Nclex Questions Management of Care - Nurselytic

Correct Answer: C

Rationale: The correct answer is that the client's contact lenses might be stained orange. Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained, making this an important side effect for the client to be aware of.

Choices A, B, and D are incorrect. There is no documented effect of Rifampin causing the client's urine to turn blue, the client remaining infectious for 48 hours, or the client's skin taking on a crimson glow.

Correct Answer: B

Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual.

Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.

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.

Correct Answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse.
Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

Correct Answer: B

Rationale: Nasogastric feedings are the most appropriate feeding method for a client who is unable to swallow. Providing nothing by mouth can lead to nutritional deficiencies, while clear liquids might cause aspiration.
Total parenteral nutrition is not necessary if the gastrointestinal tract is functional. Nasogastric feedings are preferred as they can safely provide nutrition without the risks associated with not eating or aspirating.