NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 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 2 of 5
If a visitor accidentally knocks over a plastic pleural drainage system connected to a client, causing it to crack, what should the nurse do first?
Correct Answer: C
Rationale: When a pleural drainage system is cracked, the nurse's initial action should be to change the drainage system. This is essential to prevent potential complications like air leaks or infections. While observing the client's response and checking for leaks are important steps, they are secondary to addressing the immediate issue of the cracked system. Notifying the physician, though necessary, can be carried out once the primary concern of the damaged system is resolved.
Question 3 of 5
Why is accurate documentation of assessment findings regarding pressure ulcers crucial?
Correct Answer: D
Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer.
Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.
Question 4 of 5
A gastroenterologist should be consulted for clients suffering from:
Correct Answer: A
Rationale: A gastroenterologist specializes in treating diseases and disorders of the digestive system, including the stomach, intestines, liver, and pancreas.
Therefore, clients with digestive system diseases should consult a gastroenterologist.
Choices B, C, and D are incorrect because urinary system diseases are managed by urologists, female reproductive system diseases by gynecologists, and nervous system diseases by neurologists.
Question 5 of 5
When are pressure ulcers most likely to occur?
Correct Answer: A
Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer.
Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client.
Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.