NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?
Correct Answer: C
Rationale: Autonomic dysreflexia is characterized by a sudden onset of symptoms due to an overactive autonomic nervous system. Hypotension is not indicative of autonomic dysreflexia; instead, hypertension is a hallmark sign.
Therefore, hypotension is the correct answer. Flushed face, sudden onset of headache, and nasal congestion are classic symptoms of autonomic dysreflexia caused by a noxious stimulus below the level of the spinal cord injury. These symptoms result from the body's attempt to regulate blood pressure when the normal feedback loop is interrupted.
Question 2 of 5
While caring for the following clients, a pediatric nurse tells the charge nurse she must leave due to a family emergency. Which client would the charge nurse reassign to an LPN?
Correct Answer: D
Rationale: The correct answer is a five-year-old in skeletal traction. This task is within the scope of practice for an LPN and would need minimal assistance from an RN. The children with diabetic ketoacidosis, sickle cell crisis, and dehydration require close observation, good assessment skills, IVF needs, and medications that would be better managed by an RN. Reassigning the child in skeletal traction to an LPN ensures appropriate care while allowing the RN to focus on the more critical cases.
Question 3 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 4 of 5
What is the term for the tendency of a drug to combine with its receptor?
Correct Answer: D
Rationale: The correct answer is 'affinity.' Affinity refers to the close relationship or mutual attraction between a drug and its receptor, indicating the strength of the drug-receptor bonding. Potency (
Choice
A) is related to the dose of a drug needed to produce a specific effect. Efficacy (
Choice
B) refers to a drug's ability to generate the desired effect. Kinetics (
Choice
C) deals with forces affecting the motion of material bodies or changes in a system, which is not directly associated with the bonding between a drug and its receptor.
Question 5 of 5
The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
Correct Answer: C
Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (
Choice
A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (
Choice
B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (
Choice
D) does not address the urgent need to protect the client from harm.