NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 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.
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
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 4 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 5 of 5
The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
Correct Answer: A
Rationale: In most states, indication of organ donor status is found on the client's driver's license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse.
Therefore, the correct answer is finding evidence of the client's wishes regarding organ donation on the client's driver's license.