Free NCLEX-RN Management of Care questions
22 original Management of Care questions on advance directives, assignment, delegation, supervision, confidentiality / information security, continuity of care / handoff, establishing priorities, informed consent, legal rights and responsibilities, in Next Generation NCLEX formats.
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NCLEX-RN Management of Care questions
- 22 questions
- Management of Care
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An RN delegates a stable client's 1000 vital signs to an assistive personnel (AP). The AP accepts the task. Which statement about responsibility for this client is most accurate?
Correct answer: C
Delegation transfers a task, not accountability. The delegating nurse remains answerable for the client's overall care, while the delegatee who accepts the task is responsible for completing it correctly and reporting back on time.
- A Incorrect: the delegatee is responsible for the delegated task only, not for the client's overall outcome.
- B Incorrect: the nurse who delegates keeps accountability; it does not move up to the charge nurse.
- C Correct: the licensed nurse keeps overall accountability, and the delegatee is responsible for the accepted task.
- D Incorrect: accountability is not split equally; the roles carry different responsibilities, whatever paperwork is signed.
Learn this topic: Delegation and assignment: what the RN can hand off, and to whom 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation ·
An RN on a medical-surgical unit works with one assistive personnel (AP). For each task, indicate whether the RN can give it to the AP or must keep it.
Can give to the AP RN keeps the task Measure and record urine output for a stable client Teach a client newly prescribed insulin how to self-inject Take vital signs on a client whose blood pressure has dropped since the last check Help a stable client walk to the bathroom Complete the admission assessment of a client who just arrived Remind a client to use the incentive spirometer the RN taught them to use this morning Select one option in each row.
Correct answer: Measure and record urine output for a stable client: Can give to the AP; Teach a client newly prescribed insulin how to self-inject: RN keeps the task; Take vital signs on a client whose blood pressure has dropped since the last check: RN keeps the task; Help a stable client walk to the bathroom: Can give to the AP; Complete the admission assessment of a client who just arrived: RN keeps the task; Remind a client to use the incentive spirometer the RN taught them to use this morning: Can give to the AP
Assistive personnel can do routine tasks for stable clients that need no clinical judgment: intake and output, ambulation help, and reinforcing teaching the nurse already gave. Assessment, new client teaching, and any care for an unstable client stay with the RN, because they require nursing judgment and the right circumstance (a stable client) is missing.
- Measure and record urine output for a stable client Can give to the AP: measuring intake and output is routine data collection that needs no clinical judgment.
- Teach a client newly prescribed insulin how to self-inject RN keeps: new client teaching requires nursing knowledge; AP may only reinforce teaching already given.
- Take vital signs on a client whose blood pressure has dropped since the last check RN keeps: a falling blood pressure means the client may be unstable, so the right circumstance for delegation is missing.
- Help a stable client walk to the bathroom Can give to the AP: help with ambulation and toileting for a stable client is an AP activity of daily living task.
- Complete the admission assessment of a client who just arrived RN keeps: admission assessments require clinical judgment and cannot go to an AP or LPN/VN.
- Remind a client to use the incentive spirometer the RN taught them to use this morning Can give to the AP: reminding a client to use a device the RN already taught them to use reinforces existing teaching; it is not new teaching.
Learn this topic: Delegation and assignment: what the RN can hand off, and to whom 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.3 Assignment · Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation ·
An RN asks an assistive personnel (AP) to take vital signs on a stable client every 4 hours. Which instructions by the RN reflect the right directions and communication for this delegation? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Right directions and communication means the RN states what data to collect, what to report, and the time frame, and invites questions in a two-way exchange. The delegatee may not change care on their own, cannot re-delegate, and cannot be given tasks that need assessment or judgment.
- A Correct: a specific reporting trigger tells the AP exactly what finding must come back to the RN.
- B Incorrect: a delegatee cannot delegate to another person; if unable to finish, the AP must tell the nurse.
- C Correct: two-way communication lets the delegatee ask clarifying questions before accepting.
- D Incorrect: changing treatment is a decision; the AP may not modify care without the nurse.
- E Correct: giving a time frame for completing and reporting the data is part of clear direction.
- F Incorrect: lung assessment requires clinical judgment and cannot be delegated to an AP.
