NCLEX-PN
Nclex Questions Management of Care Questions
Question 1 of 5
What intervention should the nurse take for a client who has sustained a hyphema?
Correct Answer: B
Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (
Choice
A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (
Choice
C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (
Choice
D) is not recommended for a hyphema as it can increase the risk of rebleeding.
Therefore, the correct answer is to keep the client at bed rest.
Question 2 of 5
In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?
Correct Answer: A
Rationale: In an emergency situation, assessing the client's ability to speak is crucial in determining airway obstruction. If a client can speak, it indicates that the airway is patent and not completely obstructed.
Choices B and C, assessing the ability to hear and oxygen saturation, are not directly indicative of an airway obstruction.
Choice D, adventitious breath sounds, may be present in conditions like asthma or pneumonia but are not specific to determining an airway obstruction.
Question 3 of 5
A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?
Correct Answer: C
Rationale: The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2⅜ inches to prevent entrapment of the infant's head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.
Question 4 of 5
During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
Correct Answer: C
Rationale: In cases of adenocarcinoma of the rectum with positive peritoneal lymph nodes, the most likely site of metastasis is the liver. Colon tumors commonly spread through the lymphatics and portal vein to the liver. While metastasis to the brain, bone, or mediastinum is possible, the liver is typically the first to be affected due to the anatomical pathways involved in colorectal cancer metastasis.
Therefore, the correct answer is the liver. Metastasis to the brain, bone, or mediastinum would be less likely at this stage of colorectal cancer progression.
Question 5 of 5
The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
Correct Answer: A
Rationale:
To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality.
Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality.
Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information.
Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.