NCLEX 10000 Management of Care
UPDATED ACTUAL Exam Questions and
CORRECT Answers
A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-
hour period. What is the priority nursing action? - CORRECT ANSWER - Offer the client
proportioned fluids in the day and less during the night.
Explanation:
The client and nurse should make a fluid schedule that takes into consideration factors such as
periods of wakefulness, number of meals, oral medications, and personal preferences. Avoiding
night fluids will decrease risk for aspiration.
While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of
one of the nurses. The charge nurse should: - CORRECT ANSWER - Report this to the
nursing supervisor immediately
Explanation:
This situation should be reported immediately to the nursing supervisor or manager at the time.
The nurse is liable to report a suspicious situation that could create an unsafe situation for the
clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a
high-risk situation. The supervisor will then follow the correct procedure for management and
follow-up of the situation.
The nurse is caring for an adolescent with cancer who is well informed about the medical
condition and treatment. The adolescent refused the morning medications and states intentions of
refusing all future medications. What is the best action by the nurse? - CORRECT
ANSWER - Document the adolescent's choice and offer to discuss feelings about the
medication.
Explanation:
The client has the right to choose whether to take the medication. The nurse should try to
determine the reason for the adolescent not wanting the medication other than choice (e.g., side
effects, fear of falling asleep and not waking).
A nurse who is a case manager is responsible for assigning client care to unregulated care
providers (UCPs). The nurse is planning the care for a new client who requires several
,treatments. Which of the following UCPs should the nurse assign to the new client? - CORRECT
ANSWER - The UCP with the appropriate knowledge and skills to provide the care
Explanation:
The nurse is accountable for the assignment of tasks to UCPs. The nurse must ensure that the
care being assigned is consistent with the UCP's level of knowledge, skill, and judgment.
Assignments must also consider the UCP job description, agency policy, legislation, and client
need.
A nurse is working within the managed care delivery model. Which of the following is true
regarding managed care? - CORRECT ANSWER - All systems reflect the values of
efficiency and effectiveness.
Explanation:
All systems in the managed care delivery model reflect the values of efficiency and
effectiveness. Different plans may have different values underlying the delivery of care.
However, they all reflect the business plan values of efficiency and effectiveness.
The nurse is caring for several neonates in the newborn nursery. Precautions that should be taken
to prevent an infant abduction include which of the following? - CORRECT ANSWER -
Notifying the hospital's security staff about anyone who appears unusual
Explanation:
The nurse should notify the hospital's security staff about anyone who appears unusual.
In many institutions, which of the following telephone or fax orders requires a signature within
24 hours by the ordering physician or nurse practitioner? - CORRECT ANSWER - Orders
for antibiotics.
Explanation:
Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and
antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims.
Which information should be placed on the tag? Select all that apply. - CORRECT
ANSWER - • triage priority
• medications and treatments administered
, • identifying information when possible (such as name, age, and address)
Explanation:
Tracking victims of disasters is important for casualty planning and management. All victims
should receive a tag, securely attached, that indicates the triage priority, any available identifying
information, and what care, if any, has been given along with time and date. Tag information
should be recorded in a disaster log and used to track victims and inform families.
A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the
physician for her toddler's otitis media. The nurse's best response is to: - CORRECT
ANSWER - Confer with the physician about whether a less expensive drug could be
ordered.
The nurse must act as an advocate for the client when the client cannot afford treatment. It is
possible to substitute a less expensive antibiotic. Correct procedure includes contacting the
physician to explain the mother's economic situation and request a substitution. For example,
amoxicillin is more economical than azithromycin
The nurse's unit council in the telemetry unit is responsible for performance improvement
studies. What information should they gather to study whether client education about resuming
sexual activity after an acute myocardial infarction (MI) is being taught? - CORRECT
ANSWER - The percentage of clients on the unit diagnosed with an acute MI who were
taught about resuming sexual activity
Explanation:
The unit council needs to assess the number of clients diagnosed with an acute MI on the
telemetry unit who were actually taught about resuming sexual activity. The unit council needs to
identify the number of clients who were taught, not the quality of the teaching. Only education
about resuming sexual activity is pertinent to this performance improvement study.
A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is
coming to prepare a living will and requests the nurse to sign as witness. Which of the following
actions should the nurse take? - CORRECT ANSWER - Note that the nurse caring for the
client cannot be a witness.
Explanation:
A living will is an instructive form of an advance directive. It is a written document that
identifies a person's preferences regarding medical interventions to use in a terminal condition,
irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the
health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness.
