NCLEX-PN
Nclex Questions Management of Care
1. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct answer: A
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.
2. 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.
3. The nurse acts as an advocate for the nursing profession by performing all of the following activities except:
- A. encouraging political involvement by nurses with their legislators.
- B. acting as a first-aid provider for a children's athletic team.
- C. precepting newly licensed nurses in the work situation.
- D. encouraging as many persons to become nurses as possible.
Correct answer: D
Rationale: The nurse acts as an advocate for the nursing profession by encouraging appropriate persons to become nurses, by being a positive role model and mentor, and by communicating the needs of nurses in the most professional manner possible to those making the laws. Encouraging as many persons as possible to become nurses may not align with the advocacy role, as the focus should be on quality rather than quantity. Choices A, B, and C are activities that align with being an advocate for the nursing profession by promoting political involvement, providing first aid, and precepting newly licensed nurses, respectively.
4. A client being treated for sickle cell disease has an order for pain medication. Morphine was ordered, but the nurse is having difficulty deciphering the dose. The nurse should ____.
- A. ask the attending physician to clarify the order, including the correct medication, dose, route, and frequency
- B. call the charge nurse to inform the attending physician and verify the order, including the correct medication, dose, route, and frequency
- C. call the attending physician to verbally verify the order, including the correct medication, dose, route, and frequency
- D. refrain from administering the medication until the charge nurse can assist in determining the correct dosage
Correct answer: C
Rationale: In this scenario, when a nurse encounters difficulties in deciphering an order, the appropriate action is to contact the attending physician directly to clarify and verify the medication, dose, route, and frequency. It is crucial for the nurse to have a clear understanding of the order before administering any medication to ensure patient safety and proper treatment. Option A is incorrect as it suggests asking the attending physician to clarify without specifying the urgency of the situation. Option B involves an unnecessary additional step by first contacting the charge nurse before reaching out to the attending physician, potentially delaying the clarification process. Option D is incorrect as it advises refraining from administering the medication, which may not be necessary if the correct dosage can be promptly verified by contacting the attending physician.
5. How should an infant be secured in a car?
- A. To hold the infant while sitting in the middle of the back seat of the car
- B. To place the infant in the front seat in a rear-facing infant safety seat if the car has passenger-side air bags
- C. To place the infant in a booster seat in the front seat with the shoulder and lap belts secured around the infant
- D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat
Correct answer: D
Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants. Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.
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