NCLEX-PN
Nclex Questions Management of Care Questions
Question 1 of 5
A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
Correct Answer: A
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.
Question 2 of 5
A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?
Correct Answer: D
Rationale: When a client with a nasogastric (NG) tube begins vomiting, the nurse should first check the NG tube placement. Vomiting can be a sign of tube displacement, which can lead to serious complications. Retaping the tube (Choice A), clamping it (Choice B), or removing it (Choice C) without first assessing its placement can be harmful or ineffective. Checking the NG tube placement is crucial as it ensures that the tube is in the correct position and prevents potential complications. Retaping the NG tube (Choice A) is incorrect because the priority is to check the placement first. Clamping the NG tube (Choice B) or removing it (Choice C) without verifying the placement can be dangerous if the tube is dislodged. Thus, these actions should not be taken before confirming the tube's position.
Question 3 of 5
A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?
Correct Answer: C
Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome. Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy. Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness. Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.
Question 4 of 5
To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?
Correct Answer: D
Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.
Question 5 of 5
Which of the following enzymes is indicative of pancreatitis?
Correct Answer: D
Rationale: Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. Pancreatitis is characterized by the inflammation of the pancreas, leading to the leakage of amylase into the bloodstream. Elevated levels of amylase are a key diagnostic marker for pancreatitis. Alkaline phosphatase is associated with liver and bone conditions, not pancreatitis. Acid phosphatase is more related to prostate health and is not specific to pancreatitis. Creatine phosphokinase is found in tissues like muscle and brain, and elevated levels are seen in conditions like muscle injury or heart attack, not pancreatitis.