**Priority, Delegation, and Clinical
Judgment: The NCLEX Leadership
Simulator 2025**
1. A charge nurse is making shift assignments on a medical-surgical unit. Which client should be assigned
to the most experienced RN?
A. Client with pneumonia requiring IV antibiotics every 8 hours.
B. Client with diabetes needing insulin before meals.
C. Client with new-onset chest pain and an unreadable ECG rhythm.
D. Client with a urinary tract infection and new orders for oral antibiotics.
💫RATIONALE✔️✔️: New-onset chest pain with unreadable ECG indicates potential life-threatening
arrhythmia requiring advanced assessment and intervention skills.
💫ANSWER✔️✔️: C. Client with new-onset chest pain and an unreadable ECG rhythm.
---
2. A nurse is caring for four clients. Which task can the nurse delegate to an unlicensed assistive
personnel (UAP)?
A. Assess the pain level of a post-operative client.
B. Reinforce dietary teaching for a client with heart failure.
C. Obtain a daily weight on a client with chronic kidney disease.
D. Evaluate the effectiveness of a client's incentive spirometer use.
💫RATIONALE✔️✔️: Obtaining a daily weight is a routine measurement that does not require clinical
judgment and is within UAP scope.
💫ANSWER✔️✔️: C. Obtain a daily weight on a client with chronic kidney disease.
,---
3. A nurse is caring for a client who suddenly becomes confused and has a blood pressure of 70/40 mm
Hg. Which action should the nurse take first?
A. Notify the provider.
B. Place the client in Trendelenburg position.
C. Increase the IV fluid rate.
D. Recheck the blood pressure in 5 minutes.
💫RATIONALE✔️✔️: Hypotension with confusion indicates shock; increasing IV fluids is the immediate
intervention to restore perfusion while awaiting orders.
💫ANSWER✔️✔️: C. Increase the IV fluid rate.
---
4. A charge nurse is observing a new graduate RN perform a sterile dressing change. Which action
requires immediate intervention?
A. The RN opens the sterile kit away from the body.
B. The RN sets the sterile field at waist level.
C. The RN turns their back to the sterile field to reach for tape.
D. The RN places a sterile item 2 inches from the edge of the field.
💫RATIONALE✔️✔️: Turning the back to a sterile field contaminates it because sterility cannot be
maintained when out of sight.
💫ANSWER✔️✔️: C. The RN turns their back to the sterile field to reach for tape.
---
5. A nurse receives a telephone order from a provider for a new medication. What is the nurse's priority
action?
A. Administer the medication immediately.
B. Read the order back to the provider verbatim.
C. Document the order in the client's chart.
D. Ask another nurse to listen to the order.
💫RATIONALE✔️✔️: Read-back verification (repeating the order word-for-word) is a safety mandate to
prevent telephone order errors.
,💫ANSWER✔️✔️: B. Read the order back to the provider verbatim.
---
6. A client with a do-not-resuscitate (DNR) order experiences respiratory arrest. The nurse should:
A. Begin chest compressions immediately.
B. Call a code blue and initiate CPR.
C. Provide comfort measures and support the family.
D. Intubate the client to maintain an airway.
💫RATIONALE✔️✔️: A valid DNR order means CPR and intubation are not performed; the nurse provides
comfort, positioning, and family support.
💫ANSWER✔️✔️: C. Provide comfort measures and support the family.
---
7. A nurse is preparing to administer a blood transfusion. Which action is most important to prevent a
hemolytic reaction?
A. Use a dedicated blood transfusion tubing set.
B. Obtain written informed consent from the client.
C. Verify the client identity and blood compatibility with another RN.
D. Premedicate the client with acetaminophen.
💫RATIONALE✔️✔️: Two-RN verification of client identity, blood type, and unit number is the primary
safeguard against ABO incompatibility hemolytic reactions.
💫ANSWER✔️✔️: C. Verify the client identity and blood compatibility with another RN.
