4/20/25, 9:47 AM NCLEX Prep PN: Leadership & Management
PN NCLEX LEADERSHIP & MANAGEMENT PREPARATION
ACTUAL EXAM 2025 \\NCLEX PN REAL PROCTORED EXAM LATEST
UPDATE 2025 ALL QUESTIONS WITH ANSWERS (BRAND NEW!)
Correct Answer: C. 1740
All incidents, accidents, or occurrences that cause actual or potential
The nurse finds a client on the floor in
harm to a client, employee, or visitor must be reported. The person who
the client's room. Based on the
witnesses an unusual occurrence or event must file an incident report in
documentation shown in the exhibit,
the institution's computer documentation system using an electronic
the nurse made an incorrect entry in
form. Alternately, a paper form may be completed and filed. The purposes
the client's medical record at what
of the report are to inform risk management of the occurrence, allowing
time? Click on the exhibit button for
them to consider changes that might prevent similar incidents, and to
additional information.
notify administration of a potential litigation claim.
1700 Found client lying on floor next
The nurse should not document that an incident report was filed, or refer to
to bed. Client states, "l fell out of bed
the incident report in the medical record.
while reaching for my eyeglasses and
hit my head on the bedside table."
Incorrect Answers:
Client is alert and oriented to time,
[A. 1700] Because the incident report is not a part of the medical
place, person, and situation. Denies
record, an objective note should be placed in the client's medical record
pain, dizziness, or nausea No visible
documenting the facts and events of the incident, HCP notification and
injuries.Assisted back to bed.
findings, prescriptions, treatment, follow-up care, and monitoring.
Neurological vital signs within normal
limits (see assessment flow sheet).
[B. 1710] Because the incident report is not a part of the medical record, an
Client instructed to use call bell for
objective note should be placed in the client's medical record
assistance.
documenting the facts and events of the incident, HCP notification and
Will continue to monitor _______ RN
findings, prescriptions, treatment, follow- up care, and monitoring.
1710 Health care provider (HCP)
[D. 1810] Because the incident report is not a part of the medical record, an
notified of fall. Prescribed CT of head
objective note should be placed in the client's medical record
STAT.
documenting the facts and events of the incident, HCP notification and
______ RN
findings, prescriptions, treatment, follow- up care, and monitoring.
1740 No change in neurologic
Educational objective:The person who witnesses an unusual occurrence
status.Client to CT via gurney. Report
or event must file an incident report in the institution's computer
filed per policy.
documentation system, using an electronic form. The nurse should not
_______ RN
document that an incident report was filed or refer to the incident report
1810 Client returned in th
1/149
,4/20/25, 9:47 AM NCLEX Prep PN: Leadership & Management
Correct Answer: D. Recheck the client's
blood pressure with a manual cuff
This client's abnormally high blood pressure
increases the risk for complications such as
stroke. The nurse should assess this client
and recheck the blood pressure with a
manual cuff to verify the accuracy of the
previous measurement taken by unlicensed
assistive personnel (UAP). The nurse will
need to assess the client further before
making additional nursing judgments and
taking action.
Unlicensed assistive personnel on the
cardiac floor report to the nurse that, Incorrect Answers
during the first vital sign [A. Have unlicensed assistive personnel
measurement on the shift, a client's recheck the client's blood pressure] The
blood pressure measured 198/102 nurse should not instruct UAP to perform
mm Hg on the automated blood additional blood pressure measurements as
pressure machine. What action should this client could have severe hypertension;
the nurse take first? delegation of such a task is inappropriate
(does not fit the "right circumstances" for
A. Have unlicensed assistive delegation). If the client's reading is not as
personnel recheck the client's high as previously thought after blood
blood pressure pressure measurement with a manual cuff,
B. Immediately notify the the nurse can then instruct UAP to take
supervising registered nurse subsequent measurements with a different
C. Obtain the client's prn labetalol automatic blood pressure machine.
from the medication dispensing
machine [B. Immediately notify the supervising
D. Recheck the client's blood pressure registered nurse] It may be necessary to
with a manual cuff notify the supervising registered nurse, but
this should occur only after the client has
been assessed further by the nurse.
