NCLEX Management of Care UPDATED
ACTUAL Exam Questions and CORRECT
Answers
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a
dietary consult?
1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery.
2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN).
3. Two year old taking only clear liquids since admission 24 hours ago.
4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula. - CORRECT
ANSWER - 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since
surgery.
(1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a
nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not
be adequate.
2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional
evaluation receiving supplementation for nutritional needs. After reviewing the nutritional
evaluation, the TPN will be formulated accordingly.
3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids
for more than 3 days, then would be at nutritional risk. After 3 days the nutritional status of the
child should be evaluated due to the food restrictions of a clear liquid diet.
4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is
tolerated, then the strength will be advanced; therefore, this client is not at risk.)
,A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level
on a scale of 0-10. What strategies could the nurse manager initiate to improve performance?
Select all that apply.
1. Provides "just in time" posters outlining the importance of pain assessment.
2. Conducts brief in-services for each shift.
3. Counsels nurses when pain level scale is not utilized.
4. Ensures that a complete and clear performance standard exists.
5. Assesses nurses' reasons for not using pain level scale.
6. Disciplines offenses through unpaid time off. - CORRECT ANSWER - 1. Provides "just
in time" posters outlining the importance of pain assessment.
2. Conducts brief in-services for each shift.
3. Counsels nurses when pain level scale is not utilized.
4. Ensures that a complete and clear performance standard exists.
5. Assesses nurses' reasons for not using pain level scale.
(1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill
before, but have not practiced the skill on a regular basis, a different type of education is
required. This may take the form of "just in time" tools such as posters or guidelines outlining
the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit
,may also be effective in providing on the spot refreshers. Counseling the nurses when pain level
scale is not utilized may improve understanding and performance. Ensuring that performance
standards exist, are clear and complete, and that they are readily available to staff is essential.
The first step in correcting a performance gap is to understand what the difference is between the
behavior being exhibited and what the expectations are. Always assess why staff are doing or not
doing what is needed for clients. There may be a lack of knowledge or there may be a sense of
non-importance.
6. Incorrect: Quality improvement looks at improving processes and does not use intimidation
and punishment to improve quality care.)
A new nurse is documenting in a client's electronic record. Which documentation would the
charge nurse evaluate as appropriate documentation by the new nurse?
Select all that apply.
1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services.
2. Appears to be having abdominal discomfort.
3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon.
4. Pre op Diazepam 10.0 mg given po.
5. Transferred to surgical suite per stretcher with side rails up, in stable condition. - CORRECT
ANSWER - 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for
surgical services.
3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon.
5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
, (1., 3, & 5. Correct: These are written correctly with complete, concise and objective information
for each statement pertaining to the client.
2. Incorrect: "Appears" is a subjective word. Remember to use objective words. Pain should be
assessed in an objective manner, such as by using a pain scale that is appropriate for the client's
age and communication abilities. If the client were unable to respond to a pain scale assessment,
the nurse would need to describe objectively the behavior of concern; for instance, the nurse
could document "client moaning, guarding abdominal area with both hands, and knees pulled
towards chest".
4. Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect dosage. Likewise,
always lead a decimal point with a zero (0.5).)
Which task would be appropriate for the charge nurse to assign to a LPN/VN?
Select all that apply.
1. Collect data on a new client admit.
2. Administer morphine IVP to a two day post-op client.
3. Bolus feeding a client who has a gastrostomy tube.
4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out.
5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client. -
CORRECT ANSWER - 1. Collect data on a new client admit.
3. Bolus feeding a client who has a gastrostomy tube.
4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out.
ACTUAL Exam Questions and CORRECT
Answers
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a
dietary consult?
1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery.
2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN).
3. Two year old taking only clear liquids since admission 24 hours ago.
4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula. - CORRECT
ANSWER - 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since
surgery.
(1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a
nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not
be adequate.
2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional
evaluation receiving supplementation for nutritional needs. After reviewing the nutritional
evaluation, the TPN will be formulated accordingly.
3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids
for more than 3 days, then would be at nutritional risk. After 3 days the nutritional status of the
child should be evaluated due to the food restrictions of a clear liquid diet.
4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is
tolerated, then the strength will be advanced; therefore, this client is not at risk.)
,A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level
on a scale of 0-10. What strategies could the nurse manager initiate to improve performance?
Select all that apply.
1. Provides "just in time" posters outlining the importance of pain assessment.
2. Conducts brief in-services for each shift.
3. Counsels nurses when pain level scale is not utilized.
4. Ensures that a complete and clear performance standard exists.
5. Assesses nurses' reasons for not using pain level scale.
6. Disciplines offenses through unpaid time off. - CORRECT ANSWER - 1. Provides "just
in time" posters outlining the importance of pain assessment.
2. Conducts brief in-services for each shift.
3. Counsels nurses when pain level scale is not utilized.
4. Ensures that a complete and clear performance standard exists.
5. Assesses nurses' reasons for not using pain level scale.
(1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill
before, but have not practiced the skill on a regular basis, a different type of education is
required. This may take the form of "just in time" tools such as posters or guidelines outlining
the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit
,may also be effective in providing on the spot refreshers. Counseling the nurses when pain level
scale is not utilized may improve understanding and performance. Ensuring that performance
standards exist, are clear and complete, and that they are readily available to staff is essential.
The first step in correcting a performance gap is to understand what the difference is between the
behavior being exhibited and what the expectations are. Always assess why staff are doing or not
doing what is needed for clients. There may be a lack of knowledge or there may be a sense of
non-importance.
6. Incorrect: Quality improvement looks at improving processes and does not use intimidation
and punishment to improve quality care.)
A new nurse is documenting in a client's electronic record. Which documentation would the
charge nurse evaluate as appropriate documentation by the new nurse?
Select all that apply.
1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services.
2. Appears to be having abdominal discomfort.
3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon.
4. Pre op Diazepam 10.0 mg given po.
5. Transferred to surgical suite per stretcher with side rails up, in stable condition. - CORRECT
ANSWER - 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for
surgical services.
3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon.
5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
, (1., 3, & 5. Correct: These are written correctly with complete, concise and objective information
for each statement pertaining to the client.
2. Incorrect: "Appears" is a subjective word. Remember to use objective words. Pain should be
assessed in an objective manner, such as by using a pain scale that is appropriate for the client's
age and communication abilities. If the client were unable to respond to a pain scale assessment,
the nurse would need to describe objectively the behavior of concern; for instance, the nurse
could document "client moaning, guarding abdominal area with both hands, and knees pulled
towards chest".
4. Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect dosage. Likewise,
always lead a decimal point with a zero (0.5).)
Which task would be appropriate for the charge nurse to assign to a LPN/VN?
Select all that apply.
1. Collect data on a new client admit.
2. Administer morphine IVP to a two day post-op client.
3. Bolus feeding a client who has a gastrostomy tube.
4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out.
5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client. -
CORRECT ANSWER - 1. Collect data on a new client admit.
3. Bolus feeding a client who has a gastrostomy tube.
4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out.
