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. Which of the following medications should be held 24-48 hours prior to an electroencephalogram (EEG)?
- A. Lasix (furosemide)
- B. Cardizem (diltiazem)
- C. Lanoxin (digoxin)
- D. Dilantin (phenytoin)
Correct answer: D
Rationale: Anticonvulsants like Dilantin should be held 24-48 hours before an EEG to prevent interference with the test results. Medications such as tranquilizers, barbiturates, and other sedatives should also be avoided. Lasix, Cardizem, and Lanoxin do not belong to these categories and are not known to interfere with EEG results.
3. Which of the following statements by a client with gastroesophageal reflux disease (GERD) indicates adequate understanding?
- A. "I should eat right before bedtime."?
- B. "I should eat large meals."?
- C. "I should sit up after eating."?
- D. "I should lie flat after eating."?
Correct answer: C
Rationale: The correct statement for a client with GERD is, 'I should sit up after eating.' This helps prevent reflux by keeping the stomach contents down. Choice A is incorrect as eating right before bedtime can exacerbate GERD symptoms by increasing the likelihood of reflux during the night. Choice B is incorrect because consuming large meals can lead to increased stomach pressure and worsen reflux symptoms. Choice D is incorrect because lying flat after eating can promote reflux due to gravity assisting the flow of stomach contents into the esophagus, worsening GERD.
4. When are pressure ulcers most likely to occur?
- A. when clients are left in one position in bed for extended periods of time.
- B. when clients are underweight.
- C. when clients are overweight.
- D. only in underweight and overweight clients.
Correct answer: A
Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client. Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.
5. Priorities designated as intermediate by the nurse are:
- A. the nonemergency, non-life-threatening needs of the client.
- B. those tasks that can be delegated to assistive personnel.
- C. those tasks that can be performed at the end of the shift.
- D. those tasks that can be performed at any time
Correct answer: A
Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client's immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.
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