Learn this topic: Delegation and assignment: what the RN can hand off, and to whom 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation · Open RN Nursing Management and Professional Concepts 2e, 3.3 Assignment ·
After handoff report, the nurse reviews four assigned clients. Which client should the nurse see first?
Correct answer: B
Use the ABCs and the CURE levels. New chest pain with faster breathing is a critical need that threatens breathing and circulation, so this client is seen first. The client who needs the bathroom is urgent (a safety risk) and can be helped by a teammate, while chronic pain and discharge teaching are routine.
- A Incorrect: chronic pain at a moderate level is a routine need; the body has adapted to this long-standing problem.
- B Correct: new chest pain with increased work of breathing is a critical need under the ABCs and must be assessed now.
- C Incorrect: this is an urgent safety need (fall risk), but it ranks below a critical breathing and circulation problem; the nurse can send a teammate to help.
- D Incorrect: discharge teaching for a stable client is routine care that can wait until critical needs are met.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing ·
The nurse uses the CURE levels to organize care on a medical-surgical unit. For each client need, indicate the level it belongs to.
Critical Urgent Routine Extra Client asks to have their hair washed this afternoon Client at high risk for falls says they must urinate right now Client reports sudden shortness of breath and chest pain Stable client is due for scheduled 0900 oral medications Client after surgery rates pain 7/10 when turning Select one option in each row.
Correct answer: Client asks to have their hair washed this afternoon: Extra; Client at high risk for falls says they must urinate right now: Urgent; Client reports sudden shortness of breath and chest pain: Critical; Stable client is due for scheduled 0900 oral medications: Routine; Client after surgery rates pain 7/10 when turning: Urgent
CURE ranks needs as Critical (act now to prevent decline, such as breathing or chest pain problems), Urgent (discomfort or a significant safety risk), Routine (typical scheduled care) and Extras (comfort that is not essential). Critical needs come first, and routine tasks never outrank critical or urgent ones.
- Client asks to have their hair washed this afternoon Extra: washing hair adds comfort and satisfaction but is not essential to the client's outcomes.
- Client at high risk for falls says they must urinate right now Urgent: a client at high risk for falls who must urinate now may try to get up alone, which is a significant safety risk.
- Client reports sudden shortness of breath and chest pain Critical: breathlessness with chest pain threatens breathing and circulation and needs immediate action.
- Stable client is due for scheduled 0900 oral medications Routine: scheduled medications for a stable client are typical daily nursing care.
- Client after surgery rates pain 7/10 when turning Urgent: significant pain causes discomfort and needs prompt attention, but it is not a threat to airway, breathing or circulation.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing ·
Two clients on a medical unit both have a temperature of 100.8°F (38.2°C) and a cough. Client A was admitted 2 days ago with community-acquired pneumonia and is receiving IV antibiotics; the temperature and cough are unchanged since admission. Client B was admitted yesterday for observation after a fall at home and has a history of osteoarthritis. The nurse's first action should be to because, for that client, the findings are .
Choose the best option from each list to complete the sentence.
Correct answer: assess Client B; unexpected for the client's condition
When two clients have the same findings, ask whether each finding is expected or unexpected for that client's condition. Fever and cough are expected with pneumonia, are unchanged, and are already addressed by the antibiotic plan, but they are unexpected in a client admitted after a fall and may signal a new problem, so that client is assessed first. Unexpected findings often need immediate nursing action.
- Assess Client B first: the same findings are new and unexplained in a client admitted after a fall. Client A's fever and cough fit the known pneumonia and are unchanged; rechecking temperatures delays the needed assessment, and requesting orders before assessing skips the assessment step.
- The findings are unexpected for Client B's condition; they are not expected with a fall or osteoarthritis, they are new rather than chronic, and they are actual rather than potential.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing · MedlinePlus: Community-acquired pneumonia in adults ·
The surgeon has explained a laparoscopic cholecystectomy to a client and asks the nurse to witness the consent form. Before signing, the client says, "I'm still not sure why they need to take my gallbladder out or what else I could do." What is the nurse's best action?
Correct answer: D
Consent is valid only when the client understands the reason for the procedure, its risks and benefits, and the alternatives. Explaining the procedure is the provider's responsibility. When a client voices questions or a lack of understanding, the nurse advocates by holding the signing and asking the provider to return.
