The nurse is caring for a client receiving a prescribed diltiazem infu

NCLEX Nursing Leadership and Management Questions

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Question 1 of 5.

The nurse is caring for a client receiving a prescribed diltiazem infusion. The client has the following tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit for additional client information.

A. pause the diltiazem infusion.

B. notify the primary healthcare physician (PHCP).

C. assess the client's oxygen saturation and respiratory rate (RR).

D. prepare a prescription of intravenous (IV) atropine

Explanation: The tracing shows sinus bradycardia. The priority action would be to pause the diltiazem infusion, as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion continued, it would lower the heart rate to dangerous levels, compromising cardiac output. Once paused, the nurse should contact the primary healthcare provider.

Question 2 of 5.

The emergency department (ED) nurse is triaging clients in the ED. It would be appropriate for the nurse to triage which client as nonurgent? Select all that apply.

A. with a localized abscess on the right leg.

B. reporting that they have chest pressure.

C. with nausea, vomiting, and painful urination.

D. requesting a refill of their prescribed antidepressant.

E. with a single laceration to the left hand.

Explanation: Nonurgent conditions include a localized abscess (A), antidepressant refill (D), and a single laceration (E), as they are stable and do not require immediate intervention. Chest pressure (B) suggests a cardiac emergency, and nausea, vomiting, and painful urination (C) indicate a possible urinary tract infection, both requiring urgent attention.

Question 3 of 5.

The nurse in the emergency department (ED) is caring for an unconscious client who sustained a head injury following a motor vehicle crash. The health care provider (HCP) has ordered an emergency surgery. Which action should the nurse take regarding informed consent?

A. obtain a court order for the surgical procedure in place of an informed consent

B. search the client's belongings for any identification

C. transport the client to the operating room for surgery immediately

D. call the police to report the incident, identify the client, and locate the family

Explanation: For an unconscious client requiring emergency surgery, implied consent applies, allowing immediate transport to the operating room (C) to save life or prevent harm. Court orders (A), searching belongings (B), or calling police (D) delay critical care and are not required for emergency consent.

Question 4 of 5.

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP? Select all that apply.

A. Transport a client with an ankle fracture to radiology.

B. Calculate and record a client's oral intake for the shift.

C. Ambulate a client who is eight hours post-laparoscopic surgery.

D. Assist a client with multiple sclerosis in performing oral care.

E. Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.

Explanation: UAPs can transport stable clients (A), ambulate post-surgical clients (C), and assist with oral care (D). Calculating intake (B) requires clinical judgment, and obtaining a urine culture (E) involves sterile technique, both RN/LPN tasks.

Question 5 of 5.

The nurse is triaging a group of pediatric clients. The nurse should first see the client who is

A. reporting pain 5/10 on the Numerical Rating Scale after burning their right forearm.

B. drooling and experiencing difficulty with swallowing.

C. experiencing a temperature of 101.1Â°F (38.4Â°C) and a headache.

D. reporting excessive thirst and has a thready peripheral pulse.

Explanation: Drooling and difficulty swallowing (B) suggest airway obstruction, such as epiglottitis, a life-threatening emergency. Burns (A), fever with headache (C), and thirst with thready pulse (D) are concerning but less immediately critical.

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