Leadership & Management NCLEX Questions With
Complete Solutions
A blizzard is predicted to hit a large city within a few hours. The
home care nurse is prioritizing and revising the schedule and
estimates that 3 home visits can be made before the blizzard hits.
Which clients should the nurse see? Select all that apply.
1. A client who fell and hit the head but refuses to go to the
emergency department
2. A client who is due for a maintenance dose of
cyanocobalamin
3. A client who needs pre-filled insulin syringes
4. A client who was discharged from the hospital yesterday after
heart failure treatment
5. A client with a stage 3 pressure injury in need of a dressing
change Correct Answers 1. A client who fell and hit the head
but refuses to go to the emergency department
3. A client who needs pre-filled insulin syringes
5. A client with a stage 3 pressure injury in need of a dressing
change
In this scenario, it is unknown when home care visits will
resume due to severe inclement weather. The high priority
clients are those who are at risk for harm if a scheduled visit
cannot be made in 24 hours or more. The client who fell could
have sustained a head injury and needs assessment. The client in
need of pre-filled insulin syringes could become hyperglycemic
if insulin is unavailable. The client with the stage 3 pressure
injury has a scheduled dressing change for a serious wound and
this should not be postponed.
,A client is brought to the emergency department by emergency
medical services (EMS) after being hit by a car. The name of the
client is unknown, and the client has sustained a severe head
injury and multiple fractures and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the
surgical procedure, which is the best action?
1. Obtain a court order for the surgical procedure
2. Ask the EMS team to sign the informed consent
3. Transport the victim to the operating room for surgery
4. Call the police to identify the client and locate the family
Correct Answers 3. Transport the victim to the operating room
for surgery
In general, there are two situations in which informed consent of
an adult client is not needed. One is when an emergency is
present and delaying treatment for the purpose of obtaining
informed consent would result in injury or death to the client.
The second is when the client waives the right to give informed
consent.
A client is hospitalized for a broken leg. The client has a history
of breast cancer and is receiving outpatient chemotherapy; the
last infusion was about a week ago. Which staff members can
safely care for this client? Select all that apply.
1. Nurse floated from another medical-surgical floor
2. Nurse who is 24 weeks pregnant
3. Nurse with erythematous rash and honey-color crusts on the
hand
,4. Unlicensed assistive personnel who just received the yearly
injectable flu vaccination
5. Unlicensed assistive personnel with a cold Correct Answers
1. Nurse floated from another medical-surgical floor
2. Nurse who is 24 weeks pregnant
4. Unlicensed assistive personnel who just received the yearly
injectable flu vaccination
A client who has recently received chemotherapy may be
immunocompromised and should be protected from infectious
contacts. However, the client is not radioactive or infectious and
the nurse will not be administering or handling the
chemotherapeutic agents. Therefore, it is safe for the pregnant
nurse to care for the client.
A client with AIDS treated for intractable seizure is transferred
from the intensive care unit to the medical unit. There are 4
semiprivate room beds available. Which room assignment does
the charge nurse choose as the best option for this client?
1. Room 1 - client with Clostridium difficile
2. Room 2 - client with fever of unknown origin
3. Room 3 - client with bacterial pneumonia
4. Room 4 - client with upper gastrointestinal bleed Correct
Answers 4. Room 4 - client with upper gastrointestinal bleed
The best option is room 4 as the client with the upper
gastrointestinal bleed does not put the immunocompromised
client with AIDS at increased risk for infection.
, A client with end stage renal disease, oxygen dependent chronic
obstructive pulmonary disease (COPD), and a Do Not
Resuscitate (DNR) code status is admitted to the medical floor
for COPD exacerbation. The nurse walks into the room and
finds that the client is not breathing. What should the nurse do
first?
1. Activate the code system
2. Call the health care provider (HCP) stat
3. Check the apical pulse
4. Check the blood pressure Correct Answers 3. Check the
apical pulse
The nurse should assess the client first and then call the HCP. A
stat page is not needed when the client is DNR.
A client with metastatic esophageal cancer says, "I don't want to
be kept alive being fed by a tube." What are the most
appropriate ways for the nurse to ensure that this information is
available to all who may need it for future decision-making?
Select all that apply.
1. Document this communication in the electronic health record
2. Encourage the client to discuss this decision with the health
care proxy
3. Facilitate completion of an advance directive that reflects the
client's decision
4. Obtain a signed informed consent from the client
5. Tell the HCP that the client needs a do not resuscitated (DNR)
order Correct Answers 1. Document this communication in the
electronic health record
Complete Solutions
A blizzard is predicted to hit a large city within a few hours. The
home care nurse is prioritizing and revising the schedule and
estimates that 3 home visits can be made before the blizzard hits.
