NCLEX RN Management of Care Practice
Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A charge nurse is reviewing the assignments for the shift. Which assignment
is most appropriate for a licensed practical nurse (LPN) who has worked on
the unit for 2 years?
A. A client receiving a blood transfusion who had a reaction earlier in the
shift.
B. A client who is 2 days post-operative following an abdominal aortic
aneurysm repair.
C. A client who requires a nasogastric tube feeding and has a gastrostomy
tube.
D. A client who is receiving intravenous heparin and requires frequent
activated partial thromboplastin time (aPTT) monitoring.
Answer: C
Rationale: The LPN's scope of practice includes stable clients with
predictable outcomes, such as administering enteral feedings via an
established gastrostomy tube. The charge nurse must assign care based
on staff competency and client acuity. Clients receiving blood transfusions
(A), those in the immediate postoperative period after major vascular
surgery (B), and those on titrated IV heparin with frequent lab monitoring
(D) require the ongoing assessment and critical thinking skills of a
registered nurse (RN). Assigning the client with the gastrostomy tube to
the LPN allows the RN to retain responsibility for the unstable or complex
clients.
2. A registered nurse (RN) is preparing to delegate the task of obtaining a
blood glucose level via fingerstick to a certified nursing assistant (CNA).
, Which statement by the RN demonstrates proper delegation?
A. "I am delegating this task to you, but I will not be responsible for the
results because you are performing it."
B. "Please obtain the blood glucose on the client in room 205 and call me if
it is above 200 mg/dL."
C. "You have performed this task before, so you know how to do it without
any specific instructions."
D. "You are responsible for assessing the client's response to the insulin
based on the glucose result."
Answer: B
Rationale: Effective delegation involves clear communication of the
specific task, the client, and the parameters for reporting back to the
delegating RN. Option B demonstrates this by giving a clear task and a
specific threshold for notification. The RN retains accountability for the
overall nursing care and supervision (A is incorrect). The RN must provide
specific instructions, not assume prior knowledge (C). Assessment and
evaluation of the client's response to treatment cannot be delegated to a
CNA; these are RN responsibilities (D). The RN must ensure the CNA is
competent to perform the task, but providing clear guidance is essential.
3. A nurse is prioritizing care for four clients on a medical-surgical unit. Which
client should the nurse assess first?
A. A client with chronic obstructive pulmonary disease (COPD) who has an
oxygen saturation of 88% on 2 liters of nasal cannula.
B. A client who is post-operative day 1 from a hysterectomy and has a
dressing that is saturated with serosanguineous drainage.
C. A client who is receiving a blood transfusion and reports itching and a
feeling of warmth.
D. A client with type 2 diabetes mellitus who had a blood glucose level of
150 mg/dL before lunch.
Answer: C
Rationale: The nurse must use the ABCs (Airway, Breathing, Circulation)
and safety principles to prioritize. While the client with COPD has a low
, oxygen saturation, this is a chronic baseline for many clients with COPD
and may not be an acute change. The client with the saturated dressing
requires attention but is not immediately life-threatening. The client with
diabetes has a mild elevation in glucose. However, the client receiving a
blood transfusion who reports itching and warmth is exhibiting signs of a
possible transfusion reaction, which can rapidly progress to anaphylaxis,
hypotension, and respiratory distress. This is the highest priority because
it represents an immediate threat to safety and requires urgent
intervention, including stopping the transfusion and notifying the
provider.
4. A nurse manager is conducting a staff meeting to address a recent increase
in medication errors on the unit. Which approach is most effective in
fostering a culture of safety?
A. Discouraging staff from discussing errors to prevent unnecessary panic.
B. Implementing a punitive policy that assigns blame to individual nurses.
C. Encouraging staff to report near misses and errors without fear of
retaliation.
D. Blaming the pharmacy department for providing incorrect medication
labels.
Answer: C
Rationale: A culture of safety is promoted by a just culture that
encourages open communication and reporting of errors and near misses.
