NCLEX-PN
Nclex Questions Management of Care
1. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:
- A. hypothalamus.
- B. thalamus.
- C. cortex.
- D. medulla.
Correct answer: A
Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.
2. A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?
- A. Contacting the health care provider
- B. Checking if it is time for more pain medication
- C. Encouraging the client to continue active range of motion exercises of the left arm
- D. Repositioning the client for comfort
Correct answer: A
Rationale: The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions. Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.
3. Which of the following NSAIDs is most commonly used for a brief period for acute pain?
- A. Advil
- B. Aleve
- C. Toradol
- D. Bextra
Correct answer: C
Rationale: Toradol is the correct answer because it is an NSAID known for its effectiveness in managing acute pain for short durations. It can be administered via intramuscular (IM), intravenous (IV), or oral (PO) routes. Advil (choice A) and Aleve (choice B) are commonly used for mild to moderate pain but may not be as effective for acute pain requiring immediate relief. Bextra (choice D) was withdrawn from the market due to safety concerns, making it an inappropriate choice for acute pain management.
4. What is the role of the incident report in risk management?
- A. Liability protection.
- B. To provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. To discipline staff for errors.
- D. All of the above.
Correct answer: B
Rationale: The correct answer is 'To provide data for analysis by a risk manager to determine how future problems can be avoided.' Incident reports are a crucial tool for collecting information about incidents to analyze them and prevent similar issues in the future. They are not primarily used for liability protection or disciplining staff. Therefore, choices A and C are incorrect. Selecting 'All of the above' (choice D) is not accurate as incident reports serve a specific purpose related to data analysis and risk prevention, excluding liability protection and staff discipline.
5. 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.
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