HURST REVIEW QBANK CUSTOMIZE QUIZ – MANAGEMENT OF CARE QUESTIONS
AND ANSWERS | COMPLETE NCLEX STUDY GUIDE 2026/2027
A 68-year-old client with a history of angina presents to the emergency department (ED) reporting flu
like symptoms progressively worsening over the past 24 hours. What action is most important for the
nurse to initiate?
Exhibit:
Client's Chief Complaint:
"I have the flu. I have been vomiting every couple of hours, running a fever and my chest hurts."
Vitals Signs:
Pulse-132 beats/minute
Respirations-26 breaths/minute
Blood pressure-94/60 mmHg
Temperature-101.3° F (38.5°C) orally
Capillary refill - 4 seconds
Primary Healthcare Provider Prescription:
Rapid Influenza Diagnostic Test
Normal Saline 1 liter at 250 mL/hour, then Normal Saline at 100 mL/hour.
Chest X-ray
Acetaminophen 500 mg po now.
1. Administer acetaminophen.
2. Initiate IV of Normal Saline at 250 mL/hour.
3. Notify radiology and lab of diagnostic test prescriptions.
4. Discuss IV prescription with primary healthcare provider. - ANS ✔✔4. Correct: This client needs fluid
because of dehydration, but did you notice that this client is elderly and has a history of cardiac
problems? I hope so, because giving this client NS rapidly could throw our heart client into pulmonary
edema, which would be a bad thing! Talk to the primary healthcare provider.
1. Incorrect: Acetaminophen needs to be administered but it is not the most important thing for the
nurse to do. Clarification regarding the IV fluid prescription is necessary here to prevent a possible
complication.
2. Incorrect: If this client receives an isotonic IV solution at this rapid rate, the client will be at increased
risk of developing FVE and pulmonary edema.
3. Incorrect: Again, the radiology and lab departments can be notified of the test prescriptions to be
completed. However, the nurse can assign this task to the unit secretary.
A child is admitted to the emergency department due to suspected ruptured appendicitis with
perforation. What would be the priority nursing assessment for this client?
,1. Monitor for the Rovsing sign.
2. Assess for an increase in temperature.
3. Check for rebound tenderness at McBurney's point.
4. Monitor for increasing pain and rigidity of the abdomen. - ANS ✔✔4. Correct: Increasing pain and
rigid, board-like abdomen are signs that the appendix may have ruptured, with resulting peritonitis
developing.
1. Incorrect: The Rovsing Sign results in RLQ pain that occurs with palpation of the LLQ. This suggests
peritoneal irritation due to palpation of a remote location and would indicate appendicitis.
2. Incorrect: Although children with appendicitis may have an elevated temperature, the priority would
be assessing for the signs of peritonitis which include increasing pain and rigidity of the abdomen.
Children can have an increased temperature with many different types of inflammation and infections.
3. Incorrect: Although rebound tenderness at McBurney's point is indicative of appendicitis, the nurse
should not check for this due to the possibility of rupturing the appendix.
The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions
can the nurse delegate to an experienced LPN/LVN working in the ICU?
Select all that apply
1. Determine Glasgow Coma Score.
2. Check endotracheal tube (ET) cuff pressure every shift.
3. Reposition client from side to side every 2 hours.
4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC).
5. Monitor intake and output every hour. - ANS ✔✔4., & 5. Correct: Both of these actions are within the
scope of practice for the LPN/LVN.
1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN.
2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN.
3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN;
however, this client is at risk for increased ICP during position changes. The RN must monitor.
The women's health charge nurse is making assignments for the next shift. The unit is short one staff
member and will receive a nurse from the medical surgical unit. Which group of clients should she assign
to the medical surgical nurse?
1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction.
2. C-section planning discharge, postpartum infection, mastectomy.
3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma.
4. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. - ANS ✔✔1.
Correct: This group of clients is primarily med surgical.
2. Incorrect: This group of clients needs specific teaching.
3. Incorrect: This group of clients needs specialized care.
4. Incorrect: No, the monitoring is too specific for the med-surg nurse.
, What clients could safely be delegated to the LPN/LVN?
