when the nurse is determining the appropriate size of a nasopharyngeal airway to insert which body part should be measured on the client

NCLEX-PN

Nclex Questions Management of Care

1. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

A. corner of the mouth to tragus of the ear
B. corner of the eye to top of the ear
C. tip of the chin to the sternum
D. tip of the nose to the earlobe

Correct answer: D

Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.

2. Ethics committees typically do not handle which of the following issues?

A. Nonpayment of bills.
B. Euthanasia.
C. Starting or stopping treatment.
D. Use of feeding tubes.

Correct answer: A

Rationale: Ethics committees primarily focus on addressing ethical dilemmas in healthcare. Issues like euthanasia, decisions regarding starting or stopping treatment, and the use of feeding tubes for nutritional support involve complex ethical considerations related to patient care and end-of-life decisions, which are commonly deliberated by ethics committees. However, nonpayment of bills is a financial matter and falls outside the typical scope of ethics committees' functions.

3. Which isolation procedure will be followed for secretions and blood?

A. Respiratory Isolation
B. Standard Precautions
C. Contact Isolation
D. Droplet Isolation

Correct answer: B

Rationale: The correct answer is Standard Precautions. Standard precautions are taken in all situations for all clients and involve all body secretions except sweat. They are designed to reduce the rate of transmission of microbes from one host to another or one source to another. Respiratory Isolation (Choice A) is used for diseases transmitted by airborne particles, not secretions and blood. Contact Isolation (Choice C) is for clients known or suspected to be infected with microorganisms that can be transmitted by direct or indirect contact. Droplet Isolation (Choice D) is used for diseases transmitted by large respiratory droplets expelled during coughing, sneezing, talking, or procedures.

4. The LPN is preparing to clean a client's PEG tube.The following tasks should the nurse perform EXCEPT?

A. Gently remove crusty drainage from the site.
B. Pull the tube in multiple directions to ensure it is secure.
C. Thoroughly dry the skin around the tube site with a clean towel.
D. Use mild soap to clean around the tube site.

Correct answer: B

Rationale: When cleaning a client's PEG tube, the nurse should perform tasks that focus on gentle cleaning and avoiding potential irritants. Choice A is correct as gently removing crusty drainage helps maintain hygiene. Choice C is important to prevent skin irritation and infection. Choice D is appropriate for cleaning the area. Choices B and D are incorrect. Choice B is incorrect because pulling the tube in multiple directions can lead to dislodgement or injury. Choice B is incorrect as talcum powder may irritate the stoma, and it is generally not recommended near PEG tubes.

5. Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control.
B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct answer: B

Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.