client education by the nurse entails

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. To remove hard contact lenses from an unresponsive client, what should the nurse do?

A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
B. Grasp the lens with a gentle pinching motion
C. Don sterile gloves before attempting the procedure
D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

3. How many temporary teeth should the nurse expect to find in a 5-year-old client's mouth?

A. up to 10
B. up to 15
C. up to 20
D. up to 32

Correct answer: C

Rationale: A 5-year-old child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months, and the last by age 30 months. All temporary teeth are usually shed between 6 and 13 years of age. Therefore, a 5-year-old child should have up to 20 temporary teeth. The correct answer is 'up to 20.' Choices A, B, and D are incorrect because the correct number of temporary teeth in a 5-year-old child's mouth is up to 20, not 10, 15, or 32.

4. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

A. 2 liters/minute
B. 4 liters/minute
C. 6 liters/minute
D. 8 liters/minute

Correct answer: C

Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.

5. While assisting a healthcare provider in assessing a hospitalized client, the healthcare provider is paged to report to the recovery room. The healthcare provider instructs the nurse verbally to change the solution and rate of the intravenous (IV) fluid being administered. What is the most appropriate nursing action in this situation?

A. Calling the nursing supervisor to obtain permission to accept the verbal prescription
B. Asking the healthcare provider to write the prescription in the client's record before leaving the nursing unit
C. Telling the healthcare provider that the prescription will not be implemented until it is documented in the client's record
D. Changing the solution and rate of the IV fluid per the healthcare provider's verbal prescription

Correct answer: B

Rationale: Verbal prescriptions should be avoided due to the risk of errors. If a verbal prescription is necessary, it should be promptly written and signed by the healthcare provider, typically within 24 hours. Following agency policies and procedures regarding verbal prescriptions is crucial. In this scenario, the most appropriate nursing action is to request the healthcare provider to document the prescription in the client's record before leaving the unit. Calling the nursing supervisor to accept the verbal prescription without documentation, telling the healthcare provider to delay treatment until documented, and directly changing the IV fluid based on verbal orders all pose risks and do not align with best practices in medication administration.