Nclex Questions Management of Care

Extract:

Question 1 of 5

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?

Correct Answer: C

Rationale: The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2Ã¢â€¦Å“ inches to prevent entrapment of the infant's head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.

Question 2 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:

A. the client has been admitted to the hospital three times in the last 2 months. B. the client has a Foley catheter. C. the client's family is available to care for him 24 hours a day. D. the client is ordered to continue IV antibiotics 5 days post discharge.

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 3 of 5

Which of the following is not an indication for pelvic ultrasonography?

A. to measure uterine size B. to detect multiple pregnancies C. to measure renal size D. to detect foreign bodies

Correct Answer: C

Rationale: Pelvic ultrasonography is commonly used to assess various conditions.

Choices A, B, and D are all valid reasons for performing pelvic ultrasonography. Measuring uterine size helps evaluate conditions like fibroids, while detecting multiple pregnancies is essential for prenatal care. Furthermore, identifying foreign bodies can aid in diagnosing certain conditions. However, assessing renal size is typically not a primary reason for pelvic ultrasonography, making choice C the correct answer.

Question 4 of 5

A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?

A. The history and presentation might indicate chickenpox, a highly contagious disease. B. The lesions might indicate a noncontagious infection that does not require isolation. C. The history and presentation might indicate an infectious illness called impetigo. D. The lesions are not contagious unless others have open wounds or lesions themselves.

Correct Answer: C

Rationale: The scenario describes classic impetigo, characterized by maculopapular lesions with honey-colored drainage, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Antibiotic therapy is usually indicated for impetigo. Chickenpox, a highly contagious disease, presents with a history of high fever followed by a vesicular rash, different from the described maculopapular lesions with honey-colored drainage.
Choice A is incorrect as the presentation is not consistent with chickenpox.
Choice B is incorrect because impetigo is contagious, especially through direct contact.
Choice D is also incorrect as impetigo is a contagious skin infection regardless of others having open wounds or lesions.

Question 5 of 5

Under what circumstances can an individual receive medical care without giving informed consent?

A. when the durable power of attorney for health care is not available B. in an emergency, life-or-death situation C. when the physician is not available for discussion with the client D. when they (clients) are not able to speak for themselves

Correct Answer: B

Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence.

Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.

Nclex Questions Management of Care - Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN