NCLEX - MANAGEMENT OF CARE Day1 (Part 1)

A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first?

• Client who sustained a closed, incomplete ulnar fracture while playing sports
• Client with bilateral metacarpal fractures after falling out of bed
• Client with multiple myeloma who has a vertebral fracture and aching back pain
• Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation

Answer explanation

Option 1: Client who sustained a closed, incomplete ulnar fracture while playing sports

Option 2: Client with bilateral metacarpal fractures after falling out of bed

Option 3: Client with multiple myeloma who has a vertebral fracture and aching back pain

Option 4: Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation

Correct Answer: Option 4

Explanation: Joint dislocations may compress nearby vasculature, leading to limb-threatening ischemia. Neurovascular compromise symptoms require immediate assessment.

The nurse is using SBAR to report a client’s condition to the HCP. What should the nurse do next?

• Report the total intake and output during the procedure
• Provide the client's temperature trend over the past 12 hours
• Request an order for a 500-mL bolus of lactated Ringer solution from the HCP
• Review the client's medical history and allergies

Answer explanation

3. · Option 1: Report the total intake and output during the procedure

   · Option 2: Provide the client's temperature trend over the past 12 hours

   · Option 3: Request an order for a 500-mL bolus of lactated Ringer solution from the HCP

   · Option 4: Review the client's medical history and allergies

   Correct Answer: Option 3

   Explanation: Nurse must complete the Recommendation/Request part of SBAR and advocate for treatment of hypotension and possible shock.

The nurse is caring for assigned clients. The nurse should first check the client with:

• liver cirrhosis who has a decreased RBC count and is reporting pruritis
• pneumonia who has elevated WBC count and coarse crackles bilaterally
• atrial fibrillation with irregular HR of 122/min and reporting palpitations
• pericarditis with muffled heart sounds and drop in systolic BP during inspiration

Answer explanation

4. Option 1: liver cirrhosis who has a decreased RBC count and is reporting pruritis

   Option 2: pneumonia who has elevated WBC count and coarse crackles bilaterally

   Option 3: atrial fibrillation with irregular HR of 122/min and reporting palpitations

   Option 4: pericarditis with muffled heart sounds and drop in systolic BP during inspiration

   Correct Answer: Option 4

   Explanation: Muffled heart sounds and drop in BP suggest cardiac tamponade, a life-threatening condition requiring urgent attention.

Which client should the clinic nurse call back first?

• Client with celiac disease reporting diarrhea and foul-smelling stools
• Client with chronic kidney disease reporting nausea, vomiting, and headache
• Client with nausea and diarrhea after taking amoxicillin-clavulanate
• Client with nausea, vomiting, and diarrhea after eating egg salad

Answer explanation

4. Option 1: Client with celiac disease reporting diarrhea and foul-smelling stools

   Option 2: Client with chronic kidney disease reporting nausea, vomiting, and headache

   Option 3: Client with nausea and diarrhea after taking amoxicillin-clavulanate

   Option 4: Client with nausea, vomiting, and diarrhea after eating egg salad

   Correct Answer: Option 2

   Explanation: Symptoms indicate potential hypertensive encephalopathy in CKD, requiring urgent treatment to prevent organ damage.

What should the ED charge nurse do first when ICU transfer is delayed 6 hours?

• Call the telemetry unit manager
• Notify the nursing supervisor
• Send the client to ICU hallway to wait
• Wait until resident is free to request transfer

Answer explanation

4. Option 1: Call the telemetry unit manager

   Option 2: Notify the nursing supervisor

   Option 3: Send the client to ICU hallway to wait

   Option 4: Wait until resident is free to request transfer

   Correct Answer: Option 2

   Explanation: Nursing supervisor has authority to resolve interdepartmental transfer delays and ensure appropriate client placement.

Which action should the nurse take first when UAP reports client was lightheaded post-paracentesis?

• Ask UAP to take vital signs
• Assess the symptoms reported
• Hold prescribed diuretic medications
• Instruct UAP to assist client to bed

Answer explanation

Option 1: Ask UAP to take vital signs

Option 2: Assess the symptoms reported

Option 3: Hold prescribed diuretic medications

Option 4: Instruct UAP to assist client to bed

Correct Answer: Option 2

Explanation: Nurse must validate and assess symptoms before implementing further actions in case of hypovolemia.

Which SBAR report is most appropriate?

• 43-year-old with wheezing, fever, O2 sat 90%. May need ABG testing
• 75-year-old in respiratory distress, RT gave treatment, CXR suggested
• 80-year-old with heart failure and pneumonia, O2 sat 85%, request nasal cannula
• Pneumonia client still SOB after breathing treatment, suggest labs

Answer explanation

Option 1: 43-year-old with wheezing, fever, O2 sat 90%. May need ABG testing

Option 2: 75-year-old in respiratory distress, RT gave treatment, CXR suggested

Option 3: 80-year-old with heart failure and pneumonia, O2 sat 85%, request nasal cannula

Option 4: Pneumonia client still SOB after breathing treatment, suggest labs

Correct Answer: Option 3

Explanation: Option 3 includes all SBAR components—background, assessment, and clear recommendation for intervention.

Which event should the nurse address first?

• HCP asking to speak
• Visitor lying on the hallway floor
• Client requesting analgesic for pain 8/10
• IV pump beeping during blood transfusion

Answer explanation

Option 1: HCP asking to speak

Option 2: Visitor lying on the hallway floor

Option 3: Client requesting analgesic for pain 8/10

Option 4: IV pump beeping during blood transfusion

Correct Answer: Option 2

Explanation: Addressing the fallen visitor is a potential emergency and must take priority over routine care.

What action should the nurse take first after UAP reports client’s BP 198/102?

• Have the UAP recheck the BP
• Immediately notify the HCP
• Obtain PRN labetalol from dispensing machine
• Recheck BP with a manual cuff

Answer explanation

Option 1: Have the UAP recheck the BP

Option 2: Immediately notify the HCP

Option 3: Obtain PRN labetalol from dispensing machine

Option 4: Recheck BP with a manual cuff

Correct Answer: Option 4

Explanation: Assessing and verifying a critical BP reading with a manual cuff ensures accurate evaluation before treatment or escalation.

Which topics should the nurse discuss during advance care planning?

• Financial power of attorney
• Health care proxy
• Life insurance beneficiary
• Living will
• Safe deposit box

Answer explanation

Option 1: Financial power of attorney

Option 2: Health care proxy

Option 3: Life insurance beneficiary

Option 4: Living will

Option 5: Safe deposit box

Correct Answer: Option 2,4

Explanation: Health care proxy and living will are essential components of advance directives and guide future medical care decisions.