NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
How should an infant be secured in a car?
Correct Answer: D
Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants.
Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.
Question 2 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 3 of 5
The client with a diagnosis of hepatitis is experiencing pruritus. Which would be the most appropriate nursing intervention?
Correct Answer: B
Rationale: Pruritus, or itching, in clients with hepatitis can be alleviated by adding moisturizing agents to bath water. Baby oil helps soothe and moisturize the skin, reducing dryness and itching. Warm showers, as in choice A, can be drying to the skin if taken too frequently, making it less suitable than adding oil to the bath water. Applying powder, as mentioned in choice C, can exacerbate dryness rather than alleviate it.
Choice D suggests a cool-water rinse after bathing, which can help in retaining moisture and is less drying compared to hot water rinses.
Question 4 of 5
What is distraction therapy?
Correct Answer: A
Rationale: Distraction therapy involves directing attention away from pain towards positive stimuli, which can help reduce the perception of pain.
Choice A is the correct answer as it accurately defines distraction therapy. Cognitive reappraisal (
Choice
B) involves changing the way one thinks about a situation to alter its emotional impact, which is different from distraction therapy.
Choice C is incorrect because distraction therapy does not involve replacing images of pain with other images, but rather focusing on something unrelated.
Choice D is incorrect as distraction therapy does not necessarily involve medication or meditation, but rather the redirection of attention.
Question 5 of 5
What instruction should a client who is about to undergo pelvic ultrasonography be given by a healthcare provider?
Correct Answer: D
Rationale: The correct instruction for a client about to undergo pelvic ultrasonography is to 'Drink plenty of water.' A full bladder is required to serve as a landmark to define pelvic organs during the procedure. It is important to ensure the bladder is adequately filled. 'Urinate prior to the test' (
Choice
A) would not be appropriate as a full bladder is needed for better visualization. 'Have someone drive you home' (
Choice
B) is unnecessary as no sedation is given during the procedure, so the client can drive home on their own. 'Do not drink after midnight' (
Choice
C) is unrelated and not necessary for a pelvic ultrasonography examination.