NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?
Correct Answer: C
Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed.
Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions.
Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.
Question 2 of 5
What is involved in client education by the nurse?
Correct Answer: B
Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer.
Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge.
Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively.
Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.
Question 3 of 5
The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?
Correct Answer: B
Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.
Question 4 of 5
The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
Correct Answer: C
Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (
Choice
A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (
Choice
B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (
Choice
D) does not address the urgent need to protect the client from harm.
Question 5 of 5
What is the role of an incident report in risk management?
Correct Answer: B
Rationale: The correct answer is B. Incident reports play a crucial role in risk management by providing data for analysis to prevent future problems. They are not primarily for liability protection (
A) or disciplining staff (
C).
Therefore, choice B is the most appropriate answer. Choosing option D is incorrect because incident reports do not solely exist for all the mentioned purposes, but primarily to provide data for analysis and preventive actions.