- A Incorrect: explaining the procedure, its purpose and alternatives belongs to the provider, not the witnessing nurse.
- B Incorrect: a prior explanation does not make consent informed if the client still does not understand it.
- C Incorrect: this client is alert and able to decide; a family member signs only when the client lacks capacity or is a minor.
- D Correct: the client does not yet understand the procedure or alternatives, so the provider must clarify before consent is signed.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Fundamentals, 1.6 Legal Considerations and Ethics · Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues ·
A nurse is teaching a newly admitted client about advance directives. For each statement the client makes, indicate whether it is accurate or inaccurate.
Accurate Inaccurate "My health care agent will also handle my bank accounts." "My living will says which treatments I do or don't want." "I need to hire a lawyer to make this legal." "I can change my advance directive whenever I want." "A DNR order means no one will treat my pain." "My provider writes the DNR order in my chart." Select one option in each row.
Correct answer: "My health care agent will also handle my bank accounts.": Inaccurate; "My living will says which treatments I do or don't want.": Accurate; "I need to hire a lawyer to make this legal.": Inaccurate; "I can change my advance directive whenever I want.": Accurate; "A DNR order means no one will treat my pain.": Inaccurate; "My provider writes the DNR order in my chart.": Accurate
A living will states the treatments a client wants or refuses if they become unable to decide, and a health care power of attorney names an agent for health care decisions only. Advance directives do not require an attorney and can be changed at any time. A DNR is a provider's medical order about CPR only; it does not stop other treatment such as pain medicine.
- "My health care agent will also handle my bank accounts." Inaccurate: a health care power of attorney covers health care decisions, not finances; a financial power of attorney is a separate document.
- "My living will says which treatments I do or don't want." Accurate: a living will records the treatments the client wants or refuses if incapacitated.
- "I need to hire a lawyer to make this legal." Inaccurate: advance directives do not require an attorney; social workers or chaplains often help complete them.
- "I can change my advance directive whenever I want." Accurate: a client can change advance directive decisions at any time and should share the new documents.
- "A DNR order means no one will treat my pain." Inaccurate: a DNR order is specific to CPR and does not cover pain medicine, other medicines or nutrition.
- "My provider writes the DNR order in my chart." Accurate: a DNR is a medical order written by the health care provider after discussion with the client or proxy.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues · MedlinePlus: Advance care directives · MedlinePlus: Do-not-resuscitate order ·
The provider has just explained a colonoscopy to an 81-year-old client, and the nurse is about to witness the consent form. Click to highlight the findings that should lead the nurse to question the client's decision-making capacity and contact the provider.
1430: Client is wearing reading glasses and holding the consent form. When asked if they have questions, client says, , and . Client correctly states . Client points to the corner and says . Client's son . Per the assistive personnel, client this morning, which is new since admission.
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: "Whatever you want, just do it"; asks nothing about the procedure; "the bugs are back on the wall"; could not feed or dress themself
Formal capacity decisions belong to providers, but the nurse should raise concerns when cues appear. Blanket acceptance of care, no questions about the treatment, hallucinations, and a new inability to perform activities of daily living all suggest the client may not be able to give informed consent right now, so the nurse holds the signing and contacts the provider.
- "Whatever you want, just do it" Highlight: blanket acceptance of whatever is offered is a cue to question decision-making capacity.
- asks nothing about the procedure Highlight: an absence of questions about the treatment being offered is a capacity cue.
- full name and date of birth Do not highlight: correctly stating name and date of birth is an expected, reassuring finding.
- "the bugs are back on the wall" Highlight: describing things that are not there suggests hallucinations, a cue to question capacity.
- is sitting at the bedside Do not highlight: a family member at the bedside is not a sign of impaired capacity and does not change who consents.
- could not feed or dress themself Highlight: a new inability to perform activities of daily living is a cue that decision-making capacity may have changed.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.6 Other Legal Issues ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The nurse reviews the 1000 note. Click to highlight the findings that require immediate follow-up.
1000: Assistive personnel reports that the client when helped to sit on the edge of the bed and was returned to bed. Client is . Skin . Hip dressing has . Urine output . Rates hip pain . Pedal pulses .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: got dizzy and sweaty; restless and asks, "What is happening to me?"; pale, cool and clammy; a new 12 cm (4.7 in) area of bright red drainage; 40 mL over the last 2 hours
Recognizing cues means picking out the findings that are new and point to a change in condition. Dizziness and sweating on sitting up, new restlessness, pale cool clammy skin, fresh bright red drainage and a drop in urine output are all new since 0730 and fit fluid loss. Stable pain and present pedal pulses are not new problems.
