NCLEX-RN PRACTICE
EXAM 4
High-Yield Qs & Answers with Rationales
SPECIALTY NURSING &
COMPLEX CARE
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
1
,Section A: Management of Care (Questions 1-40)
QUESTION 1
Client Needs: Management of Care
A home health nurse is supervising a licensed practical nurse (LPN) caring for a 78-year-old
client with diabetes and a stage 3 pressure ulcer. The LPN reports the wound appears infected
with purulent drainage and increased redness. The client's blood glucose is 284 mg/dL, and
vital signs show fever of 101.8°F.
Which action should the home health nurse take first?
A. Document the findings and schedule a wound care specialist consult B. Contact the primary
care provider immediately to report the assessment findings C. Instruct the LPN to increase
the frequency of wound care to twice daily D. Arrange for immediate hospitalization through
emergency medical services
Answer: B
Rationale: The combination of signs of infection (purulent drainage, increased redness,
fever) with hyperglycemia in a diabetic client represents a serious condition requiring
immediate physician notification. While documentation is important, it should not delay
urgent communication. The LPN cannot independently change wound care frequency without
orders. Hospitalization may be needed, but the physician must make this determination first.
QUESTION 2
Client Needs: Management of Care
The charge nurse in a pediatric unit receives the following assignments at the beginning of the
shift. Which client should be assigned to the most experienced registered nurse?
A. 6-month-old with bronchiolitis requiring frequent suctioning and oxygen monitoring B. 8-
year-old with appendicitis scheduled for surgery in 4 hours C. 12-year-old with diabetes
mellitus admitted for diabetic ketoacidosis D. 4-year-old with asthma receiving nebulizer
treatments every 2 hours
, Answer: C
Rationale: Diabetic ketoacidosis in pediatric clients requires complex monitoring of
electrolytes, acidbase balance, insulin administration, and neurological status with risk for
cerebral edema. This assignment demands the highest level of critical thinking and
experience. The bronchiolitis client, while requiring frequent assessment, has more
predictable care needs. The appendicitis client is stable pre-operatively. The asthma client has
routine treatment requirements.
QUESTION 3
Client Needs: Management of Care
A hospice nurse is developing a care plan for a terminally ill client with pancreatic cancer. The
client's adult daughter insists on continuing aggressive treatments despite the client
expressing wishes to focus on comfort care. The healthcare team is divided on the approach.
What is the nurse's priority action?
A. Support the daughter's decision as the primary caregiver B. Advocate for the client's
expressed wishes regarding end-of-life care C. Arrange a family meeting with the
interdisciplinary team to discuss goals of care D. Contact the hospital ethics committee for
guidance on the situation
Answer: C
Rationale: A family meeting with the interdisciplinary team allows for open
communication, clarification of the client's wishes, and education about hospice philosophy.
This collaborative approach addresses family dynamics while centering on the client's
autonomy. While advocating for the client is important, a meeting allows for better
understanding. Ethics committee involvement may be needed later if conflicts persist.
QUESTION 4
Client Needs: Management of Care
In the emergency department, a triage nurse using the 5-level Emergency Severity Index (ESI)
system evaluates four clients who arrive simultaneously. Which client should be triaged as ESI
Level 1 (most urgent)?
A. 45-year-old with severe chest pain, diaphoresis, and shortness of breath B. 32-year-old with
open fracture of the tibia with active bleeding C. 67-year-old with slurred speech, facial
drooping, and confusion of 30 minutes duration D. 28-year-old unconscious after motorcycle
accident with obvious head trauma
3
, Answer: D
Rationale: ESI Level 1 represents conditions requiring immediate life-saving intervention.
The unconscious trauma client with head injury requires immediate airway management and
neurological assessment. While the chest pain and stroke clients are urgent (ESI Level 2), they
are conscious and stable for immediate assessment. The open fracture, though serious, is ESI
Level 2 as bleeding can be controlled initially.
QUESTION 5
Client Needs: Management of Care
A psychiatric unit nurse observes that a client with bipolar disorder is becoming increasingly
agitated, pacing rapidly, and speaking in a pressured manner to other clients about
"government conspiracy." Several clients appear anxious and are moving away from the area.
What is the nurse's immediate priority?
A. Administer the client's PRN medication for agitation B. Remove other clients from the area
to ensure their safety C. Approach the client calmly and redirect to a quiet area D. Call security
to assist with physical restraint application
Answer: C
Rationale: De-escalation through calm redirection maintains therapeutic relationship while
addressing safety concerns. Approaching calmly and redirecting to a quiet area can often
prevent escalation without trauma. Removing other clients may increase the agitated client's
paranoia. PRN medication may be needed but should follow de-escalation attempts. Physical
restraints are last resort after other interventions fail.
QUESTION 6
Client Needs: Management of Care
During a telehealth visit, a nurse practitioner provides medication teaching to a client with
hypertension. The client mentions they cannot afford the prescribed medication and asks
about stopping their current medication to try herbal remedies instead. The nurse
practitioner is in a different state than the client. Which legal consideration is most
important for the nurse practitioner to address?
A. Ensuring the client understands the risks of discontinuing antihypertensive medication B.
Verifying licensure requirements for providing telehealth services across state lines C.
