Leadership & Management NCLEX Questions || Top Grade
Assured.
The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand
restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness
of the restrained hands?
1. Every 2 hours
2. Every 3 hours
3. Every 4 hours
4. Every 30 minutes correct answers 4. Every 30 minutes
The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The
neurovascular and circulatory status of the extremity should also be checked by the registered
nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours
to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of
safety devices should always be followed.
The nurse is conducting a session about the principles of first aid and is discussing the
interventions for a snakebite to an extremity. The nurse should inform those attending the session
that the first-priority intervention in the event of this occurrence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity in a position so that it is below the level of the heart.
4. Move the victim to a safe area away from the snake and encourage the victim to rest. correct
answers 4. Move the victim to a safe area away from the snake and encourage the victim to rest.
In the event of a snakebite, the first priority is to move the victim to a safe area away from the
snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and
constricting clothing are removed before swelling occurs. Immobilizing the extremity and
,maintaining the extremity below heart level would be done next; these actions limit the spread of
the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated
beverages are not given to the victim because these products may speed the absorption of the
venom. The victim should be transported to an emergency facility as soon as possible.
The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which
child should the nurse assess first?
1. A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic
treatment
2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby
syndrome is suspected
3. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of
a gastrostomy feeding tube the next day
4. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for
hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for
a computed tomography (CT) scan of the head correct answers 2. A 6-week-old infant admitted
to the hospital for decreased level of consciousness; shaken baby syndrome is suspected
The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an
altered level of consciousness suspected to have resulted from shaken baby syndrome is the most
unstable client because the infant could be developing increased intracranial pressure (ICP) and
require interventions for the complications associated with increased ICP. The 6-year-old child
on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with
cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an
admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction
could become unstable, but because this child is older and ready for the CT scan, he or she is
stable at this time.
The nurse is assigned to care for 4 clients. Which client should the nurse assess first?
1. A client who has a tympanic temperature of 99.8º F
2. A client who has a regular radial pulse of 96 beats/min
,3. A client who has a supine resting blood pressure of 148/90 mm Hg 4. A client who has a
peripheral (index finger) oxygen saturation percentage of 85% correct answers 4. A client who
has a peripheral (index finger) oxygen saturation percentage of 85%
An oxygen saturation percentage of 85% is abnormal. If this is an accurate measurement,
immediate intervention is needed to maintain the client's oxygenation status. A tympanic
temperature of 99.8º F is mildly elevated and should be monitored, but it is a lower priority than
respiratory status. A radial pulse of 96 beats/min is elevated as is the supine resting blood
pressure of 148/90 mm Hg; both merit further assessment but are a lower priority than
respiratory status.
The nurse has received the client assignment for the day. Which client should the nurse care for
first?
1. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question
about nutrition
2. The client receiving external radiation who has complaints of dryness and itching skin at the
treatment area
3. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and
pulling at the incision site
4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is
complaining of pain with urination correct answers 4. The client admitted with the medical
diagnosis of neutropenia who is afebrile and is complaining of pain with urination
The client admitted with neutropenia should be cared for first. The white blood cells serve as the
primary defense against infections by destroying bacteria in the blood. The client is complaining
of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly
to contact the primary health care provider because clients with neutropenia are more susceptible
to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question
is not a priority. It is not urgent that the nurse see the client with dryness and itching from
radiation first. This is an expected effect from radiation therapy. The client who has a
mastectomy is expected to have sensations of tightness and pulling.
, The nurse is the first responder at the scene of a train accident. Which victim should the nurse
attend to first?
1. A victim experiencing excruciating pain
2. A victim experiencing moderate anxiety
3. A victim experiencing airway obstruction
4. A victim experiencing altered level of consciousness correct answers 3. A victim experiencing
airway obstruction
Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse
would attend to the victim experiencing airway obstruction first. Care to the other victims
follows.
A client with terminal cancer arrives in the emergency department unresponsive and in
respiratory distress. The client's sister is the legal medical power of attorney. Both the client's
spouse and sister are present. Which action by the nurse is appropriate at this time?
1. Ask the spouse about the client's wishes
2. Get directions about care from the client's sister
3. Prepare for emergency intubation
4. Request that the sister provide a living will correct answers 2. Get directions about care from
the client's sister
A medial POA allows the client to designate a specific decision-making individual who can
advocate for the client as needed and can be flexible in changing circumstances. The client's
sister is designated as her POA. Though spouses are typically POA, option 1 is incorrect as he is
not the designated POA. Option 3 would be appropriate only if there were no advance directives
or family member present. Option 4 delays treatment.
Assured.
The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand
restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness
of the restrained hands?
1. Every 2 hours
2. Every 3 hours
3. Every 4 hours
4. Every 30 minutes correct answers 4. Every 30 minutes
The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The
neurovascular and circulatory status of the extremity should also be checked by the registered
nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours
to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of
safety devices should always be followed.
