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NCLEX-RN Leadership & Management Test Bank:
Master Prioritization with High-Yield Questions &
Rationales to Pass on Your First Attempt.
The nurse is giving report to an assistive personnel (AP) who will be
caring for a client in hand restraints (safety devices). How frequently
should the nurse instruct the AP to check the tightness of the restrained
hands?
1. Every 2 hours
2. Every 3 hours
3. Every 4 hours
4. Every 30 minutes - ANSWER-4. Every 30 minutes
The nurse should instruct the AP to check safety devices for tightness
every 30 minutes. The neurovascular and circulatory status of the
extremity should also be checked by the registered nurse every 30
minutes. In addition, the safety device should be removed at least every
2 hours to permit muscle exercise and to promote circulation. Agency
guidelines regarding the use of safety devices should always be
followed.
The nurse is conducting a session about the principles of first aid and is
discussing the interventions for a snakebite to an extremity. The nurse
should inform those attending the session that the first-priority
intervention in the event of this occurrence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
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3. Place the extremity in a position so that it is below the level of the
heart.
4. Move the victim to a safe area away from the snake and encourage the
victim to rest. - ANSWER-4. Move the victim to a safe area away from
the snake and encourage the victim to rest.
In the event of a snakebite, the first priority is to move the victim to a
safe area away from the snake and encourage the victim to rest to
decrease venom circulation. Next, jewelry and constricting clothing are
removed before swelling occurs. Immobilizing the extremity and
maintaining the extremity below heart level would be done next; these
actions limit the spread of the venom. The victim is kept warm and calm.
Stimulants such as alcohol or caffeinated beverages are not given to the
victim because these products may speed the absorption of the venom.
The victim should be transported to an emergency facility as soon as
possible.
The nurse is caring for 4 pediatric clients. After receiving reports from
the night shift, which child should the nurse assess first?
1. A 6-year-old child being treated for bacterial meningitis and on the
tenth day of antibiotic treatment
2. A 6-week-old infant admitted to the hospital for decreased level of
consciousness; shaken baby syndrome is suspected
3. A 2-year-old child with cerebral palsy being admitted to the hospital
for surgical placement of a gastrostomy feeding tube the next day
4. A 16-year-old child with a ventriculoperitoneal shunt that was placed
at birth for hydrocephalus; possible shunt malfunction is suspected, and
the child is scheduled and ready for a computed tomography (CT) scan
of the head - ANSWER-2. A 6-week-old infant admitted to the hospital
for decreased level of consciousness; shaken baby syndrome is
suspected
The infant or child who is the most unstable should be assessed first. A
6-week-old infant with an altered level of consciousness suspected to
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have resulted from shaken baby syndrome is the most unstable client
because the infant could be developing increased intracranial pressure
(ICP) and require interventions for the complications associated with
increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial
meningitis is a stable client. The 2-year-old child with cerebral palsy
being admitted for surgical placement of a gastrostomy tube will need an
admission assessment, but this child is stable. The 16-year-old with a
possible shunt malfunction could become unstable, but because this
child is older and ready for the CT scan, he or she is stable at this time.
The nurse is assigned to care for 4 clients. Which client should the nurse
assess first?
1. A client who has a tympanic temperature of 99.8º F
2. A client who has a regular radial pulse of 96 beats/min
3. A client who has a supine resting blood pressure of 148/90 mm Hg 4.
A client who has a peripheral (index finger) oxygen saturation
percentage of 85% - ANSWER-4. A client who has a peripheral (index
finger) oxygen saturation percentage of 85%
An oxygen saturation percentage of 85% is abnormal. If this is an
accurate measurement, immediate intervention is needed to maintain the
client's oxygenation status. A tympanic temperature of 99.8º F is mildly
elevated and should be monitored, but it is a lower priority than
respiratory status. A radial pulse of 96 beats/min is elevated as is the
supine resting blood pressure of 148/90 mm Hg; both merit further
assessment but are a lower priority than respiratory status.
The nurse has received the client assignment for the day. Which client
should the nurse care for first?
1. The client receiving chemotherapy who is on day 3 of a 5-day
regimen and has a question about nutrition
2. The client receiving external radiation who has complaints of dryness
and itching skin at the treatment area
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3. The client who had a radical mastectomy 36 hours ago and is
complaining of tightness and pulling at the incision site
4. The client admitted with the medical diagnosis of neutropenia who is
afebrile and is complaining of pain with urination - ANSWER-4. The
client admitted with the medical diagnosis of neutropenia who is afebrile
and is complaining of pain with urination
The client admitted with neutropenia should be cared for first. The white
blood cells serve as the primary defense against infections by destroying
bacteria in the blood. The client is complaining of painful urination;
therefore, the nurse should suspect urinary tract infection and act
promptly to contact the primary health care provider because clients
with neutropenia are more susceptible to bacterial infections. The client
who is tolerating the chemotherapy regimen and has a question is not a
priority. It is not urgent that the nurse see the client with dryness and
itching from radiation first. This is an expected effect from radiation
therapy. The client who has a mastectomy is expected to have sensations
of tightness and pulling.
The nurse is the first responder at the scene of a train accident. Which
victim should the nurse attend to first?
1. A victim experiencing excruciating pain
2. A victim experiencing moderate anxiety
3. A victim experiencing airway obstruction
4. A victim experiencing altered level of consciousness - ANSWER-3. A
victim experiencing airway obstruction
Client needs related to maintaining a patent airway are always the
priority. Therefore, the nurse would attend to the victim experiencing
airway obstruction first. Care to the other victims follows.
A client with terminal cancer arrives in the emergency department
unresponsive and in respiratory distress. The client's sister is the legal
NCLEX-RN Leadership & Management Test Bank:
Master Prioritization with High-Yield Questions &
Rationales to Pass on Your First Attempt.
