NCLEX-PN
Nclex Questions Management of Care
1. The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
- A. on the client's driver's license.
- B. in the client's safety deposit box.
- C. in the client's last will and testament.
- D. on the client's insurance card.
Correct answer: A
Rationale: In most states, indication of organ donor status is found on the client's driver's license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse. Therefore, the correct answer is finding evidence of the client's wishes regarding organ donation on the client's driver's license.
2. When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?
- A. Bathing a client who is confused and requires assistance with a shower
- B. Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
- C. Assisting a client requiring a bed bath and frequent ambulation with a cane
- D. Transporting a client who must be accompanied to physical therapy twice during the shift
Correct answer: B
Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.
3. All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct answer: C
Rationale: The correct answer is 'a client with an old injury.' Emergency assessments are required for immediate and life-threatening situations. Clients A, B, and D are in need of emergency assessments due to their critical conditions. Choice C, a client with an old injury, does not require an emergency assessment as it is not an acute or life-threatening situation. While the client with an old injury may still need medical attention, it does not necessitate an emergency assessment as the condition is not currently life-threatening or in need of immediate intervention.
4. What should a client room environment include?
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
Correct answer: B
Rationale: A client room environment should include a made bed to provide a sense of neatness and comfort, ensuring the client's safety at all times. It is important to maintain a clutter-free area to prevent accidents and promote a relaxing environment. Having hygiene articles nearby allows the client easy access to personal care items. Choice A is incorrect because while fresh water and thermostat regulation are important, they are not essential components of a client room environment. Choice C is incorrect as it emphasizes more on cleaning procedures rather than creating a comfortable and safe environment for the client. Choice D is incorrect as it emphasizes odor control and storage rather than the client's comfort and safety.
5. Which of the following behaviors is least appropriate when dealing with fellow staff members?
- A. Provide positive feedback and constructive criticism
- B. Serve as a resource
- C. Only report conflicts that interfere with client care
- D. Provide input for performance evaluations
Correct answer: C
Rationale: The least appropriate behavior when dealing with fellow staff members is to only report conflicts that interfere with client care. This choice implies ignoring or neglecting other conflicts that may affect team dynamics and the work environment. It is crucial to address and report all conflicts, whether they impact client care directly or not, to maintain a harmonious and effective working relationship within the healthcare setting. Providing positive feedback, constructive criticism, serving as a resource, and offering input for performance evaluations are all important and appropriate behaviors that contribute to a supportive and professional work environment. By focusing solely on conflicts that interfere with client care, essential issues that influence teamwork and overall staff morale may be overlooked, potentially leading to a negative impact on the work environment.
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