Management of Care 2

Question 1

A nurse is caring for four clients. Which client should the nurse assess first?

Accepted Answer

A client with COPD whose oxygen saturation has dropped from 94% to 88%

Answer

A drop in oxygen saturation to 88% in a COPD client represents an acute change in respiratory status and a potential airway/breathing emergency. This takes priority over the other clients using the ABCs (Airway, Breathing, Circulation) framework.

Question 2

A nurse is the charge nurse on a medical-surgical unit. A client's family member complains that they have been waiting 2 hours to speak with the physician. Which action is most appropriate?

Accepted Answer

Contact the physician to communicate the family's request for an update

Answer

The charge nurse should advocate for the client and family by contacting the physician to relay the request for communication. This is part of the charge nurse's advocacy and coordination role and addresses the family's legitimate concern.

Question 3

A nurse is caring for a client with a new diagnosis of terminal cancer who has just been told their prognosis. The client says, 'I think there's been a mistake. The tests must be wrong.' Which stage of the Kübler-Ross grief model does this represent?

Accepted Answer

Denial

Answer

Denial is the first stage of the Kübler-Ross grief model and involves refusing to accept the reality of a diagnosis or prognosis. Statements such as 'there must be a mistake' or 'the tests are wrong' are classic expressions of denial.

Question 4

A nurse is caring for a client who speaks limited English. An interpreter is needed for informed consent for a surgical procedure. Which action is most appropriate?

Accepted Answer

Utilize a professional medical interpreter (in-person or telephonic)

Answer

A professional medical interpreter (certified) is the most appropriate resource for informed consent communication. Professional interpreters are trained in medical terminology, confidentiality, and neutral interpretation, which is required for valid informed consent.

Question 5

A nurse is preparing a client for discharge. The client will be taking multiple medications at home. Which action best ensures medication safety at discharge?

Accepted Answer

Conduct teach-back by having the client explain each medication's purpose, dose, and schedule

Answer

Teach-back — having the client explain in their own words the medications' purpose, dose, and schedule — is the gold standard for verifying health literacy and ensuring the client truly understands their discharge regimen.

NCLEX Practice Test

NCLEX Practice Test

Management of Care 2