Which clients should the nurse see? Select all that apply.
1. A client who fell and hit the head but refuses to go to the
emergency department
2. A client who is due for a maintenance dose of
cyanocobalamin
3. A client who needs pre-filled insulin syringes
4. A client who was discharged from the hospital yesterday after
heart failure treatment
5. A client with a stage 3 pressure injury in need of a dressing
change Correct Answers 1. A client who fell and hit the head
but refuses to go to the emergency department
3. A client who needs pre-filled insulin syringes
5. A client with a stage 3 pressure injury in need of a dressing
change
In this scenario, it is unknown when home care visits will
resume due to severe inclement weather. The high priority
clients are those who are at risk for harm if a scheduled visit
cannot be made in 24 hours or more. The client who fell could
have sustained a head injury and needs assessment. The client in
need of pre-filled insulin syringes could become hyperglycemic
if insulin is unavailable. The client with the stage 3 pressure
injury has a scheduled dressing change for a serious wound and
this should not be postponed.
,A client is brought to the emergency department by emergency
medical services (EMS) after being hit by a car. The name of the
client is unknown, and the client has sustained a severe head
injury and multiple fractures and is unconscious. An emergency
craniotomy is required. Regarding informed consent for the
surgical procedure, which is the best action?
1. Obtain a court order for the surgical procedure
2. Ask the EMS team to sign the informed consent
3. Transport the victim to the operating room for surgery
4. Call the police to identify the client and locate the family
Correct Answers 3. Transport the victim to the operating room
for surgery
In general, there are two situations in which informed consent of
an adult client is not needed. One is when an emergency is
present and delaying treatment for the purpose of obtaining
informed consent would result in injury or death to the client.
The second is when the client waives the right to give informed
consent.
A client is hospitalized for a broken leg. The client has a history
of breast cancer and is receiving outpatient chemotherapy; the
last infusion was about a week ago. Which staff members can
safely care for this client? Select all that apply.
1. Nurse floated from another medical-surgical floor
2. Nurse who is 24 weeks pregnant
3. Nurse with erythematous rash and honey-color crusts on the
hand
,4. Unlicensed assistive personnel who just received the yearly
injectable flu vaccination
5. Unlicensed assistive personnel with a cold Correct Answers
1. Nurse floated from another medical-surgical floor
2. Nurse who is 24 weeks pregnant
4. Unlicensed assistive personnel who just received the yearly
injectable flu vaccination
A client who has recently received chemotherapy may be
immunocompromised and should be protected from infectious
contacts. However, the client is not radioactive or infectious and
the nurse will not be administering or handling the
chemotherapeutic agents. Therefore, it is safe for the pregnant
nurse to care for the client.
A client with AIDS treated for intractable seizure is transferred
from the intensive care unit to the medical unit. There are 4
semiprivate room beds available. Which room assignment does
the charge nurse choose as the best option for this client?
1. Room 1 - client with Clostridium difficile
2. Room 2 - client with fever of unknown origin
3. Room 3 - client with bacterial pneumonia
4. Room 4 - client with upper gastrointestinal bleed Correct
Answers 4. Room 4 - client with upper gastrointestinal bleed
The best option is room 4 as the client with the upper
gastrointestinal bleed does not put the immunocompromised
client with AIDS at increased risk for infection.
, A client with end stage renal disease, oxygen dependent chronic
obstructive pulmonary disease (COPD), and a Do Not
Resuscitate (DNR) code status is admitted to the medical floor
for COPD exacerbation. The nurse walks into the room and
finds that the client is not breathing. What should the nurse do
first?
1. Activate the code system
2. Call the health care provider (HCP) stat
3. Check the apical pulse
4. Check the blood pressure Correct Answers 3. Check the
apical pulse
The nurse should assess the client first and then call the HCP. A
stat page is not needed when the client is DNR.
A client with metastatic esophageal cancer says, "I don't want to
be kept alive being fed by a tube." What are the most
appropriate ways for the nurse to ensure that this information is
available to all who may need it for future decision-making?
Select all that apply.
1. Document this communication in the electronic health record
2. Encourage the client to discuss this decision with the health
care proxy
3. Facilitate completion of an advance directive that reflects the
client's decision
4. Obtain a signed informed consent from the client
5. Tell the HCP that the client needs a do not resuscitated (DNR)
order Correct Answers 1. Document this communication in the
electronic health record
