NCLEX-PN
Nclex Questions Management of Care
1. After securing the client's safety from a faulty electric bed, what should the nurse do next?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct answer: D
Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management. Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident. Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report. Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.
2. The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
- A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
- B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
- C. request that the family have a seat in the station rather than stand while awaiting its loved one.
- D. request that the family wait for its loved one in the Emergency Department waiting room.
Correct answer: A
Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality. Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality. Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information. Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.
3. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?
- A. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it
- B. Telling the nursing student to allow the client to rest
- C. Telling the client that the refusal of care will be informed to the health care provider
- D. Telling the nursing student to give the client the bath anyway
Correct answer: B
Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.
4. When documenting in the client’s record, what type of information should be recorded?
- A. educated predictions of outcomes
- B. personal opinions
- C. objective information
- D. subjective information
Correct answer: C
Rationale: When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care. Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition. Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.
5. A case management clinical pathway for congestive heart failure might include all of the following except:
- A. physician follow-up appointments with transportation
- B. client education regarding medication use
- C. a nutritional consult for diet review and accommodation
- D. insurance review for reimbursement
Correct answer: D
Rationale: In a case management clinical pathway for congestive heart failure, the focus is on providing medical care and support to the patient. Choices A, B, and C are integral parts of managing congestive heart failure. Physician follow-up appointments with transportation ensure continuity of care, client education about medication use is crucial for adherence, and a nutritional consult helps in managing the patient's diet. However, insurance review for reimbursement is not typically part of the clinical pathway as it pertains to financial aspects and is usually handled by billing departments or external agencies. Therefore, the correct answer is 'insurance review for reimbursement.'
Similar Questions
Access More Features
NCLEX PN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX PN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access