Nclex Questions Management of Care - Nurselytic

Correct Answer: B

Rationale: The correct answer is 'the severity of the client's condition and the priority decision.' When determining the method of splinting, it is crucial to consider the severity of the client's condition and make decisions based on their priority.
Choice A is incorrect because while the location of the injury and whether it is open or closed are important factors, they do not always dictate the method of splinting.
Choice C is incorrect as the number of available rescuers and the type of splints may impact the execution of splinting but do not solely dictate the method.
Choice D is incorrect as it suggests that all the factors mentioned dictate the method, but in reality, the severity of the client's condition and the priority decision are the primary factors.

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.

Correct Answer: D

Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management.
Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident.
Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report.
Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.

Correct Answer: C

Rationale: Correct. When using a rigid splint, it is essential to pad the spaces between the body part and the splint to ensure proper immobilization and increase client comfort. This padding helps prevent pressure points and ensures a proper fit of the splint without causing discomfort. Placing the client on a stretcher or a long spine board before splinting (choices A and
B) may be necessary for transportation but does not directly relate to the proper use of a rigid splint. Ensuring that the splint conforms to the body curves (choice
D) is important but not as crucial as padding the spaces to prevent discomfort and ensure proper immobilization.

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.