Questions 41

NCLEX-RN

NCLEX-RN Test Bank

Leadership and Management in Nursing NCLEX Questions Questions

Question 1 of 5

The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is

Correct Answer: B

Rationale: Bright red blood in the stool at 30 weeks gestation (
B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (
A) is normal quickening, leg cramps and swelling at 28 weeks (
C) are common, and back pain at 38 weeks (
D) is typical, all less urgent.

Question 2 of 5

The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a

Correct Answer: A

Rationale: Collaborating with others across settings to achieve client-centered goals (
A) defines the nurse’s role as a collaborator. Team leader (
B) focuses on directing a group, delegator (
C) assigns tasks, and manager (
D) oversees operations, none of which fully capture this role.

Question 3 of 5

The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.

Order the Items

Source Container

He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.

Correct Answer: E, C, A, B, D

Rationale: Using ISBAR: 1. Identification (E) introduces the nurse and client. 2. Situation (
C) outlines the current issue (chest pain, dyspnea). 3. Background (
A) provides history. 4. Assessment (
B) details vital signs and findings. 5. Recommendation (
D) includes transfer orders and next steps.

Question 4 of 5

The nurse is caring for a 14-year-old scheduled for an appendectomy. What is the nurse's role in obtaining informed consent before surgery? Select all that apply.

Correct Answer: C, D

Rationale: The nurse’s role includes validating parental competency (
C) to ensure they understand the procedure and witnessing the signature (
D) to confirm consent was given. Explaining risks/benefits (
B) is the surgeon’s responsibility. Withdrawing consent (
A) is not limited to the surgeon, and two witnesses (E) are not required.

Question 5 of 5

The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a

Correct Answer: A

Rationale: A yellow tag (
A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (
B) is for critical, black (
C) for deceased, and green (
D) for minor injuries.

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