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. Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct answer: B
Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.
3. What is the correct instruction to give a client undergoing mammography?
- A. Do not use underarm deodorant.
- B. Wear comfortable clothing.
- C. Avoid caffeine prior to the procedure.
- D. Bring a list of current medications.
Correct answer: A
Rationale: The correct instruction for a client undergoing mammography is not to use underarm deodorant. Underarm deodorant can cause confusing shadows on the X-ray film, affecting the accuracy of the mammogram. Choices B, C, and D are incorrect. While wearing comfortable clothing is advisable, it is not the primary instruction for mammography. Avoiding caffeine and bringing a list of current medications are not specific instructions related to mammography preparation and are therefore not the correct answers.
4. Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?
- A. Native American
- B. Asian-Pacific
- C. Norwegian
- D. Hispanic
Correct answer: D
Rationale: Hispanic people are at the highest risk in the United States for pesticide-related injuries due to their significant representation among migrant workers in agricultural settings. Working in such environments exposes them to pesticides more frequently, thus elevating their risk compared to other ethnic groups. In contrast, Native American, Asian-Pacific, and Norwegian populations are not as commonly engaged in agricultural work involving pesticide exposure, which makes them less susceptible to pesticide-related injuries. Therefore, the correct answer is Hispanic.
5. Which action exemplifies the use of evidence-based practice in the delivery of client care?
- A. Advising a client to agree to the treatment recommended by their healthcare provider
- B. Taking a rectal temperature from a client for whom bleeding precautions have been instituted
- C. Donning sterile gloves to change an abdominal wound dressing
- D. Encouraging a client to take an herbal substance to treat their insomnia
Correct answer: C
Rationale: Evidence-based practice is an approach to client care where the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing exemplifies evidence-based practice as it prevents the entrance of harmful bacteria into the wound, following best practice guidelines. The other options do not align with evidence-based practice. Advising a client to agree to a treatment does not involve integrating research evidence. Taking herbal substances may not be supported by strong research evidence and can pose risks. Additionally, rectal temperature-taking in a client with bleeding precautions can increase the risk of injury to the rectal mucosa, not aligning with best practices in care delivery.
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