The nurse is conducting a session about the principles of first aid and is discussing the
interventions for a snakebite to an extremity. The nurse should inform those attending the session
that the first-priority intervention in the event of this occurrence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity in a position so that it is below the level of the heart.
4. Move the victim to a safe area away from the snake and encourage the victim to rest. correct
answers 4. Move the victim to a safe area away from the snake and encourage the victim to rest.
In the event of a snakebite, the first priority is to move the victim to a safe area away from the
snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and
constricting clothing are removed before swelling occurs. Immobilizing the extremity and
,maintaining the extremity below heart level would be done next; these actions limit the spread of
the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated
beverages are not given to the victim because these products may speed the absorption of the
venom. The victim should be transported to an emergency facility as soon as possible.
The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which
child should the nurse assess first?
1. A 6-year-old child being treated for bacterial meningitis and on the tenth day of antibiotic
treatment
2. A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby
syndrome is suspected
3. A 2-year-old child with cerebral palsy being admitted to the hospital for surgical placement of
a gastrostomy feeding tube the next day
4. A 16-year-old child with a ventriculoperitoneal shunt that was placed at birth for
hydrocephalus; possible shunt malfunction is suspected, and the child is scheduled and ready for
a computed tomography (CT) scan of the head correct answers 2. A 6-week-old infant admitted
to the hospital for decreased level of consciousness; shaken baby syndrome is suspected
The infant or child who is the most unstable should be assessed first. A 6-week-old infant with an
altered level of consciousness suspected to have resulted from shaken baby syndrome is the most
unstable client because the infant could be developing increased intracranial pressure (ICP) and
require interventions for the complications associated with increased ICP. The 6-year-old child
on day 10 of antibiotics for bacterial meningitis is a stable client. The 2-year-old child with
cerebral palsy being admitted for surgical placement of a gastrostomy tube will need an
admission assessment, but this child is stable. The 16-year-old with a possible shunt malfunction
could become unstable, but because this child is older and ready for the CT scan, he or she is
stable at this time.
The nurse is assigned to care for 4 clients. Which client should the nurse assess first?
1. A client who has a tympanic temperature of 99.8º F
2. A client who has a regular radial pulse of 96 beats/min
,3. A client who has a supine resting blood pressure of 148/90 mm Hg 4. A client who has a
peripheral (index finger) oxygen saturation percentage of 85% correct answers 4. A client who
has a peripheral (index finger) oxygen saturation percentage of 85%
An oxygen saturation percentage of 85% is abnormal. If this is an accurate measurement,
immediate intervention is needed to maintain the client's oxygenation status. A tympanic
temperature of 99.8º F is mildly elevated and should be monitored, but it is a lower priority than
respiratory status. A radial pulse of 96 beats/min is elevated as is the supine resting blood
pressure of 148/90 mm Hg; both merit further assessment but are a lower priority than
respiratory status.
The nurse has received the client assignment for the day. Which client should the nurse care for
first?
1. The client receiving chemotherapy who is on day 3 of a 5-day regimen and has a question
about nutrition
2. The client receiving external radiation who has complaints of dryness and itching skin at the
treatment area
3. The client who had a radical mastectomy 36 hours ago and is complaining of tightness and
pulling at the incision site
4. The client admitted with the medical diagnosis of neutropenia who is afebrile and is
complaining of pain with urination correct answers 4. The client admitted with the medical
diagnosis of neutropenia who is afebrile and is complaining of pain with urination
The client admitted with neutropenia should be cared for first. The white blood cells serve as the
primary defense against infections by destroying bacteria in the blood. The client is complaining
of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly
to contact the primary health care provider because clients with neutropenia are more susceptible
to bacterial infections. The client who is tolerating the chemotherapy regimen and has a question
is not a priority. It is not urgent that the nurse see the client with dryness and itching from
radiation first. This is an expected effect from radiation therapy. The client who has a
mastectomy is expected to have sensations of tightness and pulling.
, The nurse is the first responder at the scene of a train accident. Which victim should the nurse
attend to first?
1. A victim experiencing excruciating pain
2. A victim experiencing moderate anxiety
3. A victim experiencing airway obstruction
4. A victim experiencing altered level of consciousness correct answers 3. A victim experiencing
airway obstruction
Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse
would attend to the victim experiencing airway obstruction first. Care to the other victims
follows.
A client with terminal cancer arrives in the emergency department unresponsive and in
respiratory distress. The client's sister is the legal medical power of attorney. Both the client's
spouse and sister are present. Which action by the nurse is appropriate at this time?
1. Ask the spouse about the client's wishes
2. Get directions about care from the client's sister
3. Prepare for emergency intubation
4. Request that the sister provide a living will correct answers 2. Get directions about care from
the client's sister
A medial POA allows the client to designate a specific decision-making individual who can
advocate for the client as needed and can be flexible in changing circumstances. The client's
sister is designated as her POA. Though spouses are typically POA, option 1 is incorrect as he is
not the designated POA. Option 3 would be appropriate only if there were no advance directives
or family member present. Option 4 delays treatment.