[C. Obtain the client's prn labetalol
from the medication dispensing
machine] The client's blood pressure
must be verified for accuracy before
administering a prn antihypertensive.
Educational objective:When unlicensed
assistive personnel (UAP) report an abnormal
vital sign to the nurse, the nurse should
assess the client further and verify the
finding. It is inappropriate delegation to
have UAP recheck the client.
2/149
,4/20/25, 9:47 AM NCLEX Prep PN: Leadership & Management
Correct Answer: A. Assist client, post hip
fracture repair, to the bathroom
Examples of tasks that can be delegated to
unlicensed assistive personnel (UAP) include
taking vital signs; assisting clients out of
bed, to the bathroom, and with activities of
daily living; and feeding clients. When a
nurse delegates a task to another staff
member, the nurse ultimately remains
responsible for both the action and its
outcome.
Incorrect Answers:
The nurse caring for multiple clients [B. Check the appearance of client's wound]
on a medical-surgical unit should Checking the wound involves assessment of
delegate which action to the nursing
its appearance. The nurse should perform
assistant?
this assessment as it is not within the scope
A. Assist client, post hip fracture of practice for the nursing assistant.
repair, to the bathroom
B. Check the appearance of client's
wound [C. Discontinue nasogastric tube if client
C. Discontinue nasogastric tube tolerates oral liquids] The nursing assistant
if client tolerates oral liquids can help with feeding. However, the
D. Offer orange juice to client if nasogastric tube should be discontinued at
bedside glucose reading is <70 the direction of the nurse as this procedure
mg/dL (3.9mmol/L) requires client assessment and monitoring.
[D. Offer orange juice to client if bedside
glucose reading is <70 mg/dL (3.9mmol/L)]
Offering orange juice is an intervention to
treat hypoglycemia that is outside the
nursing assistant's scope of practice without
the client first being assessed by the
registered nurse. The client could have
accompanying symptoms along with the low
glucose result; these would require
assessment and interpretation before
intervention.
Educational objective:The nurse may
delegate components of care but does not
delegate the nursing process (assessment,
planning, evaluation) itself. Skills requiring
critical thinking and nursing knowledge
cannot be delegated.
3/149
, 4/20/25, 9:47 AM NCLEX Prep PN: Leadership & Management
Correct Answer: B. Client reporting back
pain 1 hour following coronary angiography
Postprocedure care of a client who has
undergone cardiac catheterization should
focus on monitoring hemodynamics (eg,
blood pressure, heart rate, strength of distal
pulses, temperature of extremities). The
client should be also assessed several times
per hour (eg, approximately every 15
minutes) for active bleeding or hematoma
formation at the incision. Any report of back
or flank pain should be investigated for
possible retroperitoneal bleeding. Back
pain, tachycardia, and hypotension may be
the only indications of bleeding as it can
take up to 12 hours before a significant
The nurse has just received report drop in hematocrit can be measured.
on 4 clients. Which reported Hemorrhage after cardiac catheterization is
information is the most concerning? particularly dangerous due to the frequent
use of anticoagulant prescriptions in these
A. Client on a heparin drip with an clients.
activated partial thromboplastin time
of 60 seconds Incorrect Answers:
B. Client reporting back pain 1 [A. Client on a heparin drip with an activated
hour following coronary partial thromboplastin time of 60 seconds] A
angiography heparin infusion is used to treat deep venous
C. Client with a head injury and a thrombosis. An activated partial
Glasgow Coma Scale score of 14 thromboplastin time of 60 seconds is a
D. Client with incisional pain rated therapeutic value. The therapeutic range for
6/10 on day 2 post coronary artery a client on anticoagulation is usually 46-70
bypass graft seconds (1½ -2 times the normal value).
[C. Client with a head injury and a Glasgow
Coma Scale score of 14] A client with a
head injury should be evaluated hourly for
any change in neurological status. However,
the highest possible score on the Glasgow
Coma Scale is 15 for a fully alert person; a
client with a score of 14 does not require
urgent attention.
[D. Client with incisional pain rated 6/10 on
day 2 post coronary artery bypass graft]
The report of incisional pain on
postoperative day 2 would take second
priority for further assessment, but
evaluating a client with possible internal
bleeding is the priority.
