NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
Correct Answer: D
Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content.
Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy.
Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.
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
Which of the following lab values is elevated first after a client has a myocardial infarction?
Correct Answer: B
Rationale: The correct answer is troponin. Troponin levels are the most specific and sensitive markers for myocardial infarction, and they begin to rise within a few hours after the event. CPK, SGOT, and LDH are also enzymes that can indicate myocardial damage, but troponin is the earliest and most specific indicator. CPK typically rises 4-8 hours after an infarction, followed by SGOT (AST) at 8-12 hours, and LDH at 12-24 hours post-infarction.
Question 4 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.
Question 5 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.