WorksheetsNCLEX - MANAGEMENT OF CARE Day1
Total questions: 25
Worksheet time: 25mins
Name
Class
Date
1.
A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first?
a)
Client who sustained a closed, incomplete ulnar fracture while playing sports
b)
Client with bilateral metacarpal fractures after falling out of bed
c)
Client with multiple myeloma who has a vertebral fracture and aching back pain
d)
Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation
e)
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2.
The nurse is using SBAR to report a client’s condition to the HCP. What should the nurse do next?
a)
Report the total intake and output during the procedure
b)
Provide the client's temperature trend over the past 12 hours
c)
Request an order for a 500-mL bolus of lactated Ringer solution from the HCP
d)
Review the client's medical history and allergies
e)
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3.
The nurse is caring for assigned clients. The nurse should first check the client with:
a)
liver cirrhosis who has a decreased RBC count and is reporting pruritis
b)
pneumonia who has elevated WBC count and coarse crackles bilaterally
c)
atrial fibrillation with irregular HR of 122/min and reporting palpitations
d)
pericarditis with muffled heart sounds and drop in systolic BP during inspiration
e)
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4.
Which client should the clinic nurse call back first?
a)
Client with celiac disease reporting diarrhea and foul-smelling stools
b)
Client with chronic kidney disease reporting nausea, vomiting, and headache
c)
Client with nausea and diarrhea after taking amoxicillin-clavulanate
d)
Client with nausea, vomiting, and diarrhea after eating egg salad
e)
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5.
What should the ED charge nurse do first when ICU transfer is delayed 6 hours?
a)
Call the telemetry unit manager
b)
Notify the nursing supervisor
c)
Send the client to ICU hallway to wait
d)
Wait until resident is free to request transfer
e)
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6.
Which action should the nurse take first when UAP reports client was lightheaded post-paracentesis?
a)
Ask UAP to take vital signs
b)
Assess the symptoms reported
c)
Hold prescribed diuretic medications
d)
Instruct UAP to assist client to bed
e)
-
7.
Which SBAR report is most appropriate?
a)
43-year-old with wheezing, fever, O2 sat 90%. May need ABG testing
b)
75-year-old in respiratory distress, RT gave treatment, CXR suggested
c)
80-year-old with heart failure and pneumonia, O2 sat 85%, request nasal cannula
d)
Pneumonia client still SOB after breathing treatment, suggest labs
e)
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8.
Which event should the nurse address first?
a)
HCP asking to speak
b)
Visitor lying on the hallway floor
c)
Client requesting analgesic for pain 8/10
d)
IV pump beeping during blood transfusion
e)
-
9.
What action should the nurse take first after UAP reports client’s BP 198/102?
a)
Have the UAP recheck the BP
b)
Immediately notify the HCP
c)
Obtain PRN labetalol from dispensing machine
d)
Recheck BP with a manual cuff
e)
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10.
Which topics should the nurse discuss during advance care planning?
a)
Financial power of attorney
b)
Health care proxy
c)
Life insurance beneficiary
d)
Living will
e)
Safe deposit box
11.
Which interdisciplinary team member should nurse consult about safety of an older client’s home?
a)
Adult protective services
b)
Physical therapist
c)
Social worker
d)
Physician
e)
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12.
Which client should be reassessed first after IV morphine?
a)
22-year-old with nephrolithiasis reporting flank pain
b)
26-year-old with osteomyelitis and extremity pain
c)
55-year-old post-bowel resection reporting incision pain
d)
67-year-old with sleep apnea and fractured tibia reporting pain
e)
-
13.
Which client should the nurse assess first?
a)
Lap chole client reporting shoulder pain
b)
New tracheostomy client with pink drainage
c)
Hysterectomy client with pain and warmth in leg
d)
Gastric bypass client with fever and foul wound drainage
e)
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14.
What should night nurse do first after discovering dopamine given instead of norepinephrine?
a)
Administer correct med and check vitals
b)
Alert graduate nurse and file incident report
c)
Assess client and notify HCP
d)
Stop dopamine and tell supervisor
e)
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15.
What’s most appropriate way to handle leftover morphine in PCA cartridge?
a)
Ask UAP to witness waste
b)
Document lack of nurse available to witness
c)
Wait for a nurse and witness together
d)
Waste alone and show empty cartridge
e)
-
16.
What action should nurse take for brain-dead client registered as organ donor?
a)
Contact organ procurement organization
b)
Discontinue nursing care and provide postmortem
c)
Remove life support on family request
d)
Ask family about funeral plans
e)
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17.
Client attempts to leave AMA. What must nurse ensure?
a)
Provide client with medical record
b)
Tell client discharge forms are required
c)
Inform client they cannot return later
d)
Ensure HCP explains risks of leaving
e)
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18.
Off-going nurse must leave and incoming nurse is delayed. What should off-going nurse do?
a)
Ask another nurse to cover temporarily
b)
Record report and leave phone number
c)
Notify charge nurse to assign coverage
d)
Write client notes for incoming nurse
e)
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19.
Which client should be assigned to RN with less than 1 year experience floated from orthopedic to medical unit?
a)
Client newly admitted for ischemic stroke
b)
Client newly diagnosed with diabetes needing insulin teaching
c)
Client with COPD exacerbation and new tracheostomy
d)
Client with sickle cell crisis requiring frequent IV opioids
e)
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20.
What should nurse do when surgeon uses family to translate informed consent?
a)
Witness client sign consent
b)
Speak privately with surgeon about using trained interpreter
c)
Ask family member to confirm client’s understanding
d)
Provide additional post-op education to client
e)
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21.
Which task can RN delegate to UAP?
a)
Assist post-op hip arthroplasty client with morning care
b)
Collect urine specimen from Foley catheter
c)
Perform initial colostomy bag change
d)
Refill enteral feeding container
e)
-
22.
Which nursing task is appropriate for RN to delegate to UAP?
a)
Apply collagenase dressing for wound debridement
b)
Assist post-op hip fracture client to bathroom
c)
Feed via gastrostomy tube with HOB elevated
d)
Give orange juice if BG <70 mg/dL
e)
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23.
Which staff assignment should the charge nurse intervene in?
a)
UAP who received flu vaccine assigned to care
b)
LPN from med-surg assigned to care
c)
UAP with family member having pneumonia assigned
d)
RN with controlled asthma assigned to care
e)
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24.
What action should nurse take when spouse demands entry during bedside emergency procedure?
a)
Allow spouse in and assign staff to explain procedure
b)
Ask spouse to watch from doorway and call chaplain
c)
Update spouse after procedure ends
d)
Escort spouse to waiting area citing safety concerns
e)
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25.
Which staff assignment is most appropriate by charge nurse?
a)
LPN to client with GI bleed and hypotension on blood
b)
LPN to newly admitted bowel obstruction client
c)
RN to client with altered mental status going to ICU
d)
SN to client with MS and dysphagia needing oral/IV meds
e)
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