NCLEX-RN Management of Care
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1A nurse is caring for four clients on a medical-surgical unit. Which client should
the nurse assess first?
A. A client with heart failure who has gained 2 kg in 3 days
B. A client with pneumonia whose oxygen saturation decreased from 94% to 89%
C. A client with diabetes whose blood glucose is 214 mg/dL
D. A client 2 days postoperative who reports incisional pain rated 6/10
Answer: A client with pneumonia whose oxygen saturation decreased from 94%
to 89%.
Rationale: A declining oxygen saturation in a client with pneumonia indicates
worsening respiratory status and possible impaired gas exchange. Airway and
breathing problems take priority over fluid retention, hyperglycemia, and
postoperative pain.
2. The charge nurse is assigning clients to an experienced LPN/LVN. Which
assignment is most appropriate?
A. A client admitted with chest pain and possible myocardial infarction
B. A client requiring initial teaching about a newly prescribed insulin regimen
C. A stable client receiving routine postoperative wound care
D. A client with a new tracheostomy requiring frequent assessment
Answer: A stable client receiving routine postoperative wound care.
,Rationale: An LPN/LVN can care for stable clients with predictable outcomes and
perform routine procedures. Initial assessments, unstable clients, and initial
teaching requiring nursing judgment should remain with the RN.
3. The RN delegates vital-sign measurement to an unlicensed assistive
personnel (UAP). Which finding requires immediate reporting to the RN?
A. Temperature 37.2°C (99°F)
B. Pulse 84/min
C. Respirations 30/min
D. Blood pressure 128/76 mm Hg
Answer: Respirations 30/min.
Rationale: Tachypnea may indicate respiratory compromise and requires RN
assessment. The UAP collects the data, but the RN interprets abnormal findings
and determines appropriate interventions.
4. A client refuses a blood transfusion for religious reasons. The family asks
the nurse to administer the blood anyway because the client is “too weak
to decide.” What should the nurse do?
A. Ask the family to sign consent
B. Administer the blood because it is medically necessary
C. Respect the client's refusal and notify the provider
D. Ask another nurse to obtain consent
Answer: Respect the client's refusal and notify the provider.
Rationale: A competent adult has the right to refuse treatment, even when
refusal may result in serious harm or death. The nurse should respect autonomy,
document the refusal, and notify the appropriate provider.
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 for adverse effects
D. Document the error in the incident report only
Answer: Assess the client for adverse effects.
Rationale: Client safety is the immediate priority after a medication error. The
nurse should assess the client, notify the provider and appropriate personnel,
follow organizational policy, and complete required documentation.
6. A nurse is caring for a client who is confused and repeatedly attempts to
climb out of bed. Which intervention should the nurse implement first?
A. Apply wrist restraints
B. Request a sedative prescription
C. Determine the cause of the confusion and implement safety measures
D. Ask the family to remain at the bedside continuously
Answer: Determine the cause of the confusion and implement safety measures.
Rationale: Restraints are a last resort. The nurse should assess for reversible
causes of confusion, reduce environmental hazards, use less restrictive
interventions, and maintain client safety.
7. A nurse receives a prescription that appears unsafe because the dosage is
significantly higher than the usual range. What should the nurse do?
A. Administer the medication because the provider prescribed it
B. Ask another nurse to verify the dose and then administer it
C. Clarify the prescription with the prescribing provider
D. Change the dose to the usual range
Answer: Clarify the prescription with the prescribing provider.
Rationale: Nurses are accountable for recognizing potentially unsafe
prescriptions. The nurse should hold the medication and clarify the order rather
than independently changing the prescribed dose.
8. Which task is appropriate for the RN to delegate to a UAP?
, A. Evaluating a client's response to pain medication
B. Teaching a client how to use an incentive spirometer
C. Assisting a stable client with bathing
D. Assessing a client with new-onset confusion
Answer: Assisting a stable client with bathing.
Rationale: UAPs may perform routine, nonassessment activities for stable
clients. Assessment, evaluation, and teaching remain RN responsibilities.
9. A nurse is preparing discharge instructions for a client with heart failure.
Which finding indicates that additional teaching is needed?
A. The client weighs themselves each morning
B. The client reports calling the provider after gaining 2 kg in 2 days
C. The client states, “I will stop taking my diuretic when my swelling goes away.”
D. The client limits dietary sodium as instructed
Answer: The client states, “I will stop taking my diuretic when my swelling goes
away.”
Rationale: Prescribed medications should not be discontinued without
consultation with the provider. Heart failure management requires adherence to
the medication regimen and monitoring for worsening symptoms.
10.A client with a terminal illness tells the nurse, “I do not want any more
aggressive treatment.” Which ethical principle is primarily involved?
A. Justice
B. Autonomy
C. Fidelity
D. Nonmaleficence
Answer: Autonomy.
Rationale: Autonomy is the client's right to make informed decisions regarding
their own healthcare, including accepting or refusing treatment.
