NCLEX-RN Management of Care Exam

A new client is admitted to the surgical floor after an appendectomy.

> Which of the following interventions is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

A client with polycystic kidney disease has been admitted secondary to uncontrolled hypertension. Upon arrival to the room, the client’s blood pressure is 190/120. The healthcare provider places an order to consult both cardiology and nephrology to evaluate the client. The client asks the nurse, “Why do multiple doctors have to see me?”

> What is the most appropriate response by the nurse?

A client is pronounced dead shortly after arrival in the emergency department. The provider informs the nurse that the death requires medical examiner notification. The spouse expresses distress and states they do not want an autopsy performed.

> Which response by the nurse is most appropriate?

The nurse manager is assigning staff to care for a client diagnosed with herpes zoster.

> Which staff members should not be assigned to this client? Select all that apply.

The nurse is preparing assignments for a group of assistive personnel.

> What is the nurse’s first step in the delegation process?

While riding an elevator during a shift change, a nursing student hears two nurses discussing a client’s diagnosis and recent test results. Several visitors are also present in the elevator.

> What is the most important principle the nurses must remember in this situation?

Due to a community emergency, the nurse manager must identify stable clients for early discharge.

> Which clients can be safely discharged? Select all that apply.

A nurse questions a newly written medication order because the dosage exceeds the recommended safe range. Attempts to reach the prescribing provider are unsuccessful, and the medication administration time is approaching.

> What action should the nurse take?

Staff nurses describe their unit manager as highly directive and focused on task completion.

> Which leadership style does this description reflect?

The nurse is assigning clients to staff members for the shift.

> Which client is most appropriate to assign to the assistive personnel (AP)?

A nurse participates in disaster planning education and reviews the roles of national response organizations.

> Which activities are functions of the American Red Cross rather than the Federal Emergency Management Agency (FEMA)? Select all that apply.

The nurse reflects on professional responsibilities related to advocacy.

> In which situations is the nurse acting as a client advocate? Select all that apply.

A nurse observes that a client appears confused about a surgical procedure but is preparing to sign the consent form.

> What is the most appropriate nursing action?

The nurse on a labor and delivery unit has just received handoff reports on four clients.

> Which client should the nurse assess first?

The nurse begins morning rounds after reviewing the client assignment list.

> Which client should the nurse care for first?

The nurse is the first responder at the scene of a multi-vehicle collision on a rural highway.

> Which victim should the nurse assess first?

Due to staffing needs, the charge nurse must transfer one antepartum client to another unit with a higher nurse-to-client ratio.

> Which client is most appropriate to transfer?

A nursing student reviews the chart of an older adult admitted with fever and confusion. The urinalysis shows bacteria, and the urine culture is pending.

> Which statement by the student indicates a need for further review related to urosepsis?

The nurse is preparing to begin rounds after receiving shift report.

> Which client should the nurse see first?

An older adult presents to the emergency department with a fractured arm. The nurse observes multiple bruises in various stages of healing. The client discloses that a family member frequently becomes physically abusive.

> What is the most appropriate nursing response?