The nurse is giving report to an assistive personnel (AP) who will be
caring for a client in hand restraints (safety devices). How frequently
should the nurse instruct the AP to check the tightness of the restrained
hands?
1. Every 2 hours
2. Every 3 hours
3. Every 4 hours
4. Every 30 minutes - ANSWER-4. Every 30 minutes
The nurse should instruct the AP to check safety devices for tightness
every 30 minutes. The neurovascular and circulatory status of the
extremity should also be checked by the registered nurse every 30
minutes. In addition, the safety device should be removed at least every
2 hours to permit muscle exercise and to promote circulation. Agency
guidelines regarding the use of safety devices should always be
followed.
The nurse is conducting a session about the principles of first aid and is
discussing the interventions for a snakebite to an extremity. The nurse
should inform those attending the session that the first-priority
intervention in the event of this occurrence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
,2|Page
3. Place the extremity in a position so that it is below the level of the
heart.
4. Move the victim to a safe area away from the snake and encourage the
victim to rest. - ANSWER-4. Move the victim to a safe area away from
the snake and encourage the victim to rest.
In the event of a snakebite, the first priority is to move the victim to a
safe area away from the snake and encourage the victim to rest to
decrease venom circulation. Next, jewelry and constricting clothing are
removed before swelling occurs. Immobilizing the extremity and
maintaining the extremity below heart level would be done next; these
actions limit the spread of the venom. The victim is kept warm and calm.
Stimulants such as alcohol or caffeinated beverages are not given to the
victim because these products may speed the absorption of the venom.
The victim should be transported to an emergency facility as soon as
possible.
The nurse is caring for 4 pediatric clients. After receiving reports from
the night shift, which child should the nurse assess first?
1. A 6-year-old child being treated for bacterial meningitis and on the
tenth day of antibiotic treatment
2. A 6-week-old infant admitted to the hospital for decreased level of
consciousness; shaken baby syndrome is suspected
3. A 2-year-old child with cerebral palsy being admitted to the hospital
for surgical placement of a gastrostomy feeding tube the next day
4. A 16-year-old child with a ventriculoperitoneal shunt that was placed
at birth for hydrocephalus; possible shunt malfunction is suspected, and
the child is scheduled and ready for a computed tomography (CT) scan
of the head - ANSWER-2. A 6-week-old infant admitted to the hospital
for decreased level of consciousness; shaken baby syndrome is
suspected
The infant or child who is the most unstable should be assessed first. A
6-week-old infant with an altered level of consciousness suspected to
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have resulted from shaken baby syndrome is the most unstable client
because the infant could be developing increased intracranial pressure
(ICP) and require interventions for the complications associated with
increased ICP. The 6-year-old child on day 10 of antibiotics for bacterial
meningitis is a stable client. The 2-year-old child with cerebral palsy
being admitted for surgical placement of a gastrostomy tube will need an
admission assessment, but this child is stable. The 16-year-old with a
possible shunt malfunction could become unstable, but because this
child is older and ready for the CT scan, he or she is stable at this time.
The nurse is assigned to care for 4 clients. Which client should the nurse
assess first?
1. A client who has a tympanic temperature of 99.8º F
2. A client who has a regular radial pulse of 96 beats/min
3. A client who has a supine resting blood pressure of 148/90 mm Hg 4.
A client who has a peripheral (index finger) oxygen saturation
percentage of 85% - ANSWER-4. A client who has a peripheral (index
finger) oxygen saturation percentage of 85%
An oxygen saturation percentage of 85% is abnormal. If this is an
accurate measurement, immediate intervention is needed to maintain the
client's oxygenation status. A tympanic temperature of 99.8º F is mildly
elevated and should be monitored, but it is a lower priority than
respiratory status. A radial pulse of 96 beats/min is elevated as is the
supine resting blood pressure of 148/90 mm Hg; both merit further
assessment but are a lower priority than respiratory status.
The nurse has received the client assignment for the day. Which client
should the nurse care for first?
1. The client receiving chemotherapy who is on day 3 of a 5-day
regimen and has a question about nutrition
2. The client receiving external radiation who has complaints of dryness
and itching skin at the treatment area
, 4|Page
3. The client who had a radical mastectomy 36 hours ago and is
complaining of tightness and pulling at the incision site
4. The client admitted with the medical diagnosis of neutropenia who is
afebrile and is complaining of pain with urination - ANSWER-4. The
client admitted with the medical diagnosis of neutropenia who is afebrile
and is complaining of pain with urination
The client admitted with neutropenia should be cared for first. The white
blood cells serve as the primary defense against infections by destroying
bacteria in the blood. The client is complaining of painful urination;
therefore, the nurse should suspect urinary tract infection and act
promptly to contact the primary health care provider because clients
with neutropenia are more susceptible to bacterial infections. The client
who is tolerating the chemotherapy regimen and has a question is not a
priority. It is not urgent that the nurse see the client with dryness and
itching from radiation first. This is an expected effect from radiation
therapy. The client who has a mastectomy is expected to have sensations
of tightness and pulling.
The nurse is the first responder at the scene of a train accident. Which
victim should the nurse attend to first?
1. A victim experiencing excruciating pain
2. A victim experiencing moderate anxiety
3. A victim experiencing airway obstruction
4. A victim experiencing altered level of consciousness - ANSWER-3. A
victim experiencing airway obstruction
Client needs related to maintaining a patent airway are always the
priority. Therefore, the nurse would attend to the victim experiencing
airway obstruction first. Care to the other victims follows.
A client with terminal cancer arrives in the emergency department
unresponsive and in respiratory distress. The client's sister is the legal
