NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 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 2 of 5
Which medication might the healthcare provider prescribe if the client expresses discomfort with being in the enclosed space of a CT scanner?
Correct Answer: A
Rationale: Valium (diazepam) is a sedative that might be prescribed to help a client who feels uncomfortable in the confined space of a CT scanner. Diazepam can help reduce anxiety and promote relaxation, making the scanning process more tolerable. Clozaril (clozapine), Catapres (clonidine), and Lasix (furosemide) are not sedatives and wouldn't be appropriate for alleviating discomfort related to being in an enclosed space. Clozaril is an antipsychotic used to treat schizophrenia, Catapres is a blood pressure medication, and Lasix is a diuretic used to treat fluid retention, so they are not indicated for this situation.
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
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.
Question 5 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.