NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:
Correct Answer: D
Rationale: The correct answer is 'fifth disease.' Erythema infectiosum, also known as fifth disease, is a parvovirus flu-like illness that is self-limiting but contagious for two to three weeks.
Choice A, Kawasaki disease, is a different condition that involves inflammation of the blood vessels, predominantly affecting children.
Choices B and C, rheumatic disease and lupus erythematosus, are also different conditions unrelated to erythema infectiosum.
Question 2 of 5
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
Correct Answer: A
Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn.
Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature.
Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity.
Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'
Question 3 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 4 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 5 of 5
The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
Correct Answer: C
Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (
Choice
A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (
Choice
B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (
Choice
D) does not address the urgent need to protect the client from harm.