NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
What intervention should the nurse take for a client who has sustained a hyphema?
Correct Answer: B
Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (
Choice
A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (
Choice
C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (
Choice
D) is not recommended for a hyphema as it can increase the risk of rebleeding.
Therefore, the correct answer is to keep the client at bed rest.
Question 2 of 5
Under what circumstances can an individual receive medical care without giving informed consent?
Correct Answer: B
Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence.
Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.
Question 3 of 5
Which of the following enzymes is indicative of pancreatitis?
Correct Answer: D
Rationale: Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. Pancreatitis is characterized by the inflammation of the pancreas, leading to the leakage of amylase into the bloodstream. Elevated levels of amylase are a key diagnostic marker for pancreatitis. Alkaline phosphatase is associated with liver and bone conditions, not pancreatitis. Acid phosphatase is more related to prostate health and is not specific to pancreatitis. Creatine phosphokinase is found in tissues like muscle and brain, and elevated levels are seen in conditions like muscle injury or heart attack, not pancreatitis.
Question 4 of 5
The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?
Correct Answer: C
Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed.
Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions.
Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.
Question 5 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.