- got dizzy and sweaty Highlight: dizziness when sitting up suggests low blood pressure, and sweating is a sign of shock.
- restless and asks, "What is happening to me?" Highlight: new restlessness and anxiety are signs of poor perfusion from blood loss.
- pale, cool and clammy Highlight: pale, cool, clammy skin is a sign of hypovolemic shock.
- a new 12 cm (4.7 in) area of bright red drainage Highlight: new bright red drainage on a dressing that was dry at 0730 suggests active bleeding.
- 40 mL over the last 2 hours Highlight: 40 mL in 2 hours is far below the 60 mL/hr seen overnight; decreased urine output is a sign of fluid loss.
- 4/10, unchanged from 0730 Do not highlight: pain is unchanged and at the same level as at handoff.
- present bilaterally Do not highlight: pedal pulses are present, which is not a new or worsening finding.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · Open RN Nursing Fundamentals, 15.2 Basic Fluid and Electrolyte Concepts · Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% For each finding, indicate whether it supports or does not support hypovolemia from blood loss.
Supports hypovolemia Does not support hypovolemia Heart rate trend 84 → 98 → 122/min Temperature 98.6°F (37.0°C) Blood pressure 90/54 mm Hg at 1000 Hip pain 4/10, unchanged from 0730 Hemoglobin 11.0 → 7.6 g/dL (13.8–17.2 g/dL for males) Urine output 40 mL over 2 hours Select one option in each row.
Correct answer: Heart rate trend 84 → 98 → 122/min: Supports hypovolemia; Temperature 98.6°F (37.0°C): Does not support hypovolemia; Blood pressure 90/54 mm Hg at 1000: Supports hypovolemia; Hip pain 4/10, unchanged from 0730: Does not support hypovolemia; Hemoglobin 11.0 → 7.6 g/dL (13.8–17.2 g/dL for males): Supports hypovolemia; Urine output 40 mL over 2 hours: Supports hypovolemia
Blood loss lowers the circulating volume, so the heart speeds up, blood pressure falls, the kidneys make less urine, and hemoglobin and hematocrit drop. A normal temperature and unchanged pain do not point toward or away from bleeding, so they do not support the hypothesis.
- Heart rate trend 84 → 98 → 122/min Supports: a rapid pulse is a sign of hypovolemic shock as the heart tries to keep up output.
- Temperature 98.6°F (37.0°C) Does not support: the temperature is normal and unchanged from 0400; shock can lower body temperature, but this value gives no evidence of it.
- Blood pressure 90/54 mm Hg at 1000 Supports: low blood pressure is a sign of shock from severe blood or fluid loss.
- Hip pain 4/10, unchanged from 0730 Does not support: unchanged pain at the surgical site is not a sign of fluid loss.
- Hemoglobin 11.0 → 7.6 g/dL (13.8–17.2 g/dL for males) Supports: hemoglobin fell from 11.0 to 7.6 g/dL, far below the male normal range of 13.8–17.2 g/dL; bleeding is a cause of low hemoglobin.
- Urine output 40 mL over 2 hours Supports: decreased urine output is a sign of fluid loss and hypovolemic shock.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · MedlinePlus: Hemoglobin test · Open RN Nursing Fundamentals, 15.2 Basic Fluid and Electrolyte Concepts ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The client is most likely experiencing . The nurse's priority concern is , as shown by .
Choose the best option from each list to complete the sentence.
Correct answer: bleeding that is causing hypovolemia; inadequate tissue perfusion; falling blood pressure and rising heart rate
Fresh bright red drainage and a hemoglobin drop from 11.0 to 7.6 g/dL point to bleeding. Falling blood pressure, a rising heart rate, low urine output and cool clammy skin show the blood loss is starting to affect circulation, so poor tissue perfusion (risk of shock) outranks pain, infection and skin concerns under the ABCs.
- Bleeding with hypovolemia fits the falling hemoglobin and new bloody drainage; the temperature is normal (against infection), respirations are 24/min (against respiratory depression), and the catheter is draining (against retention).
