NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?
Correct Answer: D
Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse.
Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.
Question 2 of 5
The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:
Correct Answer: A
Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep.
Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.
Question 3 of 5
What dietary alterations should a pregnant client with congenital heart disease expect?
Correct Answer: B
Rationale: In a pregnant client with congenital heart disease, caffeine should be restricted as it can increase heart rate, which is already under stress due to pregnancy. Sodium restrictions may be necessary to prevent fluid retention, which can worsen the client's heart condition. Decreasing calories, fat, protein, or fluid may not be appropriate as these can lead to nutrient deficiencies or inadequate energy intake, which is crucial during pregnancy.
Therefore, options A, C, and D are not the expected dietary alterations in the client's diet during pregnancy with congenital heart disease.
Question 4 of 5
A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?
Correct Answer: A
Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections.
Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old.
Choice C is incorrect as infants are not shielded from all infections due to their immature immune system.
Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.
Question 5 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.