NCLEX-PN
Nclex Questions Management of Care
1. Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. butter
- B. oats or barley cereal
- C. fresh vegetables
- D. coffee or tea
Correct answer: B
Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.
2. Which fetal heart monitor pattern can indicate cord compression?
- A. variable decelerations
- B. early decelerations
- C. bradycardia
- D. tachycardia
Correct answer: A
Rationale: Variable decelerations can indicate cord compression as they are caused by umbilical cord compression or prolapse. This pattern shows an abrupt decrease in heart rate with an erratic shape, often resembling a V or W. Early decelerations (choice B) are typically caused by head compression during contractions and are considered benign. Bradycardia (choice C) is a consistent low heart rate below 110 bpm and is not specific to cord compression. Tachycardia (choice D) is an abnormally high heart rate above 160 bpm and is not associated with cord compression.
3. Priorities designated as intermediate by the nurse are:
- A. the nonemergency, non-life-threatening needs of the client.
- B. those tasks that can be delegated to assistive personnel.
- C. those tasks that can be performed at the end of the shift.
- D. those tasks that can be performed at any time
Correct answer: A
Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client's immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.
4. A licensed practical nurse tells the certified nursing assistant (CNA) staff that they will need to comply with the mandatory overtime policy that the long-term care facility has implemented. Later that day, the nurse overhears a CNA complaining about the policy and telling other CNAs that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse to use in dealing with the conflict?
- A. Providing a positive reward system for the CNA to encourage working the mandatory overtime
- B. Ignoring the complaints
- C. Avoiding assigning the CNA mandatory overtime
- D. Meeting with the CNA regarding her behavior concerning the overtime policy
Correct answer: D
Rationale: In this situation, the best approach for the nurse is to meet with the CNA regarding her behavior concerning the overtime policy. Initiating a discussion is crucial to address resistance by a staff member. A face-to-face meeting allows for the verbalization of feelings, identification of problems, and the opportunity to develop strategies to solve the issue. Ignoring the complaints and avoiding assigning mandatory overtime do not tackle the root of the problem. Providing a positive reward system might offer a temporary fix but does not directly address the resistance and conflict.
5. Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. Primary prevention.
- B. Secondary prevention.
- C. Tertiary prevention.
- D. Disability prevention.
Correct answer: B
Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.
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