NCLEX-PN
Nclex Questions Management of Care
1. What is involved in client education by the nurse?
- A. Telling the client everything about their disease, what will happen in the course of the disease, and the outcome.
- B. Giving information to the client that is accurate and understandable.
- C. Informing the client that the pain they experience might not be real.
- D. Administering medication to the client when they experience pain.
Correct answer: B
Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.
2. For a client requiring total oral care, it is important for the nurse to:
- A. assemble all equipment, assist the client to a semi-Fowler's position, and place a towel on his chest.
- B. place the client in Fowler's position, prepare the equipment, and instruct the client what to do.
- C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
- D. use gloves and clean the client's mouth, including the tongue.
Correct answer: C
Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.
3. What type of injury is associated with acute hyphema?
- A. orthopedic
- B. eye
- C. insect sting or snakebite
- D. gynecological trauma
Correct answer: B
Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.
4. What dietary alterations should a pregnant client with congenital heart disease expect?
- A. reduced calories and reduced fat
- B. caffeine and sodium restrictions
- C. decreased protein and increased complex carbohydrates
- D. fluid restriction and reduced calories
Correct answer: B
Rationale: In a pregnant client with congenital heart disease, caffeine should be restricted as it can increase heart rate, which is already under stress due to pregnancy. Sodium restrictions may be necessary to prevent fluid retention, which can worsen the client's heart condition. Decreasing calories, fat, protein, or fluid may not be appropriate as these can lead to nutrient deficiencies or inadequate energy intake, which is crucial during pregnancy. Therefore, options A, C, and D are not the expected dietary alterations in the client's diet during pregnancy with congenital heart disease.
5. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action?
- A. Check the client's apical pulse
- B. Check when the last feeding was given
- C. Check the placement of the tube
- D. Check when the last medications were given
Correct answer: C
Rationale: Before administering medications through an NG tube, the nurse must first check the placement of the tube to prevent aspiration. This is done by aspirating gastric contents and measuring the pH. Checking the client's apical pulse is unrelated to NG tube medication administration. Checking when the last feeding was given is important but not a priority before administering medications. Checking when the last medications were given is also not directly related to ensuring the safe administration of medications through an NG tube. Ensuring the correct placement of the tube is crucial to prevent complications such as pulmonary aspiration.
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