NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?
Correct Answer: D
Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.
Question 2 of 5
What is a significant point about Shigella that the nurse should acknowledge upon identifying it in a stool culture?
Correct Answer: C
Rationale: Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states.
Choices A, B, and D are incorrect. While it is important for close contacts to be aware and practice good hygiene, testing is not routinely indicated. Shigella is not an airborne infection; it is transmitted through contaminated food or water. A one-way breathing apparatus is not necessary for caring for a patient with Shigella; standard precautions, including handwashing and gloves, are sufficient.
Question 3 of 5
The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
Correct Answer: A
Rationale: When caring for a client on ventilator support pending organ donation, maintaining the systolic blood pressure at 70mmHg or greater is crucial to ensure a proper blood supply to the donor organ. This goal is a priority to maintain the viability of the organ for donation.
Choices B, C, and D are incorrect because they are unnecessary and not directly related to the immediate goal of organ donation. Maintaining urinary output, body temperature, or hematocrit levels are not the primary concerns in this situation.
Question 4 of 5
When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:
Correct Answer: B
Rationale: The correct answer is that the new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide. Pressure ulcers should not be cleaned with substances that are cytotoxic, such as hydrogen peroxide or betadine. This can cause further damage to the wound and delay the healing process.
Choice A is incorrect because irrigating the pressure ulcer with normal saline is an appropriate practice.
Choice C is incorrect because packing the wound with sterile kerlix soaked in normal saline is also an appropriate step.
Choice D is incorrect because applying a Duoderm dressing after cleansing is a standard procedure in wound care.
Question 5 of 5
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
Correct Answer: V
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.