---
8. A charge nurse is evaluating a staff nurse's response to a client with a new tracheostomy who has
desaturated to 85%. The nurse first calls a rapid response. Which statement by the charge nurse is best?
A. "You did the right thing by calling for help immediately."
B. "Next time, try to suction the tracheostomy first before calling."
C. "You should have checked the oxygen tank level first."
D. "Calling rapid response was an overreaction to this situation."
, 💫RATIONALE✔️✔️: Acute desaturation in a new tracheostomy may indicate tube obstruction; calling for
help is appropriate, but the first action should be to attempt to clear the airway.
💫ANSWER✔️✔️: B. "Next time, try to suction the tracheostomy first before calling."
---
9. A nurse manager is reviewing hand hygiene compliance. Which observation indicates a need for
further teaching?
A. A nurse uses an alcohol-based rub before donning sterile gloves.
B. A nurse washes hands with soap and water when visibly soiled.
C. A nurse wears gloves and then performs hand hygiene after removal.
D. A nurse uses alcohol-based rub for 10 seconds until dry.
💫RATIONALE✔️✔️: Alcohol-based hand rub should be applied for 15-20 seconds until dry; 10 seconds is
insufficient for effective microbial kill.
💫ANSWER✔️✔️: D. A nurse uses alcohol-based rub for 10 seconds until dry.
---
10. A client with a history of falls is being discharged home. Which referral is most important for the
nurse to initiate?
A. Physical therapy for gait training.
B. Occupational therapy for home safety evaluation.
C. Social work for financial assistance.
D. Speech therapy for swallow evaluation.
💫RATIONALE✔️✔️: Occupational therapy assesses home environmental hazards (rugs, lighting,
bathroom safety) and recommends modifications to prevent falls.
💫ANSWER✔️✔️: B. Occupational therapy for home safety evaluation.
---
11. A nurse is caring for a client with a chest tube. The drainage system is knocked over and cracks.
What is the priority action?
A. Clamp the chest tube with padded clamps.
Judgment: The NCLEX Leadership
Simulator 2025**
1. A charge nurse is making shift assignments on a medical-surgical unit. Which client should be assigned
to the most experienced RN?
A. Client with pneumonia requiring IV antibiotics every 8 hours.
B. Client with diabetes needing insulin before meals.
C. Client with new-onset chest pain and an unreadable ECG rhythm.
D. Client with a urinary tract infection and new orders for oral antibiotics.
💫RATIONALE✔️✔️: New-onset chest pain with unreadable ECG indicates potential life-threatening
arrhythmia requiring advanced assessment and intervention skills.
💫ANSWER✔️✔️: C. Client with new-onset chest pain and an unreadable ECG rhythm.
---
2. A nurse is caring for four clients. Which task can the nurse delegate to an unlicensed assistive
personnel (UAP)?
A. Assess the pain level of a post-operative client.
B. Reinforce dietary teaching for a client with heart failure.
C. Obtain a daily weight on a client with chronic kidney disease.
D. Evaluate the effectiveness of a client's incentive spirometer use.
💫RATIONALE✔️✔️: Obtaining a daily weight is a routine measurement that does not require clinical
judgment and is within UAP scope.
💫ANSWER✔️✔️: C. Obtain a daily weight on a client with chronic kidney disease.
,---
3. A nurse is caring for a client who suddenly becomes confused and has a blood pressure of 70/40 mm
Hg. Which action should the nurse take first?
A. Notify the provider.
B. Place the client in Trendelenburg position.
C. Increase the IV fluid rate.
D. Recheck the blood pressure in 5 minutes.
💫RATIONALE✔️✔️: Hypotension with confusion indicates shock; increasing IV fluids is the immediate
intervention to restore perfusion while awaiting orders.
💫ANSWER✔️✔️: C. Increase the IV fluid rate.
---
4. A charge nurse is observing a new graduate RN perform a sterile dressing change. Which action
requires immediate intervention?
