NURS-330: Management of Care 1 (Exam 1 (NCLEX-Style Questions))

A nurse is preparing to administer IV antibiotics to a client. Which action best meets the National Patient Safety Goal for patient identification?

A. Ask the client to state their room number
B. Check the client’s name on the medication label
C. Verify the client’s name and date of birth using the ID band
D. Confirm the diagnosis in the electronic medical record

C

A nurse receives a critical potassium level from the lab. What is the nurse’s priority action?

A. Document the result in the chart
B. Notify the provider during rounds
C. Immediately notify the provider and perform read-back
D. Recheck the lab value in 1 hour

C

Which information should the nurse include in the “Assessment” portion of ISBARR?

A. Client’s admitting diagnosis
B. The nurse’s clinical findings and concerns
C. Provider orders
D. The nurse’s name and unit

B

Which medication requires a second RN verification before administration?

A. Acetaminophen
B. Oral antibiotics
C. Insulin
D. Ondansetron

C

A nurse is caring for several patients and notices frequent monitor alarms going unanswered. What risk does this situation pose?

A. Increased patient satisfaction
B. Improved response time
C. Alarm fatigue
D. Equipment malfunction

C

Which nursing intervention is most effective in preventing hospital-acquired infections?

A. Administering antibiotics promptly
B. Performing hand hygiene consistently
C. Wearing gloves for all patient care
D. Isolating all admitted patients

B

Before a surgical procedure begins, the nurse participates in a “time out.” What is the purpose of this action?

A. Verify insurance coverage
B. Reduce operating room delays
C. Confirm correct client, site, and procedure
D. Allow anesthesia preparation

C

Which action is appropriate for a client placed on suicide precautions?

A. Allow personal belongings at bedside
B. Assign a roommate for safety
C. Initiate 1:1 observation
D. Use soft wrist restraints

C

A medication error was caught before the client received the medication. How should this event be classified?

A. Sentinel event
B. Patient safety event
C. Adverse event
D. Near miss

D

Which factor most commonly prevents nurses from reporting safety events?

A. Lack of clinical knowledge
B. Fear of repercussions
C. Inadequate staffing
D. Electronic charting barriers

B

Which client is at highest risk for falls and requires immediate intervention?

A. A client requesting pain medication
B. A client with a Morse Fall Risk Scale score of 55
C. A client using non-skid socks
D. A client receiving IV fluids

B

A fire breaks out on the unit. According to RACE, what is the nurse’s first action?

A. Activate the alarm
B. Extinguish the fire
C. Rescue patients
D. Close doors

C

A client with Clostridioides difficile requires which type of precautions?

A. Droplet
B. Airborne
C. Standard only
D. Contact

D

Which item should the nurse remove first when doffing PPE?

A. Gown
B. Mask
C. Goggles
D. Gloves

D

Which nursing action best demonstrates surgical asepsis?

A. Cleaning a bedside table
B. Wearing gloves during vital signs
C. Maintaining a sterile field during catheter insertion
D. Performing hand hygiene before medication administration

C

A nurse begins a head-to-toe assessment on a newly admitted client. Which action should the nurse perform first?

A. Auscultate lung sounds
B. Obtain the client’s vital signs
C. Perform a general survey
D. Palpate the abdomen

C

Which finding represents subjective data?

A. Blood pressure of 148/92 mmHg
B. Respiratory rate of 28 breaths/min
C. Client reports “feeling short of breath”
D. Oxygen saturation of 89%

C

A client presents to the emergency department with chest pain. Which assessment is most appropriate?

A. Comprehensive head-to-toe assessment
B. Focused assessment of cardiovascular and respiratory systems
C. General survey only
D. Functional assessment of ADLs

B

Which assessment technique should the nurse perform first when examining a client?

A. Percussion
B. Palpation
C. Auscultation
D. Inspection

D

Which part of the hand is best used to assess temperature during palpation?

A. Fingertips
B. Ulnar surface of the hand
C. Dorsal surface of the hand
D. Palm

C

Which action demonstrates correct auscultation technique?

A. Listening through clothing to maintain modesty
B. Using the bell for lung sounds
C. Placing the stethoscope directly on the skin
D. Auscultating before inspection

C

A client states, “My asthma has been acting up for two days.” How should the nurse document the chief complaint?

A. Asthma exacerbation
B. Shortness of breath
C. “My asthma has been acting up for two days”
D. Respiratory distress

C

Which element of OLDCARTS identifies what makes a symptom better or worse?

A. Location
B. Duration
C. Characteristics
D. Aggravating and alleviating factors

D

Which information is part of a past medical history?

A. Current pain rating
B. Childhood illnesses
C. Review of systems
D. Chief complaint

B

What is the primary purpose of the review of systems?

A. Confirm medical diagnoses
B. Identify abnormal findings across body systems
C. Replace the physical examination
D. Provide objective data

B

Which finding would be documented as an instrumental activity of daily living (IADL)?

A. Ability to bathe independently
B. Ability to feed oneself
C. Ability to manage finances
D. Ability to ambulate without assistance

C

Which nurse response best demonstrates therapeutic communication?

A. “Why didn’t you take your medication?”
B. “You should have come in sooner.”
C. “Can you tell me more about what you’re feeling?”
D. “That doesn’t sound serious.”

C

A nurse suspects a client has limited health literacy. Which intervention is most appropriate?

A. Provide detailed written instructions
B. Use medical terminology to promote learning
C. Ask the client to repeat instructions in their own words
D. Speak louder and more slowly

C

Which documentation entry is most appropriate?

A. Client appears anxious
B. Client is noncompliant
C. Client states, “I feel nervous about surgery tomorrow”
D. Client is depressed

C

Which finding during a general survey requires immediate follow-up?