EXAM 4
High-Yield Qs & Answers with Rationales
SPECIALTY NURSING &
COMPLEX CARE
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
1
,Section A: Management of Care (Questions 1-40)
QUESTION 1
Client Needs: Management of Care
A home health nurse is supervising a licensed practical nurse (LPN) caring for a 78-year-old
client with diabetes and a stage 3 pressure ulcer. The LPN reports the wound appears infected
with purulent drainage and increased redness. The client's blood glucose is 284 mg/dL, and
vital signs show fever of 101.8°F.
Which action should the home health nurse take first?
A. Document the findings and schedule a wound care specialist consult B. Contact the primary
care provider immediately to report the assessment findings C. Instruct the LPN to increase
the frequency of wound care to twice daily D. Arrange for immediate hospitalization through
emergency medical services
Answer: B
Rationale: The combination of signs of infection (purulent drainage, increased redness,
fever) with hyperglycemia in a diabetic client represents a serious condition requiring
immediate physician notification. While documentation is important, it should not delay
urgent communication. The LPN cannot independently change wound care frequency without
orders. Hospitalization may be needed, but the physician must make this determination first.
QUESTION 2
Client Needs: Management of Care
The charge nurse in a pediatric unit receives the following assignments at the beginning of the
shift. Which client should be assigned to the most experienced registered nurse?
A. 6-month-old with bronchiolitis requiring frequent suctioning and oxygen monitoring B. 8-
year-old with appendicitis scheduled for surgery in 4 hours C. 12-year-old with diabetes
mellitus admitted for diabetic ketoacidosis D. 4-year-old with asthma receiving nebulizer
treatments every 2 hours
, Answer: C
Rationale: Diabetic ketoacidosis in pediatric clients requires complex monitoring of
electrolytes, acidbase balance, insulin administration, and neurological status with risk for
cerebral edema. This assignment demands the highest level of critical thinking and
experience. The bronchiolitis client, while requiring frequent assessment, has more
predictable care needs. The appendicitis client is stable pre-operatively. The asthma client has
routine treatment requirements.
QUESTION 3
Client Needs: Management of Care
A hospice nurse is developing a care plan for a terminally ill client with pancreatic cancer. The
client's adult daughter insists on continuing aggressive treatments despite the client
expressing wishes to focus on comfort care. The healthcare team is divided on the approach.
What is the nurse's priority action?
A. Support the daughter's decision as the primary caregiver B. Advocate for the client's
expressed wishes regarding end-of-life care C. Arrange a family meeting with the
interdisciplinary team to discuss goals of care D. Contact the hospital ethics committee for
guidance on the situation
Answer: C
Rationale: A family meeting with the interdisciplinary team allows for open
communication, clarification of the client's wishes, and education about hospice philosophy.
This collaborative approach addresses family dynamics while centering on the client's
autonomy. While advocating for the client is important, a meeting allows for better
understanding. Ethics committee involvement may be needed later if conflicts persist.
QUESTION 4
Client Needs: Management of Care
In the emergency department, a triage nurse using the 5-level Emergency Severity Index (ESI)
system evaluates four clients who arrive simultaneously. Which client should be triaged as ESI
Level 1 (most urgent)?
A. 45-year-old with severe chest pain, diaphoresis, and shortness of breath B. 32-year-old with
open fracture of the tibia with active bleeding C. 67-year-old with slurred speech, facial
drooping, and confusion of 30 minutes duration D. 28-year-old unconscious after motorcycle
accident with obvious head trauma
3
, Answer: D
Rationale: ESI Level 1 represents conditions requiring immediate life-saving intervention.
The unconscious trauma client with head injury requires immediate airway management and
neurological assessment. While the chest pain and stroke clients are urgent (ESI Level 2), they
are conscious and stable for immediate assessment. The open fracture, though serious, is ESI
Level 2 as bleeding can be controlled initially.
QUESTION 5
Client Needs: Management of Care
A psychiatric unit nurse observes that a client with bipolar disorder is becoming increasingly
agitated, pacing rapidly, and speaking in a pressured manner to other clients about
"government conspiracy." Several clients appear anxious and are moving away from the area.
What is the nurse's immediate priority?
A. Administer the client's PRN medication for agitation B. Remove other clients from the area
to ensure their safety C. Approach the client calmly and redirect to a quiet area D. Call security
to assist with physical restraint application
Answer: C
Rationale: De-escalation through calm redirection maintains therapeutic relationship while
addressing safety concerns. Approaching calmly and redirecting to a quiet area can often
prevent escalation without trauma. Removing other clients may increase the agitated client's
paranoia. PRN medication may be needed but should follow de-escalation attempts. Physical
restraints are last resort after other interventions fail.
QUESTION 6
Client Needs: Management of Care
During a telehealth visit, a nurse practitioner provides medication teaching to a client with
hypertension. The client mentions they cannot afford the prescribed medication and asks
about stopping their current medication to try herbal remedies instead. The nurse
practitioner is in a different state than the client. Which legal consideration is most
important for the nurse practitioner to address?
A. Ensuring the client understands the risks of discontinuing antihypertensive medication B.
Verifying licensure requirements for providing telehealth services across state lines C.