- Inadequate tissue perfusion is a circulation problem and ranks above pain, infection risk and skin integrity.
- Falling blood pressure with a rising heart rate shows circulation is failing to keep up; pain, temperature and the catheter do not show perfusion.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing · MedlinePlus: Hemoglobin test ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The nurse plans care for the next hour. Which actions should the nurse include in the plan? Select all that apply.
Select all that apply.
Correct answer: A, C, F
An unstable client needs frequent RN assessment, a prompt structured report to the surgeon, and protection from falls caused by low blood pressure. Vital signs on an unstable client are not delegated, a blood pressure medication is held when the pressure is already low, and walking a dizzy, bleeding client is unsafe.
- A Correct: a structured SBAR report with the trend and new hemoglobin gives the surgeon what is needed to act.
- B Incorrect: vital signs on an unstable client should not be delegated; the right circumstance (a stable client) is missing.
- C Correct: dizziness from low blood pressure creates a fall risk, a safety need that comes right after the circulation problem.
- D Incorrect: the blood pressure is already 90/54 mm Hg; a medication that lowers blood pressure is held and the provider notified when readings fall below expected parameters.
- E Incorrect: getting up already caused dizziness; walking a client with low blood pressure risks a fall.
- F Correct: a high-acuity client with unstable vital signs needs frequent nursing assessment.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 3.4 Delegation · MedlinePlus: Hypovolemic shock · Open RN Nursing Fundamentals, 2.4 Communicating With Health Care Team Members · Open RN Nursing Management and Professional Concepts 2e, 2.3 Tools for Prioritizing · Open RN Nursing Pharmacology 2e, 6.4 Nursing Process Related to Cardiovascular and Renal Medications ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% The surgeon examines the client, orders 2 units of packed red blood cells, and explains the transfusion. After the surgeon leaves the room, the client, who is alert and oriented, tells the nurse, "I didn't really follow what the doctor said about the risks." The surgeon is still on the unit, and the blood bank says the first unit will be ready in 20 minutes. Which actions should the nurse take? Select all that apply.
Select all that apply.
Correct answer: B, E, F
The provider explains the transfusion and obtains written consent; when the client does not understand, the nurse asks the provider to return. Before starting, the RN confirms the signed consent is on the chart, starts the transfusion slowly, and stays with the client for the first 15 minutes to watch for a reaction. Starting blood is an RN task.
- A Incorrect: explaining risks is the provider's role; the nurse should not fill gaps in the consent discussion.
- B Correct: the client does not understand the risks, so the provider must clarify before consent is valid.
- C Incorrect: initiating a blood transfusion is an RN task and cannot be given to assistive personnel.
- D Incorrect: a transfusion starts at a slow rate, then increases only if there is no sign of a reaction.
- E Correct: unless it is an emergency, written informed consent must be in the record before a transfusion starts.
- F Correct: the nurse remains with the client during the first 15 minutes to monitor for a transfusion reaction.
Learn this topic: Informed consent and advance directives: the nurse's role 5-minute lesson
Source: Open RN Nursing Advanced Skills, 3.4 Checklist for Administration of Blood Products · Open RN Nursing Fundamentals, 1.6 Legal Considerations and Ethics · Open RN Nursing Management and Professional Concepts 2e, 3.3 Assignment ·
History
68-year-old male client on a medical-surgical unit, postoperative day 1 after an open right total hip replacement. History of hypertension and osteoarthritis. Indwelling urinary catheter in place. Peripheral IV in the left forearm with 0.9% sodium chloride infusing at 75 mL/hr.
Nurses' Notes
0730: Handoff received. Alert and oriented ×4. Rates right hip pain 4/10. Hip dressing dry and intact. Urinary catheter draining clear yellow urine, about 60 mL/hr overnight.
1000: Assistive personnel reports that the client got dizzy and sweaty when helped to sit on the edge of the bed and was returned to bed. Client is restless and asks, "What is happening to me?" Skin pale, cool and clammy. Hip dressing has a new 12 cm (4.7 in) area of bright red drainage. Urine output 40 mL over the last 2 hours. Rates hip pain 4/10, unchanged from 0730. Pedal pulses present bilaterally.
