the graduate licensed practical nurse is assigned to care for the client on ventilator support pending organ donation which goal should receive priori

NCLEX-PN

Nclex Questions Management of Care

1. The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?

A. Maintain the client's systolic blood pressure at 70mmHg or greater
B. Maintain the client's urinary output greater than 300cc per hour
C. Maintain the client's body temperature above 33�F rectal
D. Maintain the client's hematocrit below 30%

Correct answer: A

Rationale: When caring for a client on ventilator support pending organ donation, maintaining the systolic blood pressure at 70mmHg or greater is crucial to ensure a proper blood supply to the donor organ. This goal is a priority to maintain the viability of the organ for donation. Choices B, C, and D are incorrect because they are unnecessary and not directly related to the immediate goal of organ donation. Maintaining urinary output, body temperature, or hematocrit levels are not the primary concerns in this situation.

2. How often should physical restraints be released?

A. Every 2 hours
B. Between 1 and 3 hours
C. Every 30 minutes
D. At least every 4 hours

Correct answer: A

Rationale: The correct answer is to release physical restraints every 2 hours. Releasing restraints every 2 hours helps prevent complications associated with prolonged immobilization. Releasing restraints every 30 minutes (choice C) may be too frequent and disruptive to the client's care. Releasing restraints between 1 and 3 hours (choice B) introduces variability that could lead to inconsistencies in care. Releasing restraints at least every 4 hours (choice D) does not adhere to the recommended frequency of every 2 hours.

3. What is the role of an incident report in risk management?

A. To provide 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 B. Incident reports play a crucial role in risk management by providing data for analysis to prevent future problems. They are not primarily for liability protection (A) or disciplining staff (C). Therefore, choice B is the most appropriate answer. Choosing option D is incorrect because incident reports do not solely exist for all the mentioned purposes, but primarily to provide data for analysis and preventive actions.

4. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

A. Ask the nursing assistant to complete an incident report
B. Check the client's level of consciousness and vital signs
C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
D. Ask the nursing assistant to assist in getting the client back to bed

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

5. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

A. 2 liters/minute
B. 4 liters/minute
C. 6 liters/minute
D. 8 liters/minute

Correct answer: C

Rationale: The correct answer is 6 liters/minute. When a client needs oxygen therapy, the highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by a mask. Choices A, B, and D are incorrect because they suggest flow rates that exceed what can be effectively delivered through a nasal cannula.