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1A nurse is caring for four clients on a medical-surgical unit. Which client should
the nurse assess first?
A. A client with heart failure who has gained 2 kg in 3 days
B. A client with pneumonia whose oxygen saturation decreased from 94% to 89%
C. A client with diabetes whose blood glucose is 214 mg/dL
D. A client 2 days postoperative who reports incisional pain rated 6/10
Answer: A client with pneumonia whose oxygen saturation decreased from 94%
to 89%.
Rationale: A declining oxygen saturation in a client with pneumonia indicates
worsening respiratory status and possible impaired gas exchange. Airway and
breathing problems take priority over fluid retention, hyperglycemia, and
postoperative pain.
2. The charge nurse is assigning clients to an experienced LPN/LVN. Which
assignment is most appropriate?
A. A client admitted with chest pain and possible myocardial infarction
B. A client requiring initial teaching about a newly prescribed insulin regimen
C. A stable client receiving routine postoperative wound care
D. A client with a new tracheostomy requiring frequent assessment
Answer: A stable client receiving routine postoperative wound care.
,Rationale: An LPN/LVN can care for stable clients with predictable outcomes and
perform routine procedures. Initial assessments, unstable clients, and initial
teaching requiring nursing judgment should remain with the RN.
3. The RN delegates vital-sign measurement to an unlicensed assistive
personnel (UAP). Which finding requires immediate reporting to the RN?
A. Temperature 37.2°C (99°F)
B. Pulse 84/min
C. Respirations 30/min
D. Blood pressure 128/76 mm Hg
Answer: Respirations 30/min.
Rationale: Tachypnea may indicate respiratory compromise and requires RN
assessment. The UAP collects the data, but the RN interprets abnormal findings
and determines appropriate interventions.
4. A client refuses a blood transfusion for religious reasons. The family asks
the nurse to administer the blood anyway because the client is “too weak
to decide.” What should the nurse do?
A. Ask the family to sign consent
B. Administer the blood because it is medically necessary
C. Respect the client's refusal and notify the provider
D. Ask another nurse to obtain consent
Answer: Respect the client's refusal and notify the provider.
Rationale: A competent adult has the right to refuse treatment, even when
refusal may result in serious harm or death. The nurse should respect autonomy,
document the refusal, and notify the appropriate provider.
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 for adverse effects
D. Document the error in the incident report only
Answer: Assess the client for adverse effects.
Rationale: Client safety is the immediate priority after a medication error. The
nurse should assess the client, notify the provider and appropriate personnel,
follow organizational policy, and complete required documentation.
6. A nurse is caring for a client who is confused and repeatedly attempts to
climb out of bed. Which intervention should the nurse implement first?
A. Apply wrist restraints
B. Request a sedative prescription
C. Determine the cause of the confusion and implement safety measures
D. Ask the family to remain at the bedside continuously
Answer: Determine the cause of the confusion and implement safety measures.
Rationale: Restraints are a last resort. The nurse should assess for reversible
causes of confusion, reduce environmental hazards, use less restrictive
interventions, and maintain client safety.
7. A nurse receives a prescription that appears unsafe because the dosage is
significantly higher than the usual range. What should the nurse do?
A. Administer the medication because the provider prescribed it
B. Ask another nurse to verify the dose and then administer it
C. Clarify the prescription with the prescribing provider
D. Change the dose to the usual range
Answer: Clarify the prescription with the prescribing provider.
Rationale: Nurses are accountable for recognizing potentially unsafe
prescriptions. The nurse should hold the medication and clarify the order rather
than independently changing the prescribed dose.
8. Which task is appropriate for the RN to delegate to a UAP?
, A. Evaluating a client's response to pain medication
B. Teaching a client how to use an incentive spirometer
C. Assisting a stable client with bathing
D. Assessing a client with new-onset confusion
Answer: Assisting a stable client with bathing.
Rationale: UAPs may perform routine, nonassessment activities for stable
clients. Assessment, evaluation, and teaching remain RN responsibilities.
9. A nurse is preparing discharge instructions for a client with heart failure.
Which finding indicates that additional teaching is needed?
A. The client weighs themselves each morning
B. The client reports calling the provider after gaining 2 kg in 2 days
C. The client states, “I will stop taking my diuretic when my swelling goes away.”
D. The client limits dietary sodium as instructed
Answer: The client states, “I will stop taking my diuretic when my swelling goes
away.”
Rationale: Prescribed medications should not be discontinued without
consultation with the provider. Heart failure management requires adherence to
the medication regimen and monitoring for worsening symptoms.
10.A client with a terminal illness tells the nurse, “I do not want any more
aggressive treatment.” Which ethical principle is primarily involved?
A. Justice
B. Autonomy
C. Fidelity
D. Nonmaleficence
Answer: Autonomy.
Rationale: Autonomy is the client's right to make informed decisions regarding
their own healthcare, including accepting or refusing treatment.
