NCLEX-PN
Nclex Questions Management of Care
1. Which medication might the healthcare provider prescribe if the client expresses discomfort with being in the enclosed space of a CT scanner?
- A. Valium (diazepam)
- B. Clozaril (clozapine)
- C. Catapres (clonidine)
- D. Lasix (furosemide)
Correct answer: A
Rationale: Valium (diazepam) is a sedative that might be prescribed to help a client who feels uncomfortable in the confined space of a CT scanner. Diazepam can help reduce anxiety and promote relaxation, making the scanning process more tolerable. Clozaril (clozapine), Catapres (clonidine), and Lasix (furosemide) are not sedatives and wouldn't be appropriate for alleviating discomfort related to being in an enclosed space. Clozaril is an antipsychotic used to treat schizophrenia, Catapres is a blood pressure medication, and Lasix is a diuretic used to treat fluid retention, so they are not indicated for this situation.
2. A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?
- A. 'I know that it's for fluid buildup, and I think you've taken it before.''
- B. 'It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet.''
- C. 'It's to help get rid of the swelling in your feet.''
- D. ''You need to discuss this medication with your health care provider.''
Correct answer: B
Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.
3. What condition is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct answer: B
Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.
4. A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate constitutes a negligent act?
- A. Giving a verbal report to the nurse on the oncoming shift
- B. Checking neurological signs in a client with a head injury
- C. Contacting a healthcare provider about a change in a client's blood pressure
- D. Using clean gloves to change a gastrostomy tube dressing
Correct answer: D
Rationale: Negligent acts in nursing include various errors that can harm the client, such as medication errors, intravenous therapy errors, burns, falls, failure to use aseptic technique, failure to provide adequate monitoring, and failure to report significant changes in a client's condition. In this scenario, using clean gloves to change a gastrostomy tube dressing is a negligent act because sterile gloves should be used when changing a dressing over broken skin. Choices A, B, and C are not negligent acts as they involve appropriate nursing actions: giving a verbal report, checking neurological signs, and contacting a healthcare provider about a change in a client's blood pressure.
5. Which action by the nurse represents the ethical principle of benevolence?
- A. The nurse administers an immunization to a child even though it may cause discomfort
- B. The nurse follows a plan of care designed to relieve pain in a client with cancer
- C. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity
- D. The nurse upholds a client's decision to refuse chemotherapy for lung cancer
Correct answer: A
Rationale: Benevolence is taking action to help others. In this scenario, administering an immunization to a child, even though it may cause discomfort, aligns with the principle of benevolence as the benefits of protection from disease outweigh the temporary discomfort. Fidelity refers to keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person's independence, and respecting autonomy means agreeing to respect an individual's right to determine their course of action. Justice refers to fairness and equity, including the fair allocation of resources, such as nursing care for all clients. Choice B is incorrect as it pertains more to the ethical principle of beneficence rather than benevolence, which focuses on doing good for others without an expectation of something in return. Choices C and D are incorrect as they do not directly align with the principle of benevolence.
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