NCLEX-RN Management of Care
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1.
The nurse is caring for four clients on a medical-surgical unit. Which client should
the nurse assess first?
A. A client with chronic heart failure who has 2+ bilateral ankle edema
B. A client 2 days after hip replacement reporting pain of 7/10
C. A client with pneumonia who has new confusion and a respiratory rate of
30/min
D. A client with diabetes whose premeal glucose is 218 mg/dL
Answer: C. A client with pneumonia who has new confusion and a respiratory
rate of 30/min
Rationale: New confusion and tachypnea in a client with pneumonia may
indicate worsening hypoxemia or sepsis. Airway and breathing threats take
priority over pain, chronic edema, and moderate hyperglycemia.
2.
The charge nurse is assigning clients to registered nurses. Which assignment is
most appropriate for a newly licensed RN?
,A. Client receiving titrated IV vasopressors
B. Client requiring frequent neurological assessments after intracranial
hemorrhage
C. Stable client receiving routine postoperative care after an uncomplicated
appendectomy
D. Client with diabetic ketoacidosis receiving an insulin infusion
Answer: C. Stable client receiving routine postoperative care after an
uncomplicated appendectomy
Rationale: A newly licensed RN should initially receive stable clients with
predictable outcomes. Titrated vasoactive medications, intracranial
hemorrhage, and DKA require greater clinical judgment and experience.
3.
A nurse receives report on four clients. Which client should be seen first?
A. A client with COPD whose oxygen saturation is 91% on prescribed oxygen
B. A client with a tracheostomy who suddenly has noisy respirations and
increased work of breathing
C. A client with chronic kidney disease who has potassium of 5.3 mEq/L
D. A client with osteoarthritis requesting analgesia
Answer: B. A client with a tracheostomy who suddenly has noisy respirations
and increased work of breathing
Rationale: Sudden respiratory distress in a client with a tracheostomy suggests
airway obstruction or displacement. Immediate airway assessment and
intervention take priority.
4.
,A nurse delegates vital-sign measurement to an experienced UAP. Which finding
requires immediate RN follow-up?
A. Blood pressure 128/74 mm Hg
B. Heart rate 84/min
C. Respiratory rate 8/min in a client receiving IV opioids
D. Temperature 37.1°C (98.8°F)
Answer: Respiratory rate 8/min in a client receiving IV opioids
Rationale: Opioid-related respiratory depression is potentially life-threatening.
The UAP may collect the data, but the RN must interpret abnormal findings and
intervene.
5.
A nurse is caring for a client who refuses a prescribed blood transfusion because
of personal beliefs. Which action is most appropriate?
A. Ask the family to convince the client
B. Explain that the transfusion is medically necessary
C. Respect the refusal and notify the healthcare provider
D. Administer the transfusion because it is prescribed
Answer: Respect the refusal and notify the healthcare provider
Rationale: Competent clients have the right to refuse treatment, even when
refusal may result in serious harm. The nurse should verify understanding,
document the refusal, and notify the provider.
6.
Which client is most appropriate for assignment to an LPN/LVN?
, A. Client with unstable sepsis requiring frequent reassessment
B. Client receiving a continuous titrated heparin infusion
C. Stable client requiring routine wound care and oral medications
D. Newly admitted client with acute chest pain
Answer: Stable client requiring routine wound care and oral medications
Rationale: LPN/LVN assignments should generally involve stable clients with
predictable outcomes and established plans of care. Unstable clients and those
requiring complex assessments remain with the RN.
7.
A nurse discovers that another nurse administered the wrong medication dose.
The client is currently asymptomatic. What should the nurse do first?
A. Complete an incident report
B. Notify the nurse manager
C. Assess the client
D. Document the error in the medication administration record
Answer: Assess the client
Rationale: The client's immediate safety is the priority. The nurse should assess
for adverse effects, notify the provider as appropriate, implement treatment,
and then complete required reporting and documentation.
8.
A client with limited English proficiency is being prepared for surgery. Which
intervention is most appropriate?
A. Ask the client's adult child to interpret
B. Use a qualified medical interpreter
Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1.
