NCLEX-PN
Nclex Questions Management of Care
1. The method of splinting is always dictated by:
- A. location of the injury and whether it is open or closed.
- B. the severity of the client's condition and the priority decision.
- C. the number of available rescuers and the type of splints.
- D. all of the above.
Correct answer: B
Rationale: The correct answer is 'the severity of the client's condition and the priority decision.' When determining the method of splinting, it is crucial to consider the severity of the client's condition and make decisions based on their priority. Choice A is incorrect because while the location of the injury and whether it is open or closed are important factors, they do not always dictate the method of splinting. Choice C is incorrect as the number of available rescuers and the type of splints may impact the execution of splinting but do not solely dictate the method. Choice D is incorrect as it suggests that all the factors mentioned dictate the method, but in reality, the severity of the client's condition and the priority decision are the primary factors.
2. Which of the following statements by a client indicates adequate preparation for magnetic resonance imaging?
- A. "I should wear earplugs during the test."?
- B. "I should remove my metal jewelry before the test."?
- C. "I should inform the healthcare provider about my pacemaker."?
- D. "I should inform the healthcare provider about my artificial hip."?
Correct answer: A
Rationale: The correct statement is, '"I should wear earplugs during the test,"?' as MRI scanners produce loud noises requiring ear protection. Metal objects, including jewelry, are not allowed inside the MRI room due to safety concerns related to the magnetic field. Choices B, C, and D are incorrect. Choice B is wrong because metal objects, including jewelry, are not permitted in the MRI room. Choices C and D are incorrect as having a pacemaker or an artificial hip raises concerns due to the magnetic field in MRI, requiring special precautions or considerations. It is crucial for individuals with such implants to inform their healthcare provider to assess the risks and determine the appropriate course of action.
3. After delivery, a newborn undergoes an Apgar assessment. What does this scoring system evaluate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct answer: B
Rationale: The Apgar scoring system, developed by Virginia Apgar, an anesthesiologist, evaluates newborns based on five criteria: heart rate, respiratory effort, color, muscle tone, and reflex irritability. These parameters provide a quick and simple assessment of a newborn's overall condition and the need for immediate medical attention. Choices B, C, and D are incorrect as they do not encompass the essential elements evaluated by the Apgar scoring system.
4. A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)?
- A. Recording the urinary output for a client with renal calculi whose urine must be strained
- B. Dressing change instructions for a client who had a mastectomy 2 days ago
- C. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy
- D. Preprocedural teaching for a client scheduled for a cardiac stress test
Correct answer: A
Rationale: The nurse is legally responsible for client assignments and must assign tasks based on state nursing practice act guidelines and job descriptions provided by the employing agency. The nursing assistant is trained to measure, collect, and strain urine, making recording urinary output for a client with renal calculi a suitable task for the nursing assistant. This task falls within the nursing assistant's role description. Dressing change instructions for a client who had a mastectomy involve a higher level of skill and knowledge, beyond the scope of a nursing assistant. Reporting abnormal lab values to the health care provider for a client scheduled for a laparoscopic cholecystectomy requires interpretation and clinical judgment, which is typically not within the nursing assistant's role. Preprocedural teaching for a client scheduled for a cardiac stress test involves providing detailed information and education, which is usually the responsibility of a licensed nurse or other qualified healthcare provider.
5. Which of the following is not an indication for pelvic ultrasonography?
- A. to measure uterine size
- B. to detect multiple pregnancies
- C. to measure renal size
- D. to detect foreign bodies
Correct answer: C
Rationale: Pelvic ultrasonography is commonly used to assess various conditions. Choices A, B, and D are all valid reasons for performing pelvic ultrasonography. Measuring uterine size helps evaluate conditions like fibroids, while detecting multiple pregnancies is essential for prenatal care. Furthermore, identifying foreign bodies can aid in diagnosing certain conditions. However, assessing renal size is typically not a primary reason for pelvic ultrasonography, making choice C the correct answer.
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