Select all that apply
1. A client two days post appendectomy needing to ambulate.
2. A client with bronchitis receiving nebulizer treatments.
3. A newly diagnosed diabetic client awaiting discharge home.
4. A client newly admitted with exacerbation of myasthenia gravis.
5. A client admitted yesterday for observation following a fall.
6. A client with a nasogastric tube (NG) hooked to low suction. - ANS ✔✔1, 2, 5 & 6. Correct: These
clients are appropriate and stable enough for the LPN/LVN's scope of practice. While an LPN/LVN cannot
be assigned a fresh post-op, the first client had an appendectomy two days ago. The LPN/LVN could even
delegate ambulating this client to unlicensed assistive personnel (UAP). A client with bronchitis will need
a respiratory assessment by the RN at some point, but the LPN/LVN is definitely qualified to administer
aerosol treatments. The third client was admitted for observation following a fall a day ago, indicating no
injuries serious enough for a full admission. PNs can insert and monitor NG tubes.
3. Incorrect: This client is a newly diagnosed diabetic who will require extensive teaching about self care
at home. Additionally, discharging a client always involves teaching, which cannot be initiated by an
LPN/LVN. This option does not indicate that any teaching had been presented, so the client is not an
appropriate assignment for the LPN/LVN.
4. Incorrect: Myasthenia Gravis is a progressive weakening of the neuromuscular system placing the
greatest risk on the respiratory system. Although this client is on a medical-surgical floor, there is a need
for close monitoring and frequent assessment of the respiratory system, requiring an RN.
A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple
admissions. What tasks could the LPN complete until the nurse is available?
Select all that apply
1. Take initial vital signs.
2. Measure cervical dilation.
3. Check fundal height and fetal heart rate (FHR).
4. Obtain urine for protein and glucose.
5. Collect vaginal swab to test for chlamydia. - ANS ✔✔1, 4, & 5. Correct: The LPN scope of practice
varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among
the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered
tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse.
2. Incorrect: Measuring cervical dilation is an invasive assessment not within the LPN scope of practice.
An experienced registered nurse or primary healthcare provider must be specifically trained to perform
this procedure.
3. Incorrect: Fundal height is a determination of uterine size to assess fetal growth and development
which cannot be delegated to an LPN. Additionally, determining fetal heart rate involves assessment of
fetal well being and not within the LPN scope of practice.
The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge
nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8
AND ANSWERS | COMPLETE NCLEX STUDY GUIDE 2026/2027
A 68-year-old client with a history of angina presents to the emergency department (ED) reporting flu
like symptoms progressively worsening over the past 24 hours. What action is most important for the
nurse to initiate?
Exhibit:
Client's Chief Complaint:
"I have the flu. I have been vomiting every couple of hours, running a fever and my chest hurts."
Vitals Signs:
Pulse-132 beats/minute
Respirations-26 breaths/minute
Blood pressure-94/60 mmHg
Temperature-101.3° F (38.5°C) orally
Capillary refill - 4 seconds
Primary Healthcare Provider Prescription:
Rapid Influenza Diagnostic Test
Normal Saline 1 liter at 250 mL/hour, then Normal Saline at 100 mL/hour.
Chest X-ray
Acetaminophen 500 mg po now.
1. Administer acetaminophen.
2. Initiate IV of Normal Saline at 250 mL/hour.
3. Notify radiology and lab of diagnostic test prescriptions.
4. Discuss IV prescription with primary healthcare provider. - ANS ✔✔4. Correct: This client needs fluid
because of dehydration, but did you notice that this client is elderly and has a history of cardiac
problems? I hope so, because giving this client NS rapidly could throw our heart client into pulmonary
edema, which would be a bad thing! Talk to the primary healthcare provider.
1. Incorrect: Acetaminophen needs to be administered but it is not the most important thing for the
nurse to do. Clarification regarding the IV fluid prescription is necessary here to prevent a possible
complication.
2. Incorrect: If this client receives an isotonic IV solution at this rapid rate, the client will be at increased
risk of developing FVE and pulmonary edema.
3. Incorrect: Again, the radiology and lab departments can be notified of the test prescriptions to be
completed. However, the nurse can assign this task to the unit secretary.
A child is admitted to the emergency department due to suspected ruptured appendicitis with
perforation. What would be the priority nursing assessment for this client?
,1. Monitor for the Rovsing sign.