The nurse is caring for four clients on a medical-surgical unit. Which client should
the nurse assess first?
A. A client with chronic heart failure who has 2+ bilateral ankle edema
B. A client 2 days after hip replacement reporting pain of 7/10
C. A client with pneumonia who has new confusion and a respiratory rate of
30/min
D. A client with diabetes whose premeal glucose is 218 mg/dL
Answer: C. A client with pneumonia who has new confusion and a respiratory
rate of 30/min
Rationale: New confusion and tachypnea in a client with pneumonia may
indicate worsening hypoxemia or sepsis. Airway and breathing threats take
priority over pain, chronic edema, and moderate hyperglycemia.
2.
The charge nurse is assigning clients to registered nurses. Which assignment is
most appropriate for a newly licensed RN?
,A. Client receiving titrated IV vasopressors
B. Client requiring frequent neurological assessments after intracranial
hemorrhage
C. Stable client receiving routine postoperative care after an uncomplicated
appendectomy
D. Client with diabetic ketoacidosis receiving an insulin infusion
Answer: C. Stable client receiving routine postoperative care after an
uncomplicated appendectomy
Rationale: A newly licensed RN should initially receive stable clients with
predictable outcomes. Titrated vasoactive medications, intracranial
hemorrhage, and DKA require greater clinical judgment and experience.
3.
A nurse receives report on four clients. Which client should be seen first?
A. A client with COPD whose oxygen saturation is 91% on prescribed oxygen
B. A client with a tracheostomy who suddenly has noisy respirations and
increased work of breathing
C. A client with chronic kidney disease who has potassium of 5.3 mEq/L
D. A client with osteoarthritis requesting analgesia
Answer: B. A client with a tracheostomy who suddenly has noisy respirations
and increased work of breathing
Rationale: Sudden respiratory distress in a client with a tracheostomy suggests
airway obstruction or displacement. Immediate airway assessment and
intervention take priority.
4.
,A nurse delegates vital-sign measurement to an experienced UAP. Which finding
requires immediate RN follow-up?
A. Blood pressure 128/74 mm Hg
B. Heart rate 84/min
C. Respiratory rate 8/min in a client receiving IV opioids
D. Temperature 37.1°C (98.8°F)
Answer: Respiratory rate 8/min in a client receiving IV opioids
Rationale: Opioid-related respiratory depression is potentially life-threatening.
The UAP may collect the data, but the RN must interpret abnormal findings and
intervene.
5.
A nurse is caring for a client who refuses a prescribed blood transfusion because
of personal beliefs. Which action is most appropriate?
A. Ask the family to convince the client
B. Explain that the transfusion is medically necessary
C. Respect the refusal and notify the healthcare provider
D. Administer the transfusion because it is prescribed
Answer: Respect the refusal and notify the healthcare provider
Rationale: Competent clients have the right to refuse treatment, even when
refusal may result in serious harm. The nurse should verify understanding,
document the refusal, and notify the provider.
6.
Which client is most appropriate for assignment to an LPN/LVN?
, A. Client with unstable sepsis requiring frequent reassessment
B. Client receiving a continuous titrated heparin infusion
C. Stable client requiring routine wound care and oral medications
D. Newly admitted client with acute chest pain
Answer: Stable client requiring routine wound care and oral medications
Rationale: LPN/LVN assignments should generally involve stable clients with
predictable outcomes and established plans of care. Unstable clients and those
requiring complex assessments remain with the RN.
7.
A nurse discovers that another nurse administered the wrong medication dose.
The client is currently asymptomatic. What should the nurse do first?
A. Complete an incident report
B. Notify the nurse manager
C. Assess the client
D. Document the error in the medication administration record
Answer: Assess the client
Rationale: The client's immediate safety is the priority. The nurse should assess
for adverse effects, notify the provider as appropriate, implement treatment,
and then complete required reporting and documentation.
8.
A client with limited English proficiency is being prepared for surgery. Which
intervention is most appropriate?
A. Ask the client's adult child to interpret
B. Use a qualified medical interpreter