This approach allows the organization to identify system failures and
implement corrective actions. Discouraging discussion of errors (A) leads
to a culture of secrecy and prevents learning. Punitive policies (B)
discourage reporting and increase the likelihood of errors being hidden.
Blaming other departments (D) shifts accountability and does not address
the unit's internal processes. The nurse manager should facilitate a non-
punitive environment where staff can share lessons learned to improve
patient safety.
5. A client has just been admitted to the unit and presents with an advance
directive stating that they do not want life-sustaining measures. The client's
, family member states that the client is confused and asks the nurse to
ignore the directive. Which action should the nurse take first?
A. Notify the healthcare provider of the family's request.
B. Discuss the advance directive with the family and the client if possible.
C. Document the family's concerns in the client's chart.
D. Continue to provide life-sustaining care until a legal review is completed.
Answer: B
Rationale: The nurse must first clarify the client's current decision-making
capacity and the family's concerns. The nurse should discuss the advance
directive with the client and the family to understand the client's wishes. If
the client is unable to make decisions, the nurse should involve the ethics
committee or legal counsel as appropriate, but the first action is to
address the confusion through discussion. Notifying the provider (A) and
documenting (C) are secondary actions. Continuing life-sustaining care
against the client's documented wishes (D) is inappropriate unless the
directive is determined to be invalid; the nurse cannot independently
make that determination, but must advocate for the client's expressed
wishes.
6. A nurse is planning the discharge of a client who has undergone a total hip
replacement. Which referral would be most beneficial for the client to
promote safe mobility at home?
A. A dietary consultation for nutritional education.
B. A social worker for financial assistance.
C. A physical therapist for home health services.
D. A respiratory therapist for breathing exercises.
Answer: C
Rationale: Discharge planning must address the client's specific needs to
prevent readmission. For a client who has had a total hip replacement,
mobility is the primary concern. Referral to a physical therapist for home
health services will ensure the client receives assistance with ambulation,
stair climbing, and activities of daily living, which are critical for a safe
transition. Dietary consultation (A) is not the priority. Social work (B) may
Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A charge nurse is reviewing the assignments for the shift. Which assignment
is most appropriate for a licensed practical nurse (LPN) who has worked on
the unit for 2 years?
A. A client receiving a blood transfusion who had a reaction earlier in the
shift.
B. A client who is 2 days post-operative following an abdominal aortic
aneurysm repair.
C. A client who requires a nasogastric tube feeding and has a gastrostomy
tube.
D. A client who is receiving intravenous heparin and requires frequent
activated partial thromboplastin time (aPTT) monitoring.
Answer: C
Rationale: The LPN's scope of practice includes stable clients with
predictable outcomes, such as administering enteral feedings via an
established gastrostomy tube. The charge nurse must assign care based
on staff competency and client acuity. Clients receiving blood transfusions
(A), those in the immediate postoperative period after major vascular
surgery (B), and those on titrated IV heparin with frequent lab monitoring
(D) require the ongoing assessment and critical thinking skills of a
registered nurse (RN). Assigning the client with the gastrostomy tube to
the LPN allows the RN to retain responsibility for the unstable or complex
clients.
2. A registered nurse (RN) is preparing to delegate the task of obtaining a
blood glucose level via fingerstick to a certified nursing assistant (CNA).
, Which statement by the RN demonstrates proper delegation?
A. "I am delegating this task to you, but I will not be responsible for the
results because you are performing it."
B. "Please obtain the blood glucose on the client in room 205 and call me if
it is above 200 mg/dL."
C. "You have performed this task before, so you know how to do it without
any specific instructions."
D. "You are responsible for assessing the client's response to the insulin
based on the glucose result."
Answer: B
Rationale: Effective delegation involves clear communication of the
specific task, the client, and the parameters for reporting back to the
delegating RN. Option B demonstrates this by giving a clear task and a
specific threshold for notification. The RN retains accountability for the
overall nursing care and supervision (A is incorrect). The RN must provide
specific instructions, not assume prior knowledge (C). Assessment and
evaluation of the client's response to treatment cannot be delegated to a
CNA; these are RN responsibilities (D). The RN must ensure the CNA is
competent to perform the task, but providing clear guidance is essential.
