NCLEX management of care practice questions

Answer: A — A client who had thyroid surgery this morning and now has noisy, high-pitched breathing and is restless.

Airway, breathing and circulation come before all other needs, and noisy high-pitched breathing with restlessness signals a possible airway problem. The other clients have stable, chronic or nonurgent needs that can safely wait a short time.

Checked against: OpenStax Fundamentals of Nursing, 13.4 Focus of the Planning Phase, Establishing Priorities: ABCs (source)

Answer: D — A client three hours after abdominal surgery whose dressing shows spreading bright red drainage and whose heart rate has risen since the last check.

An acute problem that threatens circulation, such as new bleeding with a rising heart rate, takes priority over chronic or educational needs. The other clients' needs are real but stable, so they can be met after the bleeding client is assessed.

Checked against: OpenStax Fundamentals of Nursing, 13.4 Focus of the Planning Phase, Establishing Priorities: ABCs; Acute versus Chronic Problem (source)

Answer: B — Go to the client, assess the client and recheck the blood pressure personally.

Under right supervision and evaluation, the licensed nurse follows up on delegated tasks, evaluates outcomes and intervenes when a finding is unexpected. Waiting, simply documenting or handing the decision back to the AP leaves an unexpected change without a nursing assessment.

Checked against: NCSBN-ANA National Guidelines for Nursing Delegation (2019), Five Rights of Delegation: Right supervision and evaluation; Licensed Nurse Responsibilities 3-4

Answer: A — Have a staff member who is trained on the lift do the transfer and tell the nurse leader that the AP needs training.

A delegatee should accept only tasks he has been trained and found competent to perform, and the licensed nurse reports competence gaps to the nurse leader so training can be arranged. Reading instructions on the spot or adding untrained helpers does not make the delegation safe.

Checked against: NCSBN-ANA National Guidelines for Nursing Delegation (2019), Delegatee Responsibilities 1 and Licensed Nurse Responsibilities 5

Answer: C — The daughter, as the named health care agent, guided by the client's known wishes.

A health care proxy or agent is the specific person the client appointed to make medical decisions when the client cannot speak for himself, and advance planning exists so that the client's own wishes are followed. Disagreement from another relative does not transfer that authority.

Checked against: OpenStax Fundamentals of Nursing, 36.4 Legal and Ethical Considerations, Advance Directive (healthcare proxy); 8.1 Patient Admission (power of attorney) (source)

Answer: B — Respect the refusal, confirm the client understands the consequences, notify the provider and document.

A competent client has the right to refuse treatment, and giving a treatment without consent can be battery. The nurse's role is to confirm understanding, inform the provider and document, not to override or pressure the client.

Checked against: OpenStax Fundamentals of Nursing, 16.3 Legal Dimensions of Care, Patients' Bill of Rights and Intentional Torts (battery) (source)

Answer: A — Tell the nurse manager as early as possible and keep caring for the client until another nurse takes over.

A conscientious objection should be disclosed as soon as possible to someone with authority to change assignments, and it is an objection to an action, never to a person. Leaving a client before another qualified nurse has taken over is abandonment.

Checked against: OpenStax Fundamentals of Nursing, 16.2 Ethics in Nursing Practice, Conscientious Objection (source)

Answer: D — An introduction at the start and a read-back at the end.

SBAR stands for Situation, Background, Assessment and Recommendation; ISBARR adds an Introduction when the report begins and a Read-back at the end so the receiver confirms what was heard. The other options are not part of the format.

Checked against: OpenStax Fundamentals of Nursing, 8.2 Patient Transfer, Reformulating SBAR to ISBARR (source)

Answer: C — Study.

In PDSA, Plan develops the change, Do runs the test, Study analyzes the results and compares them with the desired results, and Act decides the next step. Comparing the fall rate with the target is analysis of results, so it belongs to Study.

Checked against: OpenStax Fundamentals of Nursing, 15.3 Quality Improvement in Nursing, QSEN Competency: The Plan-Do-Study-Act Cycle (source)

Answer: A — Report the suspected abuse to the proper authority as required for mandated reporters.

Nurses are mandated reporters who must report suspected, not only proven, abuse of children, and failing to report can bring fines or criminal charges. A parent's request does not remove the legal duty, and waiting for the child to disclose may leave the child in danger.

Checked against: OpenStax Fundamentals of Nursing, 16.3 Legal Dimensions of Care, Reporting Obligations (source)

Answer: B — Speech therapist.

Speech therapists manage swallowing problems and test which food and liquid textures a client can take safely to prevent aspiration. Occupational therapists focus on daily living skills, physical therapists on movement, and respiratory therapists on breathing treatments.

Checked against: OpenStax Fundamentals of Nursing, 15.6 Interprofessional Approach to Health Care, Speech Therapist (source)

Answer: C — Explain the risks, notify the provider, offer the against-medical-advice form and document the conversation.

A decisional client generally has the right to leave against medical advice, and the nurse makes sure the client is informed of the risks, involves the provider and documents factually; signing the form is preferred but not required. Holding a competent client against their will is not lawful, and leaving without notification or documentation is unsafe.

Checked against: OpenStax Fundamentals of Nursing, 8.3 Patient Discharge, Leaving Against Medical Advice (AMA) and Nursing Documentation for AMA Discharge (source)