NCLEX RN Management of Care
Practice Exam 4 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A Instant
Download Pdf
Question 1
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with chronic heart failure who has 2+ bilateral ankle edema
B. A client 1 day postoperative who reports incisional pain of 6/10
C. A client with pneumonia who has a new respiratory rate of 32/min
D. A client with diabetes who has a blood glucose level of 188 mg/dL
Answer: The client with pneumonia who has a new respiratory rate of 32/min
Rationale: A new increase in respiratory rate indicates possible respiratory
deterioration and takes priority according to airway and breathing principles.
Question 2
The nurse receives change-of-shift report. Which client should the nurse see
first?
A. A client with a potassium level of 3.4 mEq/L
B. A client receiving a blood transfusion who reports chills and low back pain
C. A client awaiting discharge instructions
D. A client requesting medication for chronic arthritis pain
Answer: The client receiving a blood transfusion who reports chills and low
back pain
,Rationale: Chills and low back pain during a transfusion may indicate an
acute hemolytic transfusion reaction. The transfusion should be stopped
immediately and emergency interventions initiated.
Question 3
Which task is appropriate for the RN to delegate to an experienced UAP?
A. Assessing a newly admitted client
B. Teaching a client how to use an incentive spirometer
C. Obtaining vital signs on a stable postoperative client
D. Evaluating a client's response to pain medication
Answer: Obtaining vital signs on a stable postoperative client
Rationale: Routine vital-sign measurement for a stable client can be
delegated. Assessment, teaching, and evaluation require nursing judgment.
Question 4
A nurse is assigning clients to an LPN/LVN. Which assignment is most
appropriate?
A. A newly admitted client with chest pain
B. A stable client receiving routine oral medications
C. A client requiring initial discharge teaching
D. A client with rapidly changing neurological status
Answer: A stable client receiving routine oral medications
Rationale: LPN/LVNs can care for stable clients with predictable outcomes
and administer medications within their scope of practice.
Question 5
A nurse discovers that a medication was administered to the wrong client.
What is the nurse's priority action?
A. Complete an incident report
B. Notify the nurse manager
C. Assess the client who received the medication
D. Document the error in the incident report
,Answer: Assess the client who received the medication
Rationale: The immediate priority after a medication error is determining
whether the client has experienced or is at risk for harm.
Question 6
A client refuses a prescribed surgical procedure. Which action should the nurse
take?
A. Ask the family to convince the client
B. Tell the client the procedure is necessary
C. Determine whether the client understands the risks and benefits
D. Notify security to prevent the client from leaving
Answer: Determine whether the client understands the risks and benefits
Rationale: A competent adult has the right to refuse treatment. The nurse
should verify that the refusal is informed and notify the provider as
appropriate.
Question 7
Which statement by a nurse demonstrates appropriate understanding of
informed consent?
A. “The nurse is responsible for explaining all surgical risks.”
B. “The provider performing the procedure is responsible for explaining the
procedure and risks.”
C. “The family must sign the consent for every adult client.”
D. “The nurse may sign the consent for the client if the provider is unavailable.”
Answer: “The provider performing the procedure is responsible for explaining
the procedure and risks.”
Rationale: The provider performing the procedure is responsible for obtaining
informed consent. The nurse generally witnesses the signature and verifies
voluntariness and understanding.
Question 8
A client tells the nurse, “I do not understand why I need this procedure.” What
should the nurse do?
, A. Explain the procedure in detail
B. Ask the client to sign the consent anyway
C. Notify the provider that additional explanation is needed
D. Ask a family member to explain the procedure
Answer: Notify the provider that additional explanation is needed
Rationale: The provider must explain the procedure, risks, benefits, and
alternatives. The nurse should not provide information beyond the nurse's
role or obtain consent when the client lacks understanding.
Question 9
Which client should be placed in a private room?
A. A client with a fractured femur
B. A client with pulmonary tuberculosis
C. A client with controlled hypertension
D. A client with osteoarthritis
Answer: The client with pulmonary tuberculosis
Rationale: Active pulmonary tuberculosis requires airborne precautions and
placement in an appropriate airborne infection isolation room.
Question 10
A nurse is caring for a client with Clostridioides difficile infection. Which
intervention is appropriate?
A. Use alcohol-based hand sanitizer after removing gloves
B. Place the client on droplet precautions
C. Wash hands with soap and water after client care
D. Use a standard surgical mask for all interactions
Answer: Wash hands with soap and water after client care
Rationale: C. difficile spores are not reliably removed by alcohol-based hand
sanitizer. Soap-and-water hand hygiene is required after caring for the client.