4/149
PN NCLEX LEADERSHIP & MANAGEMENT PREPARATION
ACTUAL EXAM 2025 \\NCLEX PN REAL PROCTORED EXAM LATEST
UPDATE 2025 ALL QUESTIONS WITH ANSWERS (BRAND NEW!)
Correct Answer: C. 1740
All incidents, accidents, or occurrences that cause actual or potential
The nurse finds a client on the floor in
harm to a client, employee, or visitor must be reported. The person who
the client's room. Based on the
witnesses an unusual occurrence or event must file an incident report in
documentation shown in the exhibit,
the institution's computer documentation system using an electronic
the nurse made an incorrect entry in
form. Alternately, a paper form may be completed and filed. The purposes
the client's medical record at what
of the report are to inform risk management of the occurrence, allowing
time? Click on the exhibit button for
them to consider changes that might prevent similar incidents, and to
additional information.
notify administration of a potential litigation claim.
1700 Found client lying on floor next
The nurse should not document that an incident report was filed, or refer to
to bed. Client states, "l fell out of bed
the incident report in the medical record.
while reaching for my eyeglasses and
hit my head on the bedside table."
Incorrect Answers:
Client is alert and oriented to time,
[A. 1700] Because the incident report is not a part of the medical
place, person, and situation. Denies
record, an objective note should be placed in the client's medical record
pain, dizziness, or nausea No visible
documenting the facts and events of the incident, HCP notification and
injuries.Assisted back to bed.
findings, prescriptions, treatment, follow-up care, and monitoring.
Neurological vital signs within normal
limits (see assessment flow sheet).
[B. 1710] Because the incident report is not a part of the medical record, an
Client instructed to use call bell for
objective note should be placed in the client's medical record
assistance.
documenting the facts and events of the incident, HCP notification and
Will continue to monitor _______ RN
findings, prescriptions, treatment, follow- up care, and monitoring.
1710 Health care provider (HCP)
[D. 1810] Because the incident report is not a part of the medical record, an
notified of fall. Prescribed CT of head
objective note should be placed in the client's medical record
STAT.
documenting the facts and events of the incident, HCP notification and
______ RN
findings, prescriptions, treatment, follow- up care, and monitoring.
1740 No change in neurologic
Educational objective:The person who witnesses an unusual occurrence
status.Client to CT via gurney. Report
or event must file an incident report in the institution's computer
filed per policy.
documentation system, using an electronic form. The nurse should not
_______ RN
document that an incident report was filed or refer to the incident report
1810 Client returned in th
1/149
,4/20/25, 9:47 AM NCLEX Prep PN: Leadership & Management
Correct Answer: D. Recheck the client's
blood pressure with a manual cuff
This client's abnormally high blood pressure
increases the risk for complications such as
stroke. The nurse should assess this client
and recheck the blood pressure with a
manual cuff to verify the accuracy of the
previous measurement taken by unlicensed
assistive personnel (UAP). The nurse will
need to assess the client further before
making additional nursing judgments and
taking action.
Unlicensed assistive personnel on the
cardiac floor report to the nurse that, Incorrect Answers
during the first vital sign [A. Have unlicensed assistive personnel
measurement on the shift, a client's recheck the client's blood pressure] The
blood pressure measured 198/102 nurse should not instruct UAP to perform
mm Hg on the automated blood additional blood pressure measurements as
pressure machine. What action should this client could have severe hypertension;
the nurse take first? delegation of such a task is inappropriate
(does not fit the "right circumstances" for
A. Have unlicensed assistive delegation). If the client's reading is not as
personnel recheck the client's high as previously thought after blood
blood pressure pressure measurement with a manual cuff,
B. Immediately notify the the nurse can then instruct UAP to take
supervising registered nurse subsequent measurements with a different
C. Obtain the client's prn labetalol automatic blood pressure machine.
from the medication dispensing
machine [B. Immediately notify the supervising
D. Recheck the client's blood pressure registered nurse] It may be necessary to
with a manual cuff notify the supervising registered nurse, but
this should occur only after the client has
been assessed further by the nurse.