Vital Signs
Time Temperature Heart rate Blood pressure Respirations SpO2 0400 98.6°F (37.0°C) 84/min 134/80 mm Hg 16/min 97% room air 0800 98.8°F (37.1°C) 98/min 120/72 mm Hg 18/min 96% room air 1000 98.6°F (37.0°C) 122/min 90/54 mm Hg 24/min 94% room air Laboratory Results
Test 0500 1015 Normal range (adult male) Hemoglobin 11.0 g/dL 7.6 g/dL 13.8–17.2 g/dL Hematocrit 33% 23% 37%–48% By 1600, both units of packed red blood cells have been transfused. At 1030 the nurse outlined the drainage on the dressing. Compare each current finding with the client's data at 1000–1015. Indicate whether each finding shows that care has been effective (improved since 1000–1015) or ineffective (unchanged or worse).
Effective Ineffective Heart rate 88/min Drainage has spread past the 1030 outline Blood pressure 116/70 mm Hg Hemoglobin 9.4 g/dL (13.8–17.2 g/dL for males) Urine output 25 mL over the last 2 hours Alert, oriented ×4, and no longer restless Select one option in each row.
Correct answer: Heart rate 88/min: Effective; Drainage has spread past the 1030 outline: Ineffective; Blood pressure 116/70 mm Hg: Effective; Hemoglobin 9.4 g/dL (13.8–17.2 g/dL for males): Effective; Urine output 25 mL over the last 2 hours: Ineffective; Alert, oriented ×4, and no longer restless: Effective
Evaluating outcomes means comparing each new finding with the client's earlier data. Heart rate, blood pressure, hemoglobin and mental status have all improved since 1000–1015, even though hemoglobin is not yet normal. Spreading drainage means bleeding continues, and urine output has fallen further (below 30 mL/hr), so both need prompt follow-up with the surgeon.
- Heart rate 88/min Effective: heart rate fell from 122/min toward the client's earlier baseline.
- Drainage has spread past the 1030 outline Ineffective: drainage spreading beyond the outline shows the site is still bleeding.
- Blood pressure 116/70 mm Hg Effective: blood pressure rose from 90/54 mm Hg back near the earlier readings.
- Hemoglobin 9.4 g/dL (13.8–17.2 g/dL for males) Effective: hemoglobin rose from 7.6 g/dL after the transfusion; it is still below the male normal range, but it has improved since 1015.
- Urine output 25 mL over the last 2 hours Ineffective: 25 mL in 2 hours is even lower than the 40 mL seen at 1000, so kidney perfusion has not improved.
- Alert, oriented ×4, and no longer restless Effective: the restlessness seen at 1000 has resolved, suggesting better perfusion to the brain.
Learn this topic: Which client should the nurse see first? 5-minute lesson
Source: MedlinePlus: Hypovolemic shock · MedlinePlus: Hemoglobin test · Open RN Nursing Fundamentals, 15.2 Basic Fluid and Electrolyte Concepts ·
The adult daughter of a client calls the medical unit and asks why her mother was moved to the telemetry unit overnight. The client is alert and oriented and has not told the nurse whether she wants health information shared with her family. Which response by the nurse is best?
Correct answer: C
When an alert client is available to decide, HIPAA lets the nurse share health information with a family member only after the client agrees or, given the chance, does not object, and Open RN advises checking first whether the client has granted permission (agency policy may require it in writing). Until then the nurse does not release, hint at, or summarize the information. The nurse can ask the client and then follow her wishes.
- A Incorrect: a date of birth confirms who the caller knows, not that the client agreed to share her information.
- B Incorrect: even a brief summary of her condition discloses health information the client has not agreed to share.
- C Correct: the alert client decides whether her daughter receives her health information, so the nurse asks the client first.
- D Incorrect: the provider is under the same rule; transferring the call does not replace the client's permission.
Source: Open RN Nursing Fundamentals 2e, 1.6 Legal Considerations and Ethics · 45 CFR 164.510 Uses and disclosures requiring an opportunity for the individual to agree or to object (Cornell LII) ·
A client's family files a malpractice lawsuit against a nurse. Which elements must be proven for the claim to succeed? Select all that apply.
Select all that apply.
Correct answer: A, B, C, D
Malpractice is negligence by a licensed professional, and it is an unintentional tort, so intent to harm is not part of the claim. The plaintiff must prove four elements: duty, breach of the standard of care, causation and harm with damages. Civil cases are decided by a preponderance of the evidence, not the criminal standard of beyond a reasonable doubt.