Question 11
Practice Exam 4 100 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A Instant
Download Pdf
Question 1
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with chronic heart failure who has 2+ bilateral ankle edema
B. A client 1 day postoperative who reports incisional pain of 6/10
C. A client with pneumonia who has a new respiratory rate of 32/min
D. A client with diabetes who has a blood glucose level of 188 mg/dL
Answer: The client with pneumonia who has a new respiratory rate of 32/min
Rationale: A new increase in respiratory rate indicates possible respiratory
deterioration and takes priority according to airway and breathing principles.
Question 2
The nurse receives change-of-shift report. Which client should the nurse see
first?
A. A client with a potassium level of 3.4 mEq/L
B. A client receiving a blood transfusion who reports chills and low back pain
C. A client awaiting discharge instructions
D. A client requesting medication for chronic arthritis pain
Answer: The client receiving a blood transfusion who reports chills and low
back pain
,Rationale: Chills and low back pain during a transfusion may indicate an
acute hemolytic transfusion reaction. The transfusion should be stopped
immediately and emergency interventions initiated.
Question 3
Which task is appropriate for the RN to delegate to an experienced UAP?
A. Assessing a newly admitted client
B. Teaching a client how to use an incentive spirometer
C. Obtaining vital signs on a stable postoperative client
D. Evaluating a client's response to pain medication
Answer: Obtaining vital signs on a stable postoperative client
Rationale: Routine vital-sign measurement for a stable client can be
delegated. Assessment, teaching, and evaluation require nursing judgment.
Question 4
A nurse is assigning clients to an LPN/LVN. Which assignment is most
appropriate?
A. A newly admitted client with chest pain
B. A stable client receiving routine oral medications
C. A client requiring initial discharge teaching
D. A client with rapidly changing neurological status
Answer: A stable client receiving routine oral medications
Rationale: LPN/LVNs can care for stable clients with predictable outcomes
and administer medications within their scope of practice.
Question 5
A nurse discovers that a medication was administered to the wrong client.
What is the nurse's priority action?
A. Complete an incident report
B. Notify the nurse manager
C. Assess the client who received the medication
D. Document the error in the incident report
,Answer: Assess the client who received the medication
Rationale: The immediate priority after a medication error is determining
whether the client has experienced or is at risk for harm.
Question 6
A client refuses a prescribed surgical procedure. Which action should the nurse
take?
A. Ask the family to convince the client
B. Tell the client the procedure is necessary
C. Determine whether the client understands the risks and benefits
D. Notify security to prevent the client from leaving
Answer: Determine whether the client understands the risks and benefits
Rationale: A competent adult has the right to refuse treatment. The nurse
should verify that the refusal is informed and notify the provider as
appropriate.
Question 7
Which statement by a nurse demonstrates appropriate understanding of
informed consent?
A. “The nurse is responsible for explaining all surgical risks.”
B. “The provider performing the procedure is responsible for explaining the
procedure and risks.”
C. “The family must sign the consent for every adult client.”
D. “The nurse may sign the consent for the client if the provider is unavailable.”
Answer: “The provider performing the procedure is responsible for explaining
the procedure and risks.”
Rationale: The provider performing the procedure is responsible for obtaining
informed consent. The nurse generally witnesses the signature and verifies
voluntariness and understanding.
Question 8
A client tells the nurse, “I do not understand why I need this procedure.” What
should the nurse do?
, A. Explain the procedure in detail
B. Ask the client to sign the consent anyway
C. Notify the provider that additional explanation is needed
D. Ask a family member to explain the procedure
Answer: Notify the provider that additional explanation is needed
Rationale: The provider must explain the procedure, risks, benefits, and
alternatives. The nurse should not provide information beyond the nurse's
role or obtain consent when the client lacks understanding.
Question 9
Which client should be placed in a private room?
A. A client with a fractured femur
B. A client with pulmonary tuberculosis
C. A client with controlled hypertension
D. A client with osteoarthritis
Answer: The client with pulmonary tuberculosis
Rationale: Active pulmonary tuberculosis requires airborne precautions and
placement in an appropriate airborne infection isolation room.
Question 10
A nurse is caring for a client with Clostridioides difficile infection. Which
intervention is appropriate?
A. Use alcohol-based hand sanitizer after removing gloves
B. Place the client on droplet precautions
C. Wash hands with soap and water after client care
D. Use a standard surgical mask for all interactions
Answer: Wash hands with soap and water after client care
Rationale: C. difficile spores are not reliably removed by alcohol-based hand
sanitizer. Soap-and-water hand hygiene is required after caring for the client.
Question 11
