NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
Correct Answer: A
Rationale:
To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality.
Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality.
Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information.
Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.
Question 2 of 5
A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?
Correct Answer: A
Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections.
Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old.
Choice C is incorrect as infants are not shielded from all infections due to their immature immune system.
Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.
Question 3 of 5
Pulling is easier than pushing. So pulling a client rather than pushing them has which of the following advantages?
Correct Answer: A
Rationale: When pulling a client, you work with the gravitational force instead of opposing it, which reduces the workload on your muscles. Choosing to pull a client minimizes the effort required compared to pushing.
Choice B is incorrect because the force of gravity remains constant regardless of pushing or pulling.
Choice C is irrelevant as stability is not directly related to the advantage of pulling over pushing.
Choice D is inaccurate because pulling can still strain muscles if not executed correctly, but it generally reduces the overall workload in comparison to pushing.
Question 4 of 5
A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
Correct Answer: A
Rationale: Isolation techniques are used to prevent or limit the spread of infection. Special handling of articles and linens soiled by any body fluid is essential. Linens should be placed in impervious bags before being removed from the client's bedside to prevent exposure of personnel and contamination of the environment. Double-bagging is required if the outside of the bag becomes contaminated. This practice ensures that potentially infectious materials are properly contained and disposed of.
Choices B, C, and D are incorrect because the focus in this scenario is on proper handling and disposal of soiled linens to prevent the spread of infection, not on serving meals, psychological effects of isolation, or the use of paper trays and plastic utensils.
Question 5 of 5
A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:
Correct Answer: D
Rationale: The correct answer is 'fifth disease.' Erythema infectiosum, also known as fifth disease, is a parvovirus flu-like illness that is self-limiting but contagious for two to three weeks.
Choice A, Kawasaki disease, is a different condition that involves inflammation of the blood vessels, predominantly affecting children.
Choices B and C, rheumatic disease and lupus erythematosus, are also different conditions unrelated to erythema infectiosum.