- A Correct: duty exists once the nurse accepts responsibility for the client, such as after a handoff report.
- B Correct: breach means the nurse did not act as a reasonably prudent nurse would in the same situation.
- C Correct: causation links the nurse's breach to the client's injury.
- D Correct: harm means the injury caused damages, such as added medical costs or lost function.
- E Incorrect: malpractice is an unintentional tort; intent belongs to torts such as battery.
- F Incorrect: beyond a reasonable doubt is the criminal standard; civil malpractice uses a preponderance of the evidence.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Management and Professional Concepts 2e, 5.2 Understanding the Legal System · Open RN Nursing Fundamentals 2e, 1.6 Legal Considerations and Ethics ·
A provider prescribes a medication dose that is 10 times the maximum dose listed in the drug reference. When the nurse calls, the provider says, "It's correct. Just give it." What should the nurse do next?
Correct answer: C
Safety first: a nurse who carries out an order that the nurse knew or should have known could harm a client can be disciplined, so "the provider ordered it" is not a defense. Changing the dose on one's own is practicing beyond the nurse's scope. The nurse holds the dose, follows the chain of command until the concern is resolved, and documents exactly who was notified and when.
- A Incorrect: executing an order the nurse knows could harm the client is grounds for discipline.
- B Incorrect: changing a prescribed dose without an order is practicing beyond the nurse's scope.
- C Correct: the nurse holds the dose and pursues the concern through the chain of command to resolution.
- D Incorrect: handing the unsafe dose to a coworker still exposes the client to harm and avoids the nurse's duty.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Pharmacology 2e, 2.3 Legal Foundations and National Guidelines for Safe Medication Administration · Open RN Nursing Management and Professional Concepts 2e, 5.2 Understanding the Legal System · Open RN Nursing Management and Professional Concepts 2e, 5.4 Frequent Allegations and SBON Investigations · Open RN Nursing Management and Professional Concepts 2e, 5.5 Protecting Your Nursing License ·
A nurse manager audits a nurse's electronic notes for one client. Click to highlight the entries that break legal documentation rules.
. . . . . .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: 0800: Client is lazy and will not cooperate with care; 0900: Dressing change scheduled for 1200 charted as done, entered early to save time; 1100: Client found on bathroom floor; incident report filed
Documentation must be objective, factual and professional, so labels such as "lazy" do not belong in the record. Care is never charted before it is done; missed charting is entered as a late entry showing when it was written and when the care happened. The fall, the provider notification and the orders belong in the record, but the incident report is not part of the medical record and is not mentioned there.
- 0800: Client is lazy and will not cooperate with care Highlighted: "lazy" is a judgment, not an objective, factual and professional description.
- 0815: Lungs clear in all fields; respirations 18/min and unlabored Not highlighted: this is an objective assessment the nurse performed.
- 0900: Dressing change scheduled for 1200 charted as done, entered early to save time Highlighted: documenting a task before it is done is falsification.
- 1030: Late entry for a 0930 pain reassessment; pain 2/10 Not highlighted: a late entry that shows both times is the correct way to add missed charting.
- 1100: Client found on bathroom floor; incident report filed Highlighted: the fall belongs in the record, but the incident report should not be mentioned in it.
- 1115: Dr. Patel notified at 1105 of the fall; X-ray of left hip ordered Not highlighted: provider notification is documented with the name, the time and the response.
Learn this topic: What are a nurse's legal duties, and how does charting protect clients? 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 2.5 Documentation · Open RN Nursing Management and Professional Concepts 2e, 5.5 Protecting Your Nursing License ·
Before discharge, a nurse explains a new twice-daily inhaler schedule to a client. Which question by the nurse best uses the teach-back method?
Correct answer: B
Teach-back checks understanding by asking the client to state in their own words what they need to know or do. Yes-or-no questions such as "Do you understand?" or "Does that make sense?" are not teach-back, because clients tend to say yes whether or not they understand. If teach-back shows a gap, the nurse explains it a different way and asks again.
- A Incorrect: a yes-or-no question usually gets a "yes" whether or not the client understands.
- B Correct: asking the client to explain in their own words is the teach-back method.
