Management of Care — NCLEX-RN practice questions

A nurse case manager is coordinating discharge for a client with a new colostomy, insulin-dependent diabetes, and limited support at home. Which referral is MOST appropriate to prioritize?

1. A cosmetic dermatology referral to address peristomal skin appearance and surgical scarring
2. No referral is needed, since the client received ostomy care and insulin teaching before discharge
3. A referral for a community gym membership to build stamina and support glycemic control
4. Home health nursing and case management services to support disease management and psychosocial needs

Answer: D — Home health nursing and case management services to support disease management and psychosocial needs

D) Correct — complex, multi-need discharges benefit from home health/case management to support ongoing disease management and address support gaps. A) Not relevant to the clinical needs described. C) Insufficient for the complexity described. B) In-hospital teaching alone often isn't sufficient for complex, high-risk discharges.

A client with terminal cancer has a valid advance directive declining intubation. The family insists the nurse intubate during respiratory failure. What is the nurse's BEST action?

1. Intubate the client to honor the family's wishes, since next of kin direct care once the client can no longer speak for themselves
2. Call the rapid response team and let that team decide whether intubation is warranted in this particular situation
3. Honor the advance directive, provide comfort measures, and engage the provider and ethics support to discuss with the family
4. Ask the client, who is now obtunded, one more time to confirm the directive before withholding intubation

Answer: C — Honor the advance directive, provide comfort measures, and engage the provider and ethics support to discuss with the family

C) Correct: a valid advance directive made by a competent client has legal and ethical authority over family preference; the nurse advocates for the client while supporting the family. A) Family does not override a valid directive. B) Defers responsibility and delays comfort care. D) Obtaining consent from an obtunded client is invalid; the directive already speaks for the client.

A nurse manager wants to improve staff retention on a unit with high turnover. Which evidence-based strategy is MOST likely to be effective?

1. Ignoring staff feedback about workload and scheduling concerns so that managers can concentrate on productivity and budget metrics
2. Reducing professional development and continuing education offerings so nurses stay focused on direct patient care
3. Increasing mandatory overtime without additional support in order to guarantee that every shift is fully covered
4. Implementing mentorship programs, addressing safe staffing ratios, and soliciting regular staff feedback

Answer: D — Implementing mentorship programs, addressing safe staffing ratios, and soliciting regular staff feedback

D) Correct — mentorship, safe staffing, and staff engagement are evidence-based retention strategies. A) Ignoring feedback tends to worsen retention. C) Excessive mandatory overtime is linked to burnout and turnover. B) Reduced professional development is linked to lower retention.

In a mass casualty incident using START triage, a victim is not breathing after the airway is repositioned. How should this victim be triaged?

1. Immediate/red, because respirations returned after repositioning
2. Delayed/yellow, because the victim can wait for airway care
3. Minor/green, because there is no active external bleeding
4. Deceased/expectant (black)

Answer: D — Deceased/expectant (black)

D) Correct — under START, if a victim remains apneic after a single airway repositioning attempt, they are triaged as deceased/expectant given resource constraints. A) Reserved for those breathing after repositioning or other urgent-but-salvageable findings. B) For less urgent injuries who can wait. C) For walking wounded/minor injuries.

Which action best reflects the nurse's role as a client advocate during an interdisciplinary care conference?

1. Remaining silent regardless of concerns
2. Clearly communicating the client's expressed wishes and relevant clinical concerns to the team
3. Making unilateral decisions without team input
4. Deferring entirely to family preferences over the client's own expressed wishes when the client has capacity

Answer: B — Clearly communicating the client's expressed wishes and relevant clinical concerns to the team

B) Correct — advocacy involves ensuring the client's voice and relevant clinical information are represented in team discussions. A) Silence doesn't fulfill the advocacy role. C) Advocacy works within the team process, not unilaterally. D) When a client has capacity, their own wishes take priority over family preferences.

