NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
Which of the following clients requires airborne precautions?
Correct Answer: B
Rationale: The correct answer is 'a client suspected of varicella (chickenpox).' Chickenpox is an acute, infectious airborne illness that requires airborne precautions, including wearing a respirator mask for direct contact with the patient.
Choices A, C, and D do not typically require airborne precautions.
Choice A describes symptoms that may indicate a gastrointestinal infection but do not require airborne precautions.
Choice C mentions abdominal pain and purpura, which are not specific to an airborne illness.
Choice D, a client diagnosed with AIDS, does not necessitate airborne precautions unless there are additional infectious conditions present that require such measures.
Question 2 of 5
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
Correct Answer: A
Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn.
Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature.
Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity.
Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'
Question 3 of 5
A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?
Correct Answer: C
Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome.
Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy.
Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness.
Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.
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
The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
Correct Answer: A
Rationale:
To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality.
Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality.
Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information.
Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.