A. Client wearing mismatched shoes
B. Flat affect and minimal eye contact
C. BP 120/80 mmHg
D. Client seated comfortably

B

A nurse enters the room of a postoperative client. Which assessment should the nurse perform first?

A. Measure blood pressure
B. Assess level of consciousness
C. Ask the client to rate pain
D. Obtain oxygen saturation

B

A client drank iced water 5 minutes ago. When is it appropriate to obtain an oral temperature?

A. Immediately
B. After 2 minutes
C. After 10 minutes
D. After 15 minutes

D

Which temperature reading meets the definition of fever?

A. 99.5°F (37.5°C)
B. 100.2°F (37.9°C)
C. 100.5°F (38.1°C)
D. 99.8°F (37.6°C)

C

While assessing a radial pulse, the nurse notes an irregular rhythm. What is the nurse’s next action?

A. Count for 30 seconds and multiply by 2
B. Count for a full minute
C. Switch to an electronic vital signs machine
D. Document and reassess in 1 hour

B

Which pulse description indicates decreased stroke volume?

A. 4+ bounding
B. 3+ strong
C. 2+ normal
D. 1+ weak and thready

D

Which respiratory finding requires immediate follow-up?

A. RR 16 breaths/min
B. Regular, unlabored breathing
C. Use of accessory muscles
D. Quiet, automatic respirations

C

Which action ensures the most accurate manual blood pressure reading?

A. Crossing the client’s legs for comfort
B. Using any cuff size available
C. Deflating the cuff 2 mm Hg per heartbeat
D. Measuring BP immediately after ambulation

C

A client’s BP drops 25 mm Hg when standing. How should the nurse interpret this finding?

A. Normal age-related change
B. Expected response to position change
C. Orthostatic hypotension
D. Equipment malfunction

C

Which SpO₂ reading is abnormal for an adult client?

A. 99%
B. 97%
C. 95%
D. 89%

D

Which statement best reflects correct pain-assessment practice?

A. Pain must match objective findings
B. Chronic pain is easier to assess than acute pain
C. The patient’s self-report is the most reliable indicator
D. Vital signs always correlate with pain intensity

C

Which pain scale is most appropriate for a nonverbal adult patient?

A. Numeric Rating Scale
B. Visual Analogue Scale
C. FLACC scale
D. Verbal Descriptor Scale

C

Which question addresses the “Region/Radiation” component of PQRSTU?

A. “What makes the pain better or worse?”
B. “Where is the pain located, and does it move anywhere?”
C. “How severe is the pain on a scale of 0–10?”
D. “When did the pain start?”

B

After administering IV pain medication, when should the nurse reassess pain?

A. Immediately
B. Using a different pain scale
C. After allowing time for medication onset
D. Only if the patient requests it

C

A client has an order for morphine 2–4 mg IV every 3 hours PRN for pain rated 7–10. The client rates pain as 8/10. What should guide the nurse’s decision?

A. Give the lowest dose first
B. Nurse preference
C. Client’s pain rating and response to prior doses
D. Provider availability

C

Which documentation entry is most appropriate?

A. Patient appears uncomfortable
B. Patient seems to exaggerate pain
C. Patient rates pain 8/10, grimacing and guarding abdomen
D. Patient in severe pain

C

A nurse is caring for four patients. Which patient requires immediate assessment?

A. A patient with COPD who uses pursed-lip breathing
B. A patient with SpO₂ 94% on 2 L NC
C. A patient with intercostal retractions and nasal flaring
D. A patient with a productive cough producing clear sputum

C

A patient requires a precise concentration of oxygen independent of their breathing pattern. Which device should the nurse select?

A. Nasal cannula
B. Simple face mask
C. Non-rebreather mask
D. Venturi mask

D

Which statement by the student nurse requires correction?

A. “Room air contains 21% oxygen.”
B. “Oxygen is considered a medication.”
C. “Oxygen does not require documentation.”
D. “The rights of medication administration apply to oxygen.”

C

Which task cannot be delegated to assistive personnel?

A. Measuring SpO₂
B. Reporting increased secretions
C. Nasotracheal suctioning
D. Assisting a patient to sit upright

C

Which assessment finding is most consistent with hypoxia?

A. Blood pressure 130/82
B. Cyanosis and confusion
C. Clear lung sounds
D. SpO₂ 98% on room air

B

The nurse understands that gas exchange occurs primarily in which structure?

A. Bronchi
B. Trachea
C. Alveoli
D. Pulmonary veins

C

Which patient statement indicates effective teaching regarding incentive spirometry?

A. “I’ll use this when I feel short of breath.”
B. “I should do 10 breaths every hour while awake.”
C. “I should exhale forcefully into the device.”
D. “I don’t need to hold my breath after inhaling.”

B

Which assessment finding suggests impending respiratory failure?

A. Mild dyspnea with activity
B. Barrel chest
C. Decreased level of consciousness
D. Use of pursed-lip breathing

C

Which intervention is most appropriate for a patient with COPD experiencing dyspnea?

A. Encourage rapid deep breathing
B. Administer high-flow oxygen via NRB
C. Teach pursed-lip breathing
D. Place the patient supine

C

After initiating oxygen therapy, when should the nurse reassess and document the patient’s response?

A. After 1 hour only
B. Every 2 hours
C. At 5, 15, and 30 minutes
D. At the end of the shift

C

Which finding would the nurse expect in right-sided heart failure?

A. Crackles in the lungs
B. Orthopnea
C. Peripheral edema
D. Pink frothy sputum

C

A patient reports new-onset chest pain and shortness of breath. What is the nurse’s priority action?

A. Reassess in 15 minutes
B. Notify the provider immediately
C. Document and continue monitoring
D. Encourage slow deep breathing

B