- C Incorrect: "Does this make sense?" is a yes-or-no question, not teach-back.
- D Incorrect: offering to repeat the teaching does not show what the client actually understood.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: AHRQ Health Literacy Universal Precautions Toolkit, Use the Teach-Back Method: Tool 5 ·
A nurse is giving bedside shift report for a client in a semiprivate room. The roommate has two visitors in the room. For each action, indicate whether it is good practice or should be avoided.
Good practice Avoid Introducing the oncoming nurse and inviting the client to take part Looking at the IV site and the incision together with the oncoming nurse Asking the client what she wants to happen during the next shift Stating the client's new cancer diagnosis aloud while the roommate's visitors are present Using medical shorthand so the report goes faster Scanning the room for safety hazards, such as clutter on the floor Select one option in each row.
Correct answer: Introducing the oncoming nurse and inviting the client to take part: Good practice; Looking at the IV site and the incision together with the oncoming nurse: Good practice; Asking the client what she wants to happen during the next shift: Good practice; Stating the client's new cancer diagnosis aloud while the roommate's visitors are present: Avoid; Using medical shorthand so the report goes faster: Avoid; Scanning the room for safety hazards, such as clutter on the floor: Good practice
Bedside shift report involves the client and family: introduce the oncoming nurse, invite them to take part, give the report in words they understand, look at lines, wounds and drains together, sweep the room for safety hazards, and ask what the client wants to happen during the next shift. HIPAA still applies, so sensitive information is not said aloud where visitors can overhear.
- Introducing the oncoming nurse and inviting the client to take part Good practice: the report starts by introducing staff and inviting the client and family to take part.
- Looking at the IV site and the incision together with the oncoming nurse Good practice: both nurses visually inspect IV sites, incisions and drains during the report.
- Asking the client what she wants to happen during the next shift Good practice: the report asks for the client's own goal for the next shift.
- Stating the client's new cancer diagnosis aloud while the roommate's visitors are present Avoid: HIPAA rules must be kept in mind when visitors are present or the room is shared.
- Using medical shorthand so the report goes faster Avoid: the report should use words that the client and family can understand.
- Scanning the room for safety hazards, such as clutter on the floor Good practice: a visual sweep of the room for physical safety concerns is part of the report.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: AHRQ, Bedside Shift Report Checklist (Guide to Patient and Family Engagement) · AHRQ, Strategy 3: Nurse Bedside Shift Report · Open RN Nursing Fundamentals 2e, 2.4 Communicating With Health Care Team Members ·
At discharge, a nurse compares the client's home medication list with the discharge orders. The client took furosemide daily at home, but furosemide is not mentioned anywhere in the discharge orders. The nurse should , because .
Choose the best option from each list to complete the sentence.
Correct answer: clarify the discrepancy with the provider first; medication errors often happen at transitions of care
Medication reconciliation compares the best possible medication history with current orders, resolves every difference and communicates the changes to the client and the next providers. Discrepancies are common at transitions such as discharge, so a home drug that is neither continued nor stopped in the orders is clarified with the provider before the client leaves. The discharge instructions should list every medicine, with new, changed and stopped drugs marked.
- The unexplained difference is clarified with the provider before discharge; telling the client to take everything or stop everything guesses at the provider's intent, and leaving it to the community pharmacist sends an unresolved discrepancy home.
- Medication errors often happen during transitions of care, which is why reconciliation is done at each one; the other reasons are false generalizations.
Learn this topic: How do nurses hand off care safely between shifts, units and home? 5-minute lesson
Source: Open RN Nursing Pharmacology 2e, 2.5 Preventing Medication Errors · MedlinePlus, Leaving the hospital - your discharge plan ·
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NCLEX-RN format
| Client needs category | Share of the exam |
|---|---|
| Management of Care | 15–21% |
| Safety and Infection Prevention and Control | 10–16% |
| Health Promotion and Maintenance | 6–12% |
| Psychosocial Integrity | 6–12% |
| Basic Care and Comfort | 6–12% |
| Pharmacological and Parenteral Therapies | 13–19% |
| Reduction of Risk Potential | 9–15% |
| Physiological Adaptation | 11–17% |
The exam has 85 to 150 questions in up to 5 hours, including 15 unscored pretest questions and three unfolding case studies. An on-screen calculator is provided.
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