NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymph nodes. What is the next most likely site of metastasis?
Correct Answer: C
Rationale: In cases of adenocarcinoma of the rectum with positive peritoneal lymph nodes, the most likely site of metastasis is the liver. Colon tumors commonly spread through the lymphatics and portal vein to the liver. While metastasis to the brain, bone, or mediastinum is possible, the liver is typically the first to be affected due to the anatomical pathways involved in colorectal cancer metastasis.
Therefore, the correct answer is the liver. Metastasis to the brain, bone, or mediastinum would be less likely at this stage of colorectal cancer progression.
Question 2 of 5
While caring for the following clients, a pediatric nurse tells the charge nurse she must leave due to a family emergency. Which client would the charge nurse reassign to an LPN?
Correct Answer: D
Rationale: The correct answer is a five-year-old in skeletal traction. This task is within the scope of practice for an LPN and would need minimal assistance from an RN. The children with diabetic ketoacidosis, sickle cell crisis, and dehydration require close observation, good assessment skills, IVF needs, and medications that would be better managed by an RN. Reassigning the child in skeletal traction to an LPN ensures appropriate care while allowing the RN to focus on the more critical cases.
Question 3 of 5
When managing nausea related to Morphine epidural analgesia, the nurse should administer:
Correct Answer: D
Rationale: When managing nausea related to Morphine epidural analgesia, Compazine is the appropriate medication to administer. Compazine, also known as prochlorperazine, is commonly used to treat nausea and vomiting. It works by affecting certain chemicals in the brain that trigger nausea and vomiting.
Choices A, B, and C are incorrect because Indomethacin, Codeine, and Ibuprofen are not typically used to manage nausea associated with Morphine epidural analgesia.
Question 4 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 2⅜ 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 5 of 5
Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?
Correct Answer: B
Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual.
Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.