Leadership & Management NCLEX Questions with Answers Graded A+
4. Every 30 minutes
The nurse is giving report to an assistive personnel (AP)
who will be caring for a client in hand restraints (safety The nurse should instruct the AP to check safety devices
devices). How frequently should the nurse instruct the AP for tightness every 30 minutes. The neurovascular and
to check the tightness of the restrained hands? circulatory status of the extremity should also be checked
by the registered nurse every 30 minutes. In addition, the
1. Every 2 hours
safety device should be removed at least every 2 hours to
2. Every 3 hours
permit muscle exercise and to promote circulation. Agency
3. Every 4 hours
guidelines regarding the use of safety devices should al-
4. Every 30 minutes
ways be followed.
4. Move the victim to a safe area away from the snake and
The nurse is conducting a session about the principles of encourage the victim to rest.
first aid and is discussing the interventions for a snakebite
to an extremity. The nurse should inform those attending In the event of a snakebite, the first priority is to move the
the session that the first-priority intervention in the event victim to a safe area away from the snake and encourage
of this occurrence is which action? the victim to rest to decrease venom circulation. Next, jew-
elry and constricting clothing are removed before swelling
1. Immobilize the attected extremity. occurs. Immobilizing the extremity and maintaining the
2. Remove jewelry and constricting clothing from the vic- extremity below heart level would be done next; these
tim. actions limit the spread of the venom. The victim is kept
3. Place the extremity in a position so that it is below the warm and calm. Stimulants such as alcohol or catteinated
level of the heart. beverages are not given to the victim because these prod-
4. Move the victim to a safe area away from the snake and ucts may speed the absorption of the venom. The victim
encourage the victim to rest. should be transported to an emergency facility as soon as
possible.
2. A 6-week-old infant admitted to the hospital for de-
The nurse is caring for 4 pediatric clients. After receiving
creased level of consciousness; shaken baby syndrome is
reports from the night shift, which child should the nurse
suspected
assess first?
The infant or child who is the most unstable should be
1. A 6-year-old child being treated for bacterial meningitis
assessed first. A 6-week-old infant with an altered level
,Leadership & Management NCLEX Questions with Answers Graded A+
of consciousness suspected to have resulted from shaken
and on the tenth day of antibiotic treatment
baby syndrome is the most unstable client because the
2. A 6-week-old infant admitted to the hospital for de-
infant could be developing increased intracranial pressure
creased level of consciousness; shaken baby syndrome is
(ICP) and require interventions for the complications as-
suspected
sociated with increased ICP. The 6-year-old child on day
3. A 2-year-old child with cerebral palsy being admitted
10 of antibiotics for bacterial meningitis is a stable client.
to the hospital for surgical placement of a gastrostomy
The 2-year-old child with cerebral palsy being admitted
feeding tube the next day
for surgical placement of a gastrostomy tube will need
4. A 16-year-old child with a ventriculoperitoneal shunt
an admission assessment, but this child is stable. The
that was placed at birth for hydrocephalus; possible shunt
16-year-old with a possible shunt malfunction could be-
malfunction is suspected, and the child is scheduled and
come unstable, but because this child is older and ready
ready for a computed tomography (CT) scan of the head
for the CT scan, he or she is stable at this time.
4. A client who has a peripheral (index finger) oxygen
saturation percentage of 85%
The nurse is assigned to care for 4 clients. Which client
should the nurse assess first? An oxygen saturation percentage of 85% is abnormal. If
this is an accurate measurement, immediate intervention
1. A client who has a tympanic temperature of 99.8º F is needed to maintain the client's oxygenation status. A
2. A client who has a regular radial pulse of 96 beats/min tympanic temperature of 99.8º F is mildly elevated and
3. A client who has a supine resting blood pressure of should be monitored, but it is a lower priority than res-
148/90 mm Hg 4. A client who has a peripheral (index piratory status. A radial pulse of 96 beats/min is elevated
finger) oxygen saturation percentage of 85% as is the supine resting blood pressure of 148/90 mm Hg;
both merit further assessment but are a lower priority than
respiratory status.
4. The client admitted with the medical diagnosis of neu-
The nurse has received the client assignment for the day. tropenia who is afebrile and is complaining of pain with
Which client should the nurse care for first? urination
1. The client receiving chemotherapy who is on day 3 of a The client admitted with neutropenia should be cared for
5-day regimen and has a question about nutrition first. The white blood cells serve as the primary defense
against infections by destroying bacteria in the blood.
