NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 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 2 of 5
When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?
Correct Answer: D
Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short.
Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (
Choice
A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and
C) do not correlate with the correct measurement of a nasopharyngeal airway.
Question 3 of 5
A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?
Correct Answer: C
Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome.
Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy.
Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness.
Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.
Question 4 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 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.