A patient asks the nurse not to disclose their HIV status to family members. The nurse should:

1. Tell the family anyway, since they are next of kin and share the household
2. Document the request in the chart but share the diagnosis during rounds
3. Disclose only to the spouse, who may have had exposure risk
4. Respect the patient's right to confidentiality under HIPAA

Answer: D — Respect the patient's right to confidentiality under HIPAA

HIPAA grants competent adult patients the right to control disclosure of their health information. Diagnosis cannot be shared with family without explicit consent — even spouses. Public-health reporting (state notification of certain diseases) is a separate, legally-mandated exception.

A nurse delegating tasks to UAP follows:

1. The nurse's judgment about which tasks the UAP appeared comfortable performing on previous shifts, without rechecking that assignment against facility policy or the UAP's documented competencies
2. The UAP's stated preference for particular clients and tasks, so that morale is preserved and the assignment is carried out willingly during the shift
3. The "5 rights of delegation" — right task, right circumstance, right person, right direction/communication, right supervision/evaluation — and the scope of practice for UAPs
4. The assumption that the state nurse practice act governs licensed staff only, so delegation limits are set entirely by the facility's own job descriptions

Answer: C — The "5 rights of delegation" — right task, right circumstance, right person, right direction/communication, right supervision/evaluation — and the scope of practice for UAPs

C) Standard framework. A) Familiarity does not replace matching task, circumstance, and supervision. B) Preference does not define scope. D) The practice act defines what may be delegated; facility policy cannot exceed it.

Prioritization frameworks for the NCLEX include:

1. ABCs (Airway, Breathing, Circulation), Maslow's hierarchy, acute vs chronic, stable vs unstable — guiding which client need is addressed first
2. Addressing client requests in the order they were received during the shift, so no one's concern is deferred in favor of another's
3. Following the numerical order of the chart rack or the room numbers on the assignment, which ensures that every assigned client is seen at least once during the shift
4. Completing the quickest tasks first to clear the workload, then devoting the remaining time to the more complex clients on the assignment

Answer: A — ABCs (Airway, Breathing, Circulation), Maslow's hierarchy, acute vs chronic, stable vs unstable — guiding which client need is addressed first

A) Standard frameworks. B/C/D) Each orders care by convenience or sequence rather than by physiologic urgency.

A nurse is delegating tasks. Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)?

1. Administering a scheduled oral medication during the routine morning pass
2. Assessing a postoperative wound and documenting its appearance
3. Assisting a stable patient with ambulation to the bathroom
4. Performing the initial patient teaching about a newly diagnosed condition

Answer: C — Assisting a stable patient with ambulation to the bathroom

The Five Rights of Delegation limit UAPs to tasks that are routine, predictable, and do not require nursing judgment. Ambulating a stable patient fits. Medications (A), assessment (B), and teaching (D) all require licensed nursing judgment and cannot be delegated.

When prioritizing client care, Maslow's hierarchy suggests addressing first:

1. Self-esteem needs, such as restoring the client's sense of competence and dignity after a change in functional status
2. Physiological needs (airway, breathing, circulation, nutrition, elimination) before higher-level needs
3. Love and belonging needs, ensuring the client has family contact and feels accepted by the care team on the unit
4. Self-actualization needs, helping the client find meaning and set personal goals for life after discharge

Answer: B — Physiological needs (airway, breathing, circulation, nutrition, elimination) before higher-level needs

B) Maslow bases higher needs on satisfaction of basic ones. A/C/D) Each is higher up the pyramid.

NCLEX prep duration?

200-400 hours. 2-3 months focused.

Collaborating conflict resolution style?

Best for important issues needing buy-in from all parties — a win-win approach, contrasted with avoiding/competing/accommodating/compromising.

Prioritizing multiple patients — unstable vs stable?

See unstable/acute changes first (new chest pain, dropping O2) before stable, scheduled tasks.

When question asks 'priority'?

Apply ABCs (Airway, Breathing, Circulation), then Maslow.