,Leadership & Management NCLEX Questions with Answers Graded A+
The client is complaining of painful urination; therefore,
2. The client receiving external radiation who has com- the nurse should suspect urinary tract infection and act
plaints of dryness and itching skin at the treatment area promptly to contact the primary health care provider
3. The client who had a radical mastectomy 36 hours ago because clients with neutropenia are more susceptible
and is complaining of tightness and pulling at the incision to bacterial infections. The client who is tolerating the
site chemotherapy regimen and has a question is not a priori-
4. The client admitted with the medical diagnosis of neu- ty. It is not urgent that the nurse see the client with dryness
tropenia who is afebrile and is complaining of pain with and itching from radiation first. This is an expected ettect
urination 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
3. A victim experiencing airway obstruction
accident. Which victim should the nurse attend to first?
Client needs related to maintaining a patent airway are
1. A victim experiencing excruciating pain
always the priority. Therefore, the nurse would attend to
2. A victim experiencing moderate anxiety
the victim experiencing airway obstruction first. Care to the
3. A victim experiencing airway obstruction
other victims follows.
4. A victim experiencing altered level of consciousness
A client with terminal cancer arrives in the emergency 2. Get directions about care from the client's sister
department unresponsive and in respiratory distress. The
client's sister is the legal medical power of attorney. Both A medial POA allows the client to designate a specif-
the client's spouse and sister are present. Which action by ic decision-making individual who can advocate for the
the nurse is appropriate at this time? client as needed and can be flexible in changing cir-
cumstances. The client's sister is designated as her POA.
1. Ask the spouse about the client's wishes Though spouses are typically POA, option 1 is incorrect as
2. Get directions about care from the client's sister he is not the designated POA. Option 3 would be appro-
3. Prepare for emergency intubation priate only if there were no advance directives or family
4. Request that the sister provide a living will member present. Option 4 delays treatment.
The nurse reads a journal article about a study using a
new pain management protocol for clients with terminal 2. Do the characteristics of the sample population match
cancer. What should the nurse first consider in determin- those of the nurse's unit?
ing whether the protocol is appropriate to implement on
, Leadership & Management NCLEX Questions with Answers Graded A+
the unit?
1. Did the study have institutional review board approval? When evaluating research for practice changes, the nurse
2. Do the characteristics of the sample population match must first determine if there is reasonable similarity be-
those of the nurse's unit? tween the nurse's unit population and the study popula-
3. What are the credentials of the study's researcher? tion to expect equivocal results.
4. What was the financial support provided for the study?
The charge nurse in the emergency department assigns
a client to a new nurse who has been ott orientation for a
week. Which client assignment is most appropriate?
2. 8 year old with a closed fracture of the clavicle following
1. 3 year old with a temperature of 102.4 F (39.1 C) who a fall who is talkative and rates pain as a "2" on the 0-10
had a seizure at home 30 minutes ago and is very irritable FACES pain scale
2. 8 year old with a closed fracture of the clavicle following
a fall who is talkative and rates pain as a "2" on the 0-10 A fractured clavicle is not uncommon in children age <10
FACES pain scale years and is usually treated conservatively. Additionally,
3. 32 year old with asthma who has an upper respiratory the 8 year old has minimal pain and is therefore the most
tract infection and a peak expiratory flow rate that is 45% stable. The new nurse should be given the most stable
of personal best patient.
4. 72 year old prescribe antibiotics 3 days ago to treat
acute sinusitis who reports shortness of breath and has
a rash
The nurse is caring for a hospitalized client with a diag- 2. Assist the client to bathe and change the bed linens to
nosis of thyrotoxicosis. Which of the following actions can maintain client comfort
be delegated to unlicensed assistive personnel? Select all 3. Lower the room temperature and provide cool cloths on
that apply. request
1. Administer artificial tears if the client reports eye dry- UAP are authorized to perform activities of daily living,
ness hygiene, linen changes, and positioning. Therefore, Op-
2. Assist the client to bathe and change the bed linens to tion 2 and 3 are within a UAP's scope of practice. Option
maintain client comfort 1 involves medication administration, which is under the
3. Lower the room temperature and provide cool cloths on scope of a RN. Option 4 involves client teaching and also
4. Every 30 minutes
The nurse is giving report to an assistive personnel (AP)
who will be caring for a client in hand restraints (safety The nurse should instruct the AP to check safety devices
devices). How frequently should the nurse instruct the AP for tightness every 30 minutes. The neurovascular and
to check the tightness of the restrained hands? circulatory status of the extremity should also be checked
by the registered nurse every 30 minutes. In addition, the
1. Every 2 hours
safety device should be removed at least every 2 hours to
2. Every 3 hours
permit muscle exercise and to promote circulation. Agency
3. Every 4 hours
guidelines regarding the use of safety devices should al-
4. Every 30 minutes
ways be followed.
