NCLEX-PN
Nclex Questions Management of Care
1. Which of the following conditions has a severe complication of respiratory failure?
- A. Bell's palsy
- B.
- C. Trigeminal neuralgia
- D. Tetanus
Correct answer: B
Rationale:
2. A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?
- A. The immune system of an infant is immature, and the infant is at risk for infection.
- B. The transfer of your antibodies protects your infant until the infant is 12 months old.
- C. Yes, your infant is protected from all infections.
- D. If you breastfeed, your infant is protected from infection.
Correct answer: A
Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.
3. When working with elderly clients, the healthcare provider should keep in mind that falls are most likely to happen to the elderly who are:
- A. in their 80s.
- B. living at home.
- C. hospitalized.
- D. living on only Social Security income.
Correct answer: C
Rationale: The correct answer is 'hospitalized.' Elderly individuals are at a higher risk of falls, especially when they are in new environments like hospitals due to unfamiliarity with the surroundings, medications, and potential mobility challenges. Being in a hospital can disrupt their usual routines and increase the risk of falls. Choice A ('in their 80s') is not as directly related to the increased risk of falls in a hospital environment. Choice B ('living at home') is a common setting for the elderly but does not address the specific risk associated with being hospitalized. Choice D ('living on only Social Security income') is unrelated to the risk of falls based on the environment.
4. When managing time effectively, which of the following stimuli should the nurse respond to first?
- A. the physician's loud verbal direction
- B. the nursing supervisor who is going to a meeting
- C. unit staff leaving on a break
- D. the care needs of the returning postoperative client just exiting the elevator
Correct answer: D
Rationale: The correct answer is to attend to the care needs of the returning postoperative client just exiting the elevator first. In a healthcare setting, patient care should always take precedence, especially for complex or unstable clients requiring immediate assessment and care. The physician's loud verbal direction, the nursing supervisor going to a meeting, and unit staff leaving on a break are important but do not involve direct patient care. Therefore, the nurse should prioritize responding to the returning postoperative client to ensure their immediate needs are met.
5. Which of the following isoenzymes is elevated in a client who has had a myocardial infarction?
- A. CPK-BB
- B. CPK-MM
- C. CPK-MB
- D. CPK-MI
Correct answer: C
Rationale: CPK-MB is the correct answer as it is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients with brain damage, and CPK-MM is elevated in clients with skeletal muscle damage. CPK-MI, mentioned in the rationale, does not exist, making it an incorrect choice.
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