UPDATED ACTUAL Exam Questions and
CORRECT Answers
A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-
hour period. What is the priority nursing action? - CORRECT ANSWER - Offer the client
proportioned fluids in the day and less during the night.
Explanation:
The client and nurse should make a fluid schedule that takes into consideration factors such as
periods of wakefulness, number of meals, oral medications, and personal preferences. Avoiding
night fluids will decrease risk for aspiration.
While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of
one of the nurses. The charge nurse should: - CORRECT ANSWER - Report this to the
nursing supervisor immediately
Explanation:
This situation should be reported immediately to the nursing supervisor or manager at the time.
The nurse is liable to report a suspicious situation that could create an unsafe situation for the
clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a
high-risk situation. The supervisor will then follow the correct procedure for management and
follow-up of the situation.
The nurse is caring for an adolescent with cancer who is well informed about the medical
condition and treatment. The adolescent refused the morning medications and states intentions of
refusing all future medications. What is the best action by the nurse? - CORRECT
ANSWER - Document the adolescent's choice and offer to discuss feelings about the
medication.
Explanation:
The client has the right to choose whether to take the medication. The nurse should try to
determine the reason for the adolescent not wanting the medication other than choice (e.g., side
effects, fear of falling asleep and not waking).
A nurse who is a case manager is responsible for assigning client care to unregulated care
providers (UCPs). The nurse is planning the care for a new client who requires several
,treatments. Which of the following UCPs should the nurse assign to the new client? - CORRECT
ANSWER - The UCP with the appropriate knowledge and skills to provide the care
Explanation:
The nurse is accountable for the assignment of tasks to UCPs. The nurse must ensure that the
care being assigned is consistent with the UCP's level of knowledge, skill, and judgment.
Assignments must also consider the UCP job description, agency policy, legislation, and client
need.
A nurse is working within the managed care delivery model. Which of the following is true
regarding managed care? - CORRECT ANSWER - All systems reflect the values of
efficiency and effectiveness.
Explanation:
All systems in the managed care delivery model reflect the values of efficiency and
effectiveness. Different plans may have different values underlying the delivery of care.
However, they all reflect the business plan values of efficiency and effectiveness.
The nurse is caring for several neonates in the newborn nursery. Precautions that should be taken
to prevent an infant abduction include which of the following? - CORRECT ANSWER -
Notifying the hospital's security staff about anyone who appears unusual
Explanation:
The nurse should notify the hospital's security staff about anyone who appears unusual.
In many institutions, which of the following telephone or fax orders requires a signature within
24 hours by the ordering physician or nurse practitioner? - CORRECT ANSWER - Orders
for antibiotics.
Explanation:
Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and
antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims.
Which information should be placed on the tag? Select all that apply. - CORRECT
ANSWER - • triage priority
• medications and treatments administered
, • identifying information when possible (such as name, age, and address)
Explanation:
Tracking victims of disasters is important for casualty planning and management. All victims
should receive a tag, securely attached, that indicates the triage priority, any available identifying
information, and what care, if any, has been given along with time and date. Tag information
should be recorded in a disaster log and used to track victims and inform families.
A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the
physician for her toddler's otitis media. The nurse's best response is to: - CORRECT
ANSWER - Confer with the physician about whether a less expensive drug could be
ordered.
The nurse must act as an advocate for the client when the client cannot afford treatment. It is
possible to substitute a less expensive antibiotic. Correct procedure includes contacting the
physician to explain the mother's economic situation and request a substitution. For example,
amoxicillin is more economical than azithromycin
The nurse's unit council in the telemetry unit is responsible for performance improvement
studies. What information should they gather to study whether client education about resuming
sexual activity after an acute myocardial infarction (MI) is being taught? - CORRECT
ANSWER - The percentage of clients on the unit diagnosed with an acute MI who were
taught about resuming sexual activity
Explanation:
The unit council needs to assess the number of clients diagnosed with an acute MI on the
telemetry unit who were actually taught about resuming sexual activity. The unit council needs to
identify the number of clients who were taught, not the quality of the teaching. Only education
about resuming sexual activity is pertinent to this performance improvement study.
A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is
coming to prepare a living will and requests the nurse to sign as witness. Which of the following
actions should the nurse take? - CORRECT ANSWER - Note that the nurse caring for the
client cannot be a witness.
Explanation:
A living will is an instructive form of an advance directive. It is a written document that
identifies a person's preferences regarding medical interventions to use in a terminal condition,
irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the
health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness.
