NCLEX-PN
Nclex Questions Management of Care
1. To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?
- A. flexion, extension, hyperextension
- B. flexion, extension, abduction, adduction
- C. external rotation, internal rotation
- D. extension, flexion, inversion, eversion
Correct answer: D
Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.
2. A gastroenterologist should be consulted for clients suffering from:
- A. digestive system diseases
- B. urinary system diseases
- C. female reproductive system diseases
- D. nervous system diseases
Correct answer: A
Rationale: A gastroenterologist specializes in treating diseases and disorders of the digestive system, including the stomach, intestines, liver, and pancreas. Therefore, clients with digestive system diseases should consult a gastroenterologist. Choices B, C, and D are incorrect because urinary system diseases are managed by urologists, female reproductive system diseases by gynecologists, and nervous system diseases by neurologists.
3. Why would a nurse employed at a hospital be asked by a nurse manager to review the organizational chart?
- A. To be aware of the geographic area that the organization serves
- B. To be familiar with the organization's line of authority
- C. To understand the organization's reason for existence
- D. To be familiar with the beliefs and values of the organization
Correct answer: B
Rationale: The correct answer is 'To be familiar with the organization's line of authority.' Organizational charts provide a visual representation of the chain of command, reporting relationships, and structure within an organization. This helps employees understand who they report to, who reports to them, and the overall hierarchy. Choice A is incorrect because understanding the geographic area served is more about the organization's scope, not depicted in an organizational chart. Choice C is incorrect as it relates to the organization's reason for existence, usually found in its mission statement. Choice D is incorrect as beliefs and values are linked to the organization's culture, not typically shown in an organizational chart.
4. 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.
5. 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.
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