NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
A test that can correctly identify those who do not have a given disease is:
Correct Answer: A
Rationale: The correct answer is 'specific.' Specificity refers to the ability of a test to correctly identify individuals who do not have a particular disease. In this case, when the client's lab culture report is negative for the suspected infection, a specific test would correctly identify that the client does not have the disease. 'Sensitive' (
Choice
B) is incorrect as sensitivity refers to the ability of a test to correctly identify individuals who do have the disease. 'Negative culture' (
Choice
C) is incorrect as it does not describe the test's ability but rather the result itself. 'Marginal finding' (
Choice
D) is irrelevant to the concept being tested in this question.
Question 2 of 5
Which of the following lab values is elevated first after a client has a myocardial infarction?
Correct Answer: B
Rationale: The correct answer is troponin. Troponin levels are the most specific and sensitive markers for myocardial infarction, and they begin to rise within a few hours after the event. CPK, SGOT, and LDH are also enzymes that can indicate myocardial damage, but troponin is the earliest and most specific indicator. CPK typically rises 4-8 hours after an infarction, followed by SGOT (AST) at 8-12 hours, and LDH at 12-24 hours post-infarction.
Question 3 of 5
A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
Correct Answer: A
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.
Question 4 of 5
When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:
Correct Answer: B
Rationale: The correct answer is that the new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide. Pressure ulcers should not be cleaned with substances that are cytotoxic, such as hydrogen peroxide or betadine. This can cause further damage to the wound and delay the healing process.
Choice A is incorrect because irrigating the pressure ulcer with normal saline is an appropriate practice.
Choice C is incorrect because packing the wound with sterile kerlix soaked in normal saline is also an appropriate step.
Choice D is incorrect because applying a Duoderm dressing after cleansing is a standard procedure in wound care.
Question 5 of 5
A test that can correctly identify those who do not have a given disease is:
Correct Answer: A
Rationale: The correct answer is 'specific.' Specificity refers to the ability of a test to correctly identify individuals who do not have a particular disease. In this case, when the client's lab culture report is negative for the suspected infection, a specific test would correctly identify that the client does not have the disease. 'Sensitive' (
Choice
B) is incorrect as sensitivity refers to the ability of a test to correctly identify individuals who do have the disease. 'Negative culture' (
Choice
C) is incorrect as it does not describe the test's ability but rather the result itself. 'Marginal finding' (
Choice
D) is irrelevant to the concept being tested in this question.