3. A nurse is prioritizing care for four clients on a medical-surgical unit. Which
client should the nurse assess first?
A. A client with chronic obstructive pulmonary disease (COPD) who has an
oxygen saturation of 88% on 2 liters of nasal cannula.
B. A client who is post-operative day 1 from a hysterectomy and has a
dressing that is saturated with serosanguineous drainage.
C. A client who is receiving a blood transfusion and reports itching and a
feeling of warmth.
D. A client with type 2 diabetes mellitus who had a blood glucose level of
150 mg/dL before lunch.
Answer: C
Rationale: The nurse must use the ABCs (Airway, Breathing, Circulation)
and safety principles to prioritize. While the client with COPD has a low
, oxygen saturation, this is a chronic baseline for many clients with COPD
and may not be an acute change. The client with the saturated dressing
requires attention but is not immediately life-threatening. The client with
diabetes has a mild elevation in glucose. However, the client receiving a
blood transfusion who reports itching and warmth is exhibiting signs of a
possible transfusion reaction, which can rapidly progress to anaphylaxis,
hypotension, and respiratory distress. This is the highest priority because
it represents an immediate threat to safety and requires urgent
intervention, including stopping the transfusion and notifying the
provider.
4. A nurse manager is conducting a staff meeting to address a recent increase
in medication errors on the unit. Which approach is most effective in
fostering a culture of safety?
A. Discouraging staff from discussing errors to prevent unnecessary panic.
B. Implementing a punitive policy that assigns blame to individual nurses.
C. Encouraging staff to report near misses and errors without fear of
retaliation.
D. Blaming the pharmacy department for providing incorrect medication
labels.
Answer: C
Rationale: A culture of safety is promoted by a just culture that
encourages open communication and reporting of errors and near misses.
This approach allows the organization to identify system failures and
implement corrective actions. Discouraging discussion of errors (A) leads
to a culture of secrecy and prevents learning. Punitive policies (B)
discourage reporting and increase the likelihood of errors being hidden.
Blaming other departments (D) shifts accountability and does not address
the unit's internal processes. The nurse manager should facilitate a non-
punitive environment where staff can share lessons learned to improve
patient safety.
5. A client has just been admitted to the unit and presents with an advance
directive stating that they do not want life-sustaining measures. The client's
, family member states that the client is confused and asks the nurse to
ignore the directive. Which action should the nurse take first?
A. Notify the healthcare provider of the family's request.
B. Discuss the advance directive with the family and the client if possible.
C. Document the family's concerns in the client's chart.
D. Continue to provide life-sustaining care until a legal review is completed.
Answer: B
Rationale: The nurse must first clarify the client's current decision-making
capacity and the family's concerns. The nurse should discuss the advance
directive with the client and the family to understand the client's wishes. If
the client is unable to make decisions, the nurse should involve the ethics
committee or legal counsel as appropriate, but the first action is to
address the confusion through discussion. Notifying the provider (A) and
documenting (C) are secondary actions. Continuing life-sustaining care
against the client's documented wishes (D) is inappropriate unless the
directive is determined to be invalid; the nurse cannot independently
make that determination, but must advocate for the client's expressed
wishes.
6. A nurse is planning the discharge of a client who has undergone a total hip
replacement. Which referral would be most beneficial for the client to
promote safe mobility at home?
A. A dietary consultation for nutritional education.
B. A social worker for financial assistance.
C. A physical therapist for home health services.
D. A respiratory therapist for breathing exercises.
Answer: C
Rationale: Discharge planning must address the client's specific needs to
prevent readmission. For a client who has had a total hip replacement,
mobility is the primary concern. Referral to a physical therapist for home
health services will ensure the client receives assistance with ambulation,
stair climbing, and activities of daily living, which are critical for a safe
transition. Dietary consultation (A) is not the priority. Social work (B) may
