NCLEX-PN
Nclex Questions Management of Care Questions
Extract:
Question 1 of 5
Why is accurate documentation of assessment findings regarding pressure ulcers crucial?
Correct Answer: D
Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer.
Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.
Question 2 of 5
The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?
Correct Answer: C
Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed.
Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions.
Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.
Question 3 of 5
When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?
Correct Answer: D
Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short.
Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (
Choice
A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and
C) do not correlate with the correct measurement of a nasopharyngeal airway.
Question 4 of 5
Why is accurate documentation of assessment findings regarding pressure ulcers crucial?
Correct Answer: D
Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer.
Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.
Question 5 of 5
A discharge planning nurse is making arrangements for a client with an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
Correct Answer: B
Rationale: In this scenario, the priority is the safety and well-being of the client. The neighborhood facility's lack of experience in caring for a client with an epidural catheter for continuous opioid infusion raises concerns about the quality of care they can provide.
Therefore, the most appropriate action for the discharge planning nurse is to explain the situation to the client and family and seek another long-term care facility that can provide the necessary care. Option A, arranging for immediate in-services, may not be feasible or timely, considering the urgent need for appropriate care. Option C, encouraging the family to hire private duty nurses, does not ensure the facility's overall capability to manage the client's complex needs. Option D, 'None of the above,' is not the best choice as the client's safety should be the priority in this situation.