2. Assess for an increase in temperature.
3. Check for rebound tenderness at McBurney's point.
4. Monitor for increasing pain and rigidity of the abdomen. - ANS ✔✔4. Correct: Increasing pain and
rigid, board-like abdomen are signs that the appendix may have ruptured, with resulting peritonitis
developing.
1. Incorrect: The Rovsing Sign results in RLQ pain that occurs with palpation of the LLQ. This suggests
peritoneal irritation due to palpation of a remote location and would indicate appendicitis.
2. Incorrect: Although children with appendicitis may have an elevated temperature, the priority would
be assessing for the signs of peritonitis which include increasing pain and rigidity of the abdomen.
Children can have an increased temperature with many different types of inflammation and infections.
3. Incorrect: Although rebound tenderness at McBurney's point is indicative of appendicitis, the nurse
should not check for this due to the possibility of rupturing the appendix.
The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions
can the nurse delegate to an experienced LPN/LVN working in the ICU?
Select all that apply
1. Determine Glasgow Coma Score.
2. Check endotracheal tube (ET) cuff pressure every shift.
3. Reposition client from side to side every 2 hours.
4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC).
5. Monitor intake and output every hour. - ANS ✔✔4., & 5. Correct: Both of these actions are within the
scope of practice for the LPN/LVN.
1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN.
2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN.
3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN;
however, this client is at risk for increased ICP during position changes. The RN must monitor.
The women's health charge nurse is making assignments for the next shift. The unit is short one staff
member and will receive a nurse from the medical surgical unit. Which group of clients should she assign
to the medical surgical nurse?
1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction.
2. C-section planning discharge, postpartum infection, mastectomy.
3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma.
4. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. - ANS ✔✔1.
Correct: This group of clients is primarily med surgical.
2. Incorrect: This group of clients needs specific teaching.
3. Incorrect: This group of clients needs specialized care.
4. Incorrect: No, the monitoring is too specific for the med-surg nurse.
, What clients could safely be delegated to the LPN/LVN?
Select all that apply
1. A client two days post appendectomy needing to ambulate.
2. A client with bronchitis receiving nebulizer treatments.
3. A newly diagnosed diabetic client awaiting discharge home.
4. A client newly admitted with exacerbation of myasthenia gravis.
5. A client admitted yesterday for observation following a fall.
6. A client with a nasogastric tube (NG) hooked to low suction. - ANS ✔✔1, 2, 5 & 6. Correct: These
clients are appropriate and stable enough for the LPN/LVN's scope of practice. While an LPN/LVN cannot
be assigned a fresh post-op, the first client had an appendectomy two days ago. The LPN/LVN could even
delegate ambulating this client to unlicensed assistive personnel (UAP). A client with bronchitis will need
a respiratory assessment by the RN at some point, but the LPN/LVN is definitely qualified to administer
aerosol treatments. The third client was admitted for observation following a fall a day ago, indicating no
injuries serious enough for a full admission. PNs can insert and monitor NG tubes.
3. Incorrect: This client is a newly diagnosed diabetic who will require extensive teaching about self care
at home. Additionally, discharging a client always involves teaching, which cannot be initiated by an
LPN/LVN. This option does not indicate that any teaching had been presented, so the client is not an
appropriate assignment for the LPN/LVN.
4. Incorrect: Myasthenia Gravis is a progressive weakening of the neuromuscular system placing the
greatest risk on the respiratory system. Although this client is on a medical-surgical floor, there is a need
for close monitoring and frequent assessment of the respiratory system, requiring an RN.
A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple
admissions. What tasks could the LPN complete until the nurse is available?
Select all that apply
1. Take initial vital signs.
2. Measure cervical dilation.
3. Check fundal height and fetal heart rate (FHR).
4. Obtain urine for protein and glucose.
5. Collect vaginal swab to test for chlamydia. - ANS ✔✔1, 4, & 5. Correct: The LPN scope of practice
varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among
the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered
tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse.
2. Incorrect: Measuring cervical dilation is an invasive assessment not within the LPN scope of practice.
An experienced registered nurse or primary healthcare provider must be specifically trained to perform
this procedure.
3. Incorrect: Fundal height is a determination of uterine size to assess fetal growth and development
which cannot be delegated to an LPN. Additionally, determining fetal heart rate involves assessment of
fetal well being and not within the LPN scope of practice.
The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge
nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8
