Nclex Questions Management of Care - Nurselytic

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.

Correct Answer: C

Rationale: Correct. When using a rigid splint, it is essential to pad the spaces between the body part and the splint to ensure proper immobilization and increase client comfort. This padding helps prevent pressure points and ensures a proper fit of the splint without causing discomfort. Placing the client on a stretcher or a long spine board before splinting (choices A and
B) may be necessary for transportation but does not directly relate to the proper use of a rigid splint. Ensuring that the splint conforms to the body curves (choice
D) is important but not as crucial as padding the spaces to prevent discomfort and ensure proper immobilization.

Correct Answer: A

Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.

Correct Answer: D

Rationale: When a client with a nasogastric (NG) tube begins vomiting, the nurse should first check the NG tube placement. Vomiting can be a sign of tube displacement, which can lead to serious complications. Retaping the tube (
Choice
A), clamping it (
Choice
B), or removing it (
Choice
C) without first assessing its placement can be harmful or ineffective. Checking the NG tube placement is crucial as it ensures that the tube is in the correct position and prevents potential complications. Retaping the NG tube (
Choice
A) is incorrect because the priority is to check the placement first. Clamping the NG tube (
Choice
B) or removing it (
Choice
C) without verifying the placement can be dangerous if the tube is dislodged. Thus, these actions should not be taken before confirming the tube's position.

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.