NCLEX EXAM zm
Exam Solution zm
Leadership & Management NCLEX Questions 2026 A+ zm zm zm zm zm zm zm
GRADE ASSURED COMPLETE SOLUTIONS AND VERIFIE zm zm zm zm zm
D ANSWERS (29C51)
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QUESTION 1 zm
Term
ANSWER
Definition
QUESTION 2 zm
The nurse is giving report to an assistive personnel (AP) who will be caring for a clie
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nt in hand restraints (safety devices). How frequently should the nurse instruct the A
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P to check the tightness of the restrained hands? 1. Every 2 hours 2. Every 3 hours 3.
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Every 4 hours 4. Every 30 minutes
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ANSWER
4. Every 30 minutes The nurse should instruct the AP to check safety devices for tightness every 30
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mminutes. The neurovascular and circulatory status of the extremity should also be checked by the re
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gistered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 h
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ours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of s
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afety devices should always be followed.
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QUESTION 3 zm
The nurse is assigned to care for 4 clients. Which client should the nurse assess first?
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1. A client who has a tympanic temperature of 99.8º F 2. A client who has a regular r
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adial pulse of 96 beats/min 3. A client who has a supine resting blood pressure of 14
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8/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percent
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age of 85% zm zm
ANSWER
, 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% An oxygen satu
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ration percentage of 85% is abnormal. If this is an accurate measurement, immediate intervention is
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mneeded to maintain the client's oxygenation status. A tympanic temperature of 99.8º F is mildly elev
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ated and should be monitored, but it is a lower priority than respiratory status. A radial pulse of 96
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beats/min is elevated as is the supine resting blood pressure of 148/90 mm Hg; both merit further
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massessment but are a lower priority than respiratory status.
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QUESTION 4 zm
The nurse is the first responder at the scene of a train accident. Which victim should
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the nurse attend to first? 1. A victim experiencing excruciating pain 2. A victim experi
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encing moderate anxiety 3. A victim experiencing airway obstruction 4. A victim exper
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iencing altered level of consciousness
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ANSWER
3. A victim experiencing airway obstruction Client needs related to maintaining a patent airway are
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always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction
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mfirst. Care to the other victims follows.
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QUESTION 5 zm
The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told
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mthe UAP that the client is feeling short of breath. What should the charge nurse do fir
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st? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report bac
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k 3. Notify the client's assigned licensed practical nurse (LPN) to assess the client 4. P
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ersonally go and auscultate the client's lungs
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ANSWER
4. Personally go and auscultate the client's lungs When a registered nurse (RN) receives a report of
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a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN sh
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ould personally assess the client. This is the primary nursing assessment that will be used to decide
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mif an urgent need exists and a change in the nursing plan of care is needed.
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QUESTION 6 zm
An emergency department nurse is assigned to triage. Which client should the nurse a
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ssess first? 1. Five year old with a superficial leg laceration 2. Lethargic 3 month old
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with diarrhea for the past 12 hours 3. Seven year old with a elevated temperature of
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101 F and hematuria 4. Seventeen year old with severe, acute abdominal pain
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ANSWER
2. Lethargic 3 month old with diarrhea for the past 12 hours Infants have a high percentage of bod
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y water (70%-
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80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and el
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ectrolyte disturbances. In addition, the infant is lethargic, indicating a change in LOC.
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Exam Solution zm
Leadership & Management NCLEX Questions 2026 A+ zm zm zm zm zm zm zm
GRADE ASSURED COMPLETE SOLUTIONS AND VERIFIE zm zm zm zm zm
D ANSWERS (29C51)
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QUESTION 1 zm
Term
ANSWER
Definition
QUESTION 2 zm
The nurse is giving report to an assistive personnel (AP) who will be caring for a clie
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nt in hand restraints (safety devices). How frequently should the nurse instruct the A
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P to check the tightness of the restrained hands? 1. Every 2 hours 2. Every 3 hours 3.
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Every 4 hours 4. Every 30 minutes
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ANSWER
4. Every 30 minutes The nurse should instruct the AP to check safety devices for tightness every 30
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mminutes. The neurovascular and circulatory status of the extremity should also be checked by the re
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gistered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 h
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ours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of s
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afety devices should always be followed.
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QUESTION 3 zm
The nurse is assigned to care for 4 clients. Which client should the nurse assess first?
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1. A client who has a tympanic temperature of 99.8º F 2. A client who has a regular r
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adial pulse of 96 beats/min 3. A client who has a supine resting blood pressure of 14
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8/90 mm Hg 4. A client who has a peripheral (index finger) oxygen saturation percent
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age of 85% zm zm
ANSWER
, 4. A client who has a peripheral (index finger) oxygen saturation percentage of 85% An oxygen satu
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ration percentage of 85% is abnormal. If this is an accurate measurement, immediate intervention is
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mneeded to maintain the client's oxygenation status. A tympanic temperature of 99.8º F is mildly elev
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ated and should be monitored, but it is a lower priority than respiratory status. A radial pulse of 96
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beats/min is elevated as is the supine resting blood pressure of 148/90 mm Hg; both merit further
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massessment but are a lower priority than respiratory status.
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QUESTION 4 zm
The nurse is the first responder at the scene of a train accident. Which victim should
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the nurse attend to first? 1. A victim experiencing excruciating pain 2. A victim experi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
encing moderate anxiety 3. A victim experiencing airway obstruction 4. A victim exper
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iencing altered level of consciousness
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ANSWER
3. A victim experiencing airway obstruction Client needs related to maintaining a patent airway are
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always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction
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mfirst. Care to the other victims follows.
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QUESTION 5 zm
The unlicensed assistive personnel (UAP) notifies the charge nurse that the client told
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mthe UAP that the client is feeling short of breath. What should the charge nurse do fir
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st? 1. Activate a rapid response team 2. Ask the UAP to take vital signs and report bac
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k 3. Notify the client's assigned licensed practical nurse (LPN) to assess the client 4. P
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ersonally go and auscultate the client's lungs
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ANSWER
4. Personally go and auscultate the client's lungs When a registered nurse (RN) receives a report of
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a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN sh
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ould personally assess the client. This is the primary nursing assessment that will be used to decide
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mif an urgent need exists and a change in the nursing plan of care is needed.
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QUESTION 6 zm
An emergency department nurse is assigned to triage. Which client should the nurse a
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ssess first? 1. Five year old with a superficial leg laceration 2. Lethargic 3 month old
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with diarrhea for the past 12 hours 3. Seven year old with a elevated temperature of
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101 F and hematuria 4. Seventeen year old with severe, acute abdominal pain
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ANSWER
2. Lethargic 3 month old with diarrhea for the past 12 hours Infants have a high percentage of bod
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y water (70%-
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80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and el
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ectrolyte disturbances. In addition, the infant is lethargic, indicating a change in LOC.
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