pressure ulcers usually occur

NCLEX-PN

Nclex Questions Management of Care

1. When are pressure ulcers most likely to occur?

A. when clients are left in one position in bed for extended periods of time.
B. when clients are underweight.
C. when clients are overweight.
D. only in underweight and overweight clients.

Correct answer: A

Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client. Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.

2. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?

A. "You really need to listen to what the physician says."?
B. "You will get too tired to take care of him at home."?
C. "What can I do to assist you to care for him at home?"?
D. "You are too busy to be taking care of an elderly person."?

Correct answer: C

Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.

3. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?

A. The LPN elevates the head of the bed by at least 30 degrees.
B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
C. The LPN should discard the residual before administering the tube feeding.
D. The residual pH level is tested to ensure appropriate placement.

Correct answer: C

Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.

4. Which of the following is not a function of parathyroid hormone?

A. moving calcium from bones to the bloodstream
B. inhibiting renal tubular reabsorption of phosphorus
C. promoting renal tubular reabsorption of calcium
D. enhancing renal production of vitamin D metabolites

Correct answer: B

Rationale: The correct answer is 'inhibiting renal tubular reabsorption of phosphorus.' Parathyroid hormone actually inhibits renal tubular reabsorption of phosphorus, making this choice the opposite of its function. Parathyroid hormone functions to move calcium from bones to the bloodstream (Choice A), promote renal tubular reabsorption of calcium (Choice C), and enhance renal production of vitamin D metabolites (Choice D). Therefore, all other choices are functions of parathyroid hormone except for the inhibition of phosphorus reabsorption.

5. Which NSAID is comparable to morphine in efficacy?

A. Feldene
B. Stodal
C. Toradol
D. Elavil

Correct answer: C

Rationale: The correct answer is Toradol. Toradol is the first injectable NSAID that has been found to be comparable to morphine in terms of efficacy. Feldene (choice A) is not known for being comparable to morphine in efficacy. Stodal (choice B) is a homeopathic cough syrup and not an NSAID. Elavil (choice D) is a tricyclic antidepressant and not an NSAID, so it is not comparable to morphine in efficacy. Therefore, Toradol is the most appropriate choice as it matches the description provided in the question.