4. Move the victim to a safe area away from the snake and
The nurse is conducting a session about the principles of encourage the victim to rest.
first aid and is discussing the interventions for a snakebite
to an extremity. The nurse should inform those attending In the event of a snakebite, the first priority is to move the
the session that the first-priority intervention in the event victim to a safe area away from the snake and encourage
of this occurrence is which action? the victim to rest to decrease venom circulation. Next, jew-
elry and constricting clothing are removed before swelling
1. Immobilize the attected extremity. occurs. Immobilizing the extremity and maintaining the
2. Remove jewelry and constricting clothing from the vic- extremity below heart level would be done next; these
tim. actions limit the spread of the venom. The victim is kept
3. Place the extremity in a position so that it is below the warm and calm. Stimulants such as alcohol or catteinated
level of the heart. beverages are not given to the victim because these prod-
4. Move the victim to a safe area away from the snake and ucts may speed the absorption of the venom. The victim
encourage the victim to rest. should be transported to an emergency facility as soon as
possible.
2. A 6-week-old infant admitted to the hospital for de-
The nurse is caring for 4 pediatric clients. After receiving
creased level of consciousness; shaken baby syndrome is
reports from the night shift, which child should the nurse
suspected
assess first?
The infant or child who is the most unstable should be
1. A 6-year-old child being treated for bacterial meningitis
assessed first. A 6-week-old infant with an altered level
,Leadership & Management NCLEX Questions with Answers Graded A+
of consciousness suspected to have resulted from shaken
and on the tenth day of antibiotic treatment
baby syndrome is the most unstable client because the
2. A 6-week-old infant admitted to the hospital for de-
infant could be developing increased intracranial pressure
creased level of consciousness; shaken baby syndrome is
(ICP) and require interventions for the complications as-
suspected
sociated with increased ICP. The 6-year-old child on day
3. A 2-year-old child with cerebral palsy being admitted
10 of antibiotics for bacterial meningitis is a stable client.
to the hospital for surgical placement of a gastrostomy
The 2-year-old child with cerebral palsy being admitted
feeding tube the next day
for surgical placement of a gastrostomy tube will need
4. A 16-year-old child with a ventriculoperitoneal shunt
an admission assessment, but this child is stable. The
that was placed at birth for hydrocephalus; possible shunt
16-year-old with a possible shunt malfunction could be-
malfunction is suspected, and the child is scheduled and
come unstable, but because this child is older and ready
ready for a computed tomography (CT) scan of the head
for the CT scan, he or she is stable at this time.
4. A client who has a peripheral (index finger) oxygen
saturation percentage of 85%
The nurse is assigned to care for 4 clients. Which client
should the nurse assess first? An oxygen saturation percentage of 85% is abnormal. If
this is an accurate measurement, immediate intervention
1. A client who has a tympanic temperature of 99.8º F is needed to maintain the client's oxygenation status. A
2. A client who has a regular radial pulse of 96 beats/min tympanic temperature of 99.8º F is mildly elevated and
3. A client who has a supine resting blood pressure of should be monitored, but it is a lower priority than res-
148/90 mm Hg 4. A client who has a peripheral (index piratory status. A radial pulse of 96 beats/min is elevated
finger) oxygen saturation percentage of 85% as is the supine resting blood pressure of 148/90 mm Hg;
both merit further assessment but are a lower priority than
respiratory status.
4. The client admitted with the medical diagnosis of neu-
The nurse has received the client assignment for the day. tropenia who is afebrile and is complaining of pain with
Which client should the nurse care for first? urination
1. The client receiving chemotherapy who is on day 3 of a The client admitted with neutropenia should be cared for
5-day regimen and has a question about nutrition first. The white blood cells serve as the primary defense
against infections by destroying bacteria in the blood.
