NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
Correct Answer: V
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.
Question 2 of 5
When managing time effectively, which of the following stimuli should the nurse respond to first?
Correct Answer: D
Rationale: The correct answer is to attend to the care needs of the returning postoperative client just exiting the elevator first. In a healthcare setting, patient care should always take precedence, especially for complex or unstable clients requiring immediate assessment and care. The physician's loud verbal direction, the nursing supervisor going to a meeting, and unit staff leaving on a break are important but do not involve direct patient care.
Therefore, the nurse should prioritize responding to the returning postoperative client to ensure their immediate needs are met.
Question 3 of 5
The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
Correct Answer: A
Rationale: In most states, indication of organ donor status is found on the client's driver's license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse.
Therefore, the correct answer is finding evidence of the client's wishes regarding organ donation on the client's driver's license.
Question 4 of 5
Following abdominal surgery, a client has a nasogastric (NG) tube in place. What is the purpose of this tube immediately after surgery?
Correct Answer: C
Rationale: The correct answer is to prevent accumulation of fluids and gas. Immediately after abdominal surgery, the NG tube is used to keep the stomach decompressed, preventing the accumulation of fluids and gas. This helps in maintaining decompression to prevent surgical-site disruption and fluid loss through vomiting.
Choices A, B, and D are incorrect because the primary purpose of the NG tube following abdominal surgery is to prevent complications related to fluid and gas build-up rather than simplifying medication administration, measuring input and output, or collecting specimens.
Question 5 of 5
Which of the following conditions has a severe complication of respiratory failure?
Correct Answer: B
Rationale: Guillain-Barré syndrome is characterized by a severe complication of respiratory failure due to the involvement of the peripheral nerves that control breathing. While Bell's palsy, trigeminal neuralgia, and tetanus are also conditions affecting peripheral nerves, they do not typically lead to respiratory failure like Guillain-Barré syndrome. Bell's palsy causes facial muscle weakness, trigeminal neuralgia results in severe facial pain, and tetanus leads to muscle stiffness and spasms, but none of these conditions directly involve respiratory failure.