NCLEX-PN
Nclex Questions Management of Care
1. Pulling is easier than pushing. So pulling a client rather than pushing them has which of the following advantages?
- A. reduces workload
- B. decreases opposition from gravity
- C. maintains stability
- D. prevents muscle strain
Correct answer: A
Rationale: When pulling a client, you work with the gravitational force instead of opposing it, which reduces the workload on your muscles. Choosing to pull a client minimizes the effort required compared to pushing. Choice B is incorrect because the force of gravity remains constant regardless of pushing or pulling. Choice C is irrelevant as stability is not directly related to the advantage of pulling over pushing. Choice D is inaccurate because pulling can still strain muscles if not executed correctly, but it generally reduces the overall workload in comparison to pushing.
2. A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?
- A. Ignoring the situation
- B. Documenting the problem in the nursing assistant's personnel file
- C. Asking other staff members to cover for the nursing assistant
- D. Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures
Correct answer: D
Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.
3. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: B
Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.
4. Which of the following is not an advanced directive?
- A. informed consent
- B. living will
- C. durable power of attorney for health care
- D. health care proxy
Correct answer: A
Rationale: Informed consent is the process of obtaining permission from a patient before conducting a healthcare intervention. It is not considered an advanced directive. A living will is a legal document that outlines a person's preferences for medical treatment if they are unable to communicate. A durable power of attorney for health care designates a person to make medical decisions on behalf of the patient. A health care proxy, which is another term for a durable power of attorney for health care, also involves appointing someone to make healthcare decisions for an individual if they become unable to do so. Therefore, the correct answer is 'informed consent,' as it is not an advanced directive but rather a different aspect of patient care.
5. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms.
- B. nutritional status.
- C. bleeding problems.
- D. availability of insulin.
Correct answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse needs to consider various factors. Diabetic signs and symptoms, nutritional status, and availability of insulin are crucial aspects to assess for appropriate management during a crisis. However, bleeding problems are not directly related to diabetes or insulin therapy. Therefore, assessing for bleeding problems is not a priority in this context. Choice C, bleeding problems, is the correct answer as it is not typically associated with diabetes, unlike the other options provided.
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