[C. Obtain the client's prn labetalol
from the medication dispensing
machine] The client's blood pressure
must be verified for accuracy before
administering a prn antihypertensive.
Educational objective:When unlicensed
assistive personnel (UAP) report an abnormal
vital sign to the nurse, the nurse should
assess the client further and verify the
finding. It is inappropriate delegation to
have UAP recheck the client.
2/149
,4/20/25, 9:47 AM NCLEX Prep PN: Leadership & Management
Correct Answer: A. Assist client, post hip
fracture repair, to the bathroom
Examples of tasks that can be delegated to
unlicensed assistive personnel (UAP) include
taking vital signs; assisting clients out of
bed, to the bathroom, and with activities of
daily living; and feeding clients. When a
nurse delegates a task to another staff
member, the nurse ultimately remains
responsible for both the action and its
outcome.
Incorrect Answers:
The nurse caring for multiple clients [B. Check the appearance of client's wound]
on a medical-surgical unit should Checking the wound involves assessment of
delegate which action to the nursing
its appearance. The nurse should perform
assistant?
this assessment as it is not within the scope
A. Assist client, post hip fracture of practice for the nursing assistant.
repair, to the bathroom
B. Check the appearance of client's
wound [C. Discontinue nasogastric tube if client
C. Discontinue nasogastric tube tolerates oral liquids] The nursing assistant
if client tolerates oral liquids can help with feeding. However, the
D. Offer orange juice to client if nasogastric tube should be discontinued at
bedside glucose reading is <70 the direction of the nurse as this procedure
mg/dL (3.9mmol/L) requires client assessment and monitoring.
[D. Offer orange juice to client if bedside
glucose reading is <70 mg/dL (3.9mmol/L)]
Offering orange juice is an intervention to
treat hypoglycemia that is outside the
nursing assistant's scope of practice without
the client first being assessed by the
registered nurse. The client could have
accompanying symptoms along with the low
glucose result; these would require
assessment and interpretation before
intervention.
Educational objective:The nurse may
delegate components of care but does not
delegate the nursing process (assessment,
planning, evaluation) itself. Skills requiring
critical thinking and nursing knowledge
cannot be delegated.
3/149
, 4/20/25, 9:47 AM NCLEX Prep PN: Leadership & Management
Correct Answer: B. Client reporting back
pain 1 hour following coronary angiography
Postprocedure care of a client who has
undergone cardiac catheterization should
focus on monitoring hemodynamics (eg,
blood pressure, heart rate, strength of distal
pulses, temperature of extremities). The
client should be also assessed several times
per hour (eg, approximately every 15
minutes) for active bleeding or hematoma
formation at the incision. Any report of back
or flank pain should be investigated for
possible retroperitoneal bleeding. Back
pain, tachycardia, and hypotension may be
the only indications of bleeding as it can
take up to 12 hours before a significant
The nurse has just received report drop in hematocrit can be measured.
on 4 clients. Which reported Hemorrhage after cardiac catheterization is
information is the most concerning? particularly dangerous due to the frequent
use of anticoagulant prescriptions in these
A. Client on a heparin drip with an clients.
activated partial thromboplastin time
of 60 seconds Incorrect Answers:
B. Client reporting back pain 1 [A. Client on a heparin drip with an activated
hour following coronary partial thromboplastin time of 60 seconds] A
angiography heparin infusion is used to treat deep venous
C. Client with a head injury and a thrombosis. An activated partial
Glasgow Coma Scale score of 14 thromboplastin time of 60 seconds is a
D. Client with incisional pain rated therapeutic value. The therapeutic range for
6/10 on day 2 post coronary artery a client on anticoagulation is usually 46-70
bypass graft seconds (1½ -2 times the normal value).
[C. Client with a head injury and a Glasgow
Coma Scale score of 14] A client with a
head injury should be evaluated hourly for
any change in neurological status. However,
the highest possible score on the Glasgow
Coma Scale is 15 for a fully alert person; a
client with a score of 14 does not require
urgent attention.
[D. Client with incisional pain rated 6/10 on
day 2 post coronary artery bypass graft]
The report of incisional pain on
postoperative day 2 would take second
priority for further assessment, but
evaluating a client with possible internal
bleeding is the priority.
4/149
