NCLEX-PN
Nclex Questions Management of Care
1. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?
- A. To comply with legal requirements for documenting lesions.
- B. To meet hospital policies for documenting lesions.
- C. To fulfill physician's documentation requirements for lesions.
- D. Because the nursing assessment of ulcers is a standard of nursing practice.
Correct answer: D
Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.
2. Which of these would be an appropriate meal for a client with Celiac disease?
- A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
- B. turkey sandwich with rye bread, carrots
- C. chicken and rice, apple, and tapioca pudding
- D. granola and dried apricots with cow's milk
Correct answer: C
Rationale: For individuals with Celiac disease, it's crucial to avoid gluten-containing foods. Choice C, which includes chicken, rice, apple, and tapioca pudding, is the most suitable option as all these foods are naturally gluten-free. Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be gluten-free if specially labeled, but many are processed on shared equipment with wheat. Granola often contains oats that may have been exposed to gluten. Dried and prepackaged fruits may contain gluten additives. Rye is a wheat derivative, and cream sauces usually contain flour as a base, making choices A and B inappropriate for individuals with Celiac disease.
3. In a community hospital, a nurse is employed as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description?
- A. Accepting responsibility for the actions of others
- B. The official power to ensure that an organizational decision is enforced
- C. Bearing the legal responsibility for others' performance of tasks
- D. Taking responsibility for what staff members do
Correct answer: B
Rationale: The term authority refers to the official power of an individual to approve or command an action or to ensure that a decision is enforced. In the context of the nurse's position supervised by a nurse manager, having authority means having the official power to ensure that organizational decisions are carried out. Choice A, accepting responsibility for the actions of others, is more related to accountability rather than authority. Choice C, bearing the legal responsibility for others' performance of tasks, is more about legal liability rather than authority. Choice D, taking responsibility for what staff members do, is similar to choice A and is more about accountability rather than having the official power to enforce decisions. Therefore, the correct answer is B as it directly relates to the concept of authority in the context described.
4. The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
- A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
- B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
- C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
- D. Proceed with transporting the client to the operating room without obtaining informed consent.
Correct answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
5. Which of the following tests is commonly performed on newborns with jaundice?
- A. blood urea nitrogen
- B. magnesium
- C. bilirubin
- D. prolactin
Correct answer: C
Rationale: The correct answer is C: bilirubin. A high bilirubin level is found in newborns with hepatic immaturity, leading to jaundice. Testing bilirubin levels is crucial in diagnosing and monitoring jaundice in newborns. Choices A, B, and D (blood urea nitrogen, magnesium, and prolactin) are not commonly performed tests for evaluating jaundice in newborns. Blood urea nitrogen is a measure of kidney function, magnesium levels are usually checked in metabolic disorders, and prolactin is a hormone related to lactation, none of which are directly relevant to assessing jaundice in newborns.
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