Management of Care

Question 1

A charge nurse has a unit with four clients needing care. Which client should be assessed first?

Accepted Answer

A client with chest pain radiating to the left arm who is diaphoretic

Answer

Chest pain radiating to the left arm with diaphoresis suggests acute myocardial infarction — a life-threatening emergency that requires immediate assessment and intervention. Prioritization follows the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy.

Question 2

A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which task is most appropriate to delegate to the UAP?

Accepted Answer

Measure and record vital signs for a client 4 hours post-surgery

Answer

Measuring and recording vital signs for a stable postoperative client is within the UAP's scope of practice and does not require clinical judgment. Assessment, medication administration, and client education require RN or LPN licensure and may not be delegated to UAPs.

Question 3

A nurse suspects that a colleague is diverting controlled substances. The nurse's most appropriate first action is to:

Accepted Answer

Report the suspicion to the nurse manager or through the facility's chain of command

Answer

Drug diversion is a patient safety and legal issue. The nurse has a professional and ethical obligation to report the suspicion through the proper chain of command (charge nurse, nurse manager, or risk management). Confronting the colleague or delaying reporting is inappropriate.

Question 4

A client with terminal cancer has a valid do-not-resuscitate (DNR) order. The client's adult child insists the nurse 'do everything possible' if the client stops breathing. The nurse should:

Accepted Answer

Honor the client's DNR order and explain it reflects the client's own wishes

Answer

A legally executed DNR order reflects the autonomous decision of a competent client and must be honored. Family members cannot override a valid advance directive. The nurse should communicate compassionately with the family while upholding the client's rights.

Question 5

A nurse is completing an incident report after a client received the wrong dose of a medication. The report should include:

Accepted Answer

Objective facts: what happened, when, who was involved, and what actions were taken

Answer

Incident reports are objective factual accounts used for quality improvement, not punitive assignment of blame. They should describe what happened, when it occurred, who was involved, and what interventions followed. The incident report itself is never referenced in the medical record.

NCLEX Practice Test

NCLEX Practice Test

Management of Care