationale: Floating is a legal practice used by hospitals to solve understaffing problems and in
most situations, nurses cannot refuse to float, therefore option 2 is inappropriate. When nurses
are placed in this situation, it is important for them to set priorities and identify potential areas of
harm to the patient (Silvestri, 2014). Option 3 should be considered if the nurses was expected
to perform activities they could not perform safety and option 4 is premature.

4. Which identifies accurate nursing documentation notations? Select all that apply?
1. The patient slept through the night.
2. Abdominal wound dressing is dry and intact without drainage.
3. The patient seemed angry when awakened for vital sign measurement.
4. The patient appears to become anxious when it is time for respiratory
treatments.
5. The patient’s left lower medial leg wound is 3cm in length without
redness, drainage, or edema.
Level of Cognitive Ability: Analysis
This question is at the analysis level because the learner needs to breakdown the question into
parts and recognize what information is factual and what information is vague and subjective
(Bastable, 2014). The learner needs to identify the relationship between the correct answers.
Client Needs: Safe and Effective Care Environment: Management of Care
Rationale: Accurate factual documentation includes what the nurse hears, sees, feels, and smells
(Silvestri, 2014). In options 3 and 4, vague terms like seemed and appears are not appropriate
because they are the nurse’s opinion (Silvestri, 2014).

5. Two staff members have called in sick on the medical-surgical unit and no additional
help is available. The remaining team members consist of an RN, an LPN and
unlicensed assistive personnel (UAP). Which of the following should be considered
by the nurse when making patient assignments? Select all that apply:
1. Assess and verify the competency of the health care team.
2. Identify what tasks are appropriate to delegate for each specific patient.
3. Assess the health status and complexity of care required by the patient.
4. Continually provide supervision, either directly or indirectly, to the team.
5. Evaluate patient needs to determine if assigned nurse can meet plan of care
outcomes.
Level of Cognitive Ability: Evaluation
This question is at the evaluation level because the learner has to judge which of the answers are
correct by applying the appropriate standards of RN delegation and scope of practice (Bastable,
2014). The leaner has to have knowledge on delegation and RN scope of practice, demonstrate
understanding of these roles in this particular situation, and identify a relationship between the
correct answers before being able to recommend which of these actions are the appropriate by
the nurse when making the patient assignment.
Client Needs: Safe and Effective Care Environment: Management of Care
 References

Bastable, S.B. (2014). Behavioral objectives (Ed.), Nurse as educator (4th ed.) (pp. 423-

468). Sudbury, MA: Jones & Bartlett.

National Council of State Boards of Nursing. (2016). RN test plan 2016. Retrieved from

https://www.ncsbn.org/RN_Test_Plan_2016_Final.pdf

Silvestri, L.A. (2014). Saunders comprehensive review for the NCLEX-RN. St. Louis, MO:

Elsevier.