NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 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 2 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.
Question 3 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 4 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.
Question 5 of 5
The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:
Correct Answer: A
Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep.
Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.