A. The RN opens the sterile kit away from the body.
B. The RN sets the sterile field at waist level.
C. The RN turns their back to the sterile field to reach for tape.
D. The RN places a sterile item 2 inches from the edge of the field.
💫RATIONALE✔️✔️: Turning the back to a sterile field contaminates it because sterility cannot be
maintained when out of sight.
💫ANSWER✔️✔️: C. The RN turns their back to the sterile field to reach for tape.
---
5. A nurse receives a telephone order from a provider for a new medication. What is the nurse's priority
action?
A. Administer the medication immediately.
B. Read the order back to the provider verbatim.
C. Document the order in the client's chart.
D. Ask another nurse to listen to the order.
💫RATIONALE✔️✔️: Read-back verification (repeating the order word-for-word) is a safety mandate to
prevent telephone order errors.
,💫ANSWER✔️✔️: B. Read the order back to the provider verbatim.
---
6. A client with a do-not-resuscitate (DNR) order experiences respiratory arrest. The nurse should:
A. Begin chest compressions immediately.
B. Call a code blue and initiate CPR.
C. Provide comfort measures and support the family.
D. Intubate the client to maintain an airway.
💫RATIONALE✔️✔️: A valid DNR order means CPR and intubation are not performed; the nurse provides
comfort, positioning, and family support.
💫ANSWER✔️✔️: C. Provide comfort measures and support the family.
---
7. A nurse is preparing to administer a blood transfusion. Which action is most important to prevent a
hemolytic reaction?
A. Use a dedicated blood transfusion tubing set.
B. Obtain written informed consent from the client.
C. Verify the client identity and blood compatibility with another RN.
D. Premedicate the client with acetaminophen.
💫RATIONALE✔️✔️: Two-RN verification of client identity, blood type, and unit number is the primary
safeguard against ABO incompatibility hemolytic reactions.
💫ANSWER✔️✔️: C. Verify the client identity and blood compatibility with another RN.
---
8. A charge nurse is evaluating a staff nurse's response to a client with a new tracheostomy who has
desaturated to 85%. The nurse first calls a rapid response. Which statement by the charge nurse is best?
A. "You did the right thing by calling for help immediately."
B. "Next time, try to suction the tracheostomy first before calling."
C. "You should have checked the oxygen tank level first."
D. "Calling rapid response was an overreaction to this situation."
, 💫RATIONALE✔️✔️: Acute desaturation in a new tracheostomy may indicate tube obstruction; calling for
help is appropriate, but the first action should be to attempt to clear the airway.
💫ANSWER✔️✔️: B. "Next time, try to suction the tracheostomy first before calling."
---
9. A nurse manager is reviewing hand hygiene compliance. Which observation indicates a need for
further teaching?
A. A nurse uses an alcohol-based rub before donning sterile gloves.
B. A nurse washes hands with soap and water when visibly soiled.
C. A nurse wears gloves and then performs hand hygiene after removal.
D. A nurse uses alcohol-based rub for 10 seconds until dry.
💫RATIONALE✔️✔️: Alcohol-based hand rub should be applied for 15-20 seconds until dry; 10 seconds is
insufficient for effective microbial kill.
💫ANSWER✔️✔️: D. A nurse uses alcohol-based rub for 10 seconds until dry.
---
10. A client with a history of falls is being discharged home. Which referral is most important for the
nurse to initiate?
A. Physical therapy for gait training.
B. Occupational therapy for home safety evaluation.
C. Social work for financial assistance.
D. Speech therapy for swallow evaluation.
💫RATIONALE✔️✔️: Occupational therapy assesses home environmental hazards (rugs, lighting,
bathroom safety) and recommends modifications to prevent falls.
💫ANSWER✔️✔️: B. Occupational therapy for home safety evaluation.
---
11. A nurse is caring for a client with a chest tube. The drainage system is knocked over and cracks.
What is the priority action?
A. Clamp the chest tube with padded clamps.
