NCLEX-PN
Nclex Questions Management of Care
1. Which of the following enzymes is indicative of pancreatitis?
- A. alkaline phosphatase
- B. acid phosphatase
- C. creatine phosphokinase
- D. amylase
Correct answer: D
Rationale: Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. Pancreatitis is characterized by the inflammation of the pancreas, leading to the leakage of amylase into the bloodstream. Elevated levels of amylase are a key diagnostic marker for pancreatitis. Alkaline phosphatase is associated with liver and bone conditions, not pancreatitis. Acid phosphatase is more related to prostate health and is not specific to pancreatitis. Creatine phosphokinase is found in tissues like muscle and brain, and elevated levels are seen in conditions like muscle injury or heart attack, not pancreatitis.
2. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms.
- B. nutritional status.
- C. bleeding problems.
- D. availability of insulin.
Correct answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse needs to consider various factors. Diabetic signs and symptoms, nutritional status, and availability of insulin are crucial aspects to assess for appropriate management during a crisis. However, bleeding problems are not directly related to diabetes or insulin therapy. Therefore, assessing for bleeding problems is not a priority in this context. Choice C, bleeding problems, is the correct answer as it is not typically associated with diabetes, unlike the other options provided.
3. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
- A. Notify maintenance to come and check the pump immediately.
- B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
- C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
- D. Tag the equipment for maintenance.
Correct answer: C
Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.
4. In a centralized decision-making process within an organization, where is the authority to make decisions vested?
- A. Every employee
- B. A few individuals, such as the board of directors
- C. Many individuals, with decisions filtering down to the individual employee
- D. All nursing employees, pharmacists, and hospital health care providers
Correct answer: B
Rationale: In a centralized decision-making process within an organization, the authority to make decisions is concentrated in a few individuals, such as the board of directors. This means that key decision-making power is held by a select group at the top of the organizational hierarchy. Choices A, C, and D are incorrect because in a centralized structure, decision-making authority is not distributed among every employee, does not filter down to individual employees, and is not shared among all nursing employees, pharmacists, or hospital health care providers. Centralized decision-making implies a more top-down approach.
5. A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?
- A. Heart rate
- B. Peripheral pulses
- C. Blood pressure (BP)
- D. Radial pulse rate
Correct answer: B
Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.
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