,Leadership & Management NCLEX Questions with Answers Graded A+
The client is complaining of painful urination; therefore,
2. The client receiving external radiation who has com- the nurse should suspect urinary tract infection and act
plaints of dryness and itching skin at the treatment area promptly to contact the primary health care provider
3. The client who had a radical mastectomy 36 hours ago because clients with neutropenia are more susceptible
and is complaining of tightness and pulling at the incision to bacterial infections. The client who is tolerating the
site chemotherapy regimen and has a question is not a priori-
4. The client admitted with the medical diagnosis of neu- ty. It is not urgent that the nurse see the client with dryness
tropenia who is afebrile and is complaining of pain with and itching from radiation first. This is an expected ettect
urination 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
3. A victim experiencing airway obstruction
accident. Which victim should the nurse attend to first?
Client needs related to maintaining a patent airway are
1. A victim experiencing excruciating pain
always the priority. Therefore, the nurse would attend to
2. A victim experiencing moderate anxiety
the victim experiencing airway obstruction first. Care to the
3. A victim experiencing airway obstruction
other victims follows.
4. A victim experiencing altered level of consciousness
A client with terminal cancer arrives in the emergency 2. Get directions about care from the client's sister
department unresponsive and in respiratory distress. The
client's sister is the legal medical power of attorney. Both A medial POA allows the client to designate a specif-
the client's spouse and sister are present. Which action by ic decision-making individual who can advocate for the
the nurse is appropriate at this time? client as needed and can be flexible in changing cir-
cumstances. The client's sister is designated as her POA.
1. Ask the spouse about the client's wishes Though spouses are typically POA, option 1 is incorrect as
2. Get directions about care from the client's sister he is not the designated POA. Option 3 would be appro-
3. Prepare for emergency intubation priate only if there were no advance directives or family
4. Request that the sister provide a living will member present. Option 4 delays treatment.
The nurse reads a journal article about a study using a
new pain management protocol for clients with terminal 2. Do the characteristics of the sample population match
cancer. What should the nurse first consider in determin- those of the nurse's unit?
ing whether the protocol is appropriate to implement on
, Leadership & Management NCLEX Questions with Answers Graded A+
the unit?
1. Did the study have institutional review board approval? When evaluating research for practice changes, the nurse
2. Do the characteristics of the sample population match must first determine if there is reasonable similarity be-
those of the nurse's unit? tween the nurse's unit population and the study popula-
3. What are the credentials of the study's researcher? tion to expect equivocal results.
4. What was the financial support provided for the study?
The charge nurse in the emergency department assigns
a client to a new nurse who has been ott orientation for a
week. Which client assignment is most appropriate?
2. 8 year old with a closed fracture of the clavicle following
1. 3 year old with a temperature of 102.4 F (39.1 C) who a fall who is talkative and rates pain as a "2" on the 0-10
had a seizure at home 30 minutes ago and is very irritable FACES pain scale
2. 8 year old with a closed fracture of the clavicle following
a fall who is talkative and rates pain as a "2" on the 0-10 A fractured clavicle is not uncommon in children age <10
FACES pain scale years and is usually treated conservatively. Additionally,
3. 32 year old with asthma who has an upper respiratory the 8 year old has minimal pain and is therefore the most
tract infection and a peak expiratory flow rate that is 45% stable. The new nurse should be given the most stable
of personal best patient.
4. 72 year old prescribe antibiotics 3 days ago to treat
acute sinusitis who reports shortness of breath and has
a rash
The nurse is caring for a hospitalized client with a diag- 2. Assist the client to bathe and change the bed linens to
nosis of thyrotoxicosis. Which of the following actions can maintain client comfort
be delegated to unlicensed assistive personnel? Select all 3. Lower the room temperature and provide cool cloths on
that apply. request
1. Administer artificial tears if the client reports eye dry- UAP are authorized to perform activities of daily living,
ness hygiene, linen changes, and positioning. Therefore, Op-
2. Assist the client to bathe and change the bed linens to tion 2 and 3 are within a UAP's scope of practice. Option
maintain client comfort 1 involves medication administration, which is under the
3. Lower the room temperature and provide cool cloths on scope of a RN. Option 4 involves client teaching and also
