Questions 41

NCLEX-RN

NCLEX-RN Test Bank

Leadership and Management NCLEX Questions Questions

Question 1 of 5

The nurse is caring for assigned clients. The nurse should initially assess the client who

Correct Answer: A

Rationale: Numbness post-femoral angioplasty (
A) suggests vascular compromise, such as occlusion, requiring immediate assessment. Insulin refusal (
B), stable GCS post-alteplase (
C), and constipation in spinal injury (
D) are less urgent.

Question 2 of 5

The emergency department (ED) nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up?

Correct Answer: C

Rationale: A MAP of 51 mm Hg in DKA (
C) indicates severe hypotension and organ hypoperfusion, requiring immediate fluid resuscitation. RR 23 (
A) and glucose 319 (
B) are expected in DKA, and PaO2 90 (
D) is normal, none requiring immediate action.

Question 3 of 5

The nurse is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed

Correct Answer: A

Rationale: Muscle stiffness and feeling hot with olanzapine (
A) suggest neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Blurred vision/constipation (
B), mouth twitches (
C), and restlessness (
D) are less urgent side effects.

Question 4 of 5

While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

Correct Answer: B

Rationale: A high-pressure alarm suggests obstruction or resistance, so assessing the client’s condition (
B) first identifies the cause (e.g., tube kinking, secretions). Disconnecting (
A), calling for help (
C), or resetting (
D) without assessment risks harm or delays resolution.

Question 5 of 5

A nurse observes a colleague failing to perform hand hygiene before entering multiple client rooms and administering medications. What is the most appropriate action by the nurse?

Correct Answer: C

Rationale: Reporting to the nurse manager (
C) ensures prompt follow-up on a serious infection control breach that risks client safety. Confronting in a client’s room (
A) is unprofessional, documenting without action (
B) delays intervention, and assuming busyness (
D) ignores the safety violation.

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