NCLEX-PN
Nclex Questions Management of Care
1. The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?
- A. Car safety seat in the back seat in a face-forward position
- B. Booster seat with one of the car's seat belts placed over the child
- C. Booster seat in a rear-facing position in the front seat
- D. Car safety seat in a face-forward position in the front seat
Correct answer: B
Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.
2. A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by undertaking which action?
- A. Reassuring the client that the risks are minimal
- B. Noting in the client's record that the client was not told about the risks of the surgery
- C. Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room
- D. Informing the surgeon verbally about the lack of information provided to the client
Correct answer: B
Rationale: A nurse serves as a client advocate by protecting the client's right to be informed and to participate in decisions regarding care. In this scenario, the nurse should document in the client's record that the client was not informed about the risks of the surgery. This action ensures that the issue is officially noted and can be addressed by the healthcare team. Reassuring the client that the risks are minimal is incorrect because it dismisses the client's concerns and does not address the lack of information provided. Writing a note on the client's chart to inform the surgeon is not as effective as ensuring that the issue is officially documented in the client's record, where it can be reviewed and addressed by the healthcare team. Informing the surgeon verbally is not as reliable as documenting the concern in the client's record, which provides a formal and lasting record for review and follow-up.
3. Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency?
- A. Shear-reducing mattress
- B. Sequential compression devices
- C. Hiking stockings
- D. Non-skid socks
Correct answer: B
Rationale: For a bedridden patient with potential venous insufficiency, sequential compression devices (SCDs) and compression stockings are appropriate choices. SCDs help improve venous return from the lower extremities by applying sequential pressure, aiding circulation. Compression stockings also assist in preventing blood from pooling in the legs by applying pressure to support venous return. Shear-reducing mattresses are not directly related to managing venous insufficiency, as they are designed to reduce friction and shear forces on the skin to prevent pressure ulcers. Non-skid socks are primarily used for fall prevention and have no direct impact on venous insufficiency.
4. A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level due to impaired liver function. The liver normally converts ammonia into urea for excretion. In cirrhosis, this process is compromised, leading to elevated ammonia levels in the blood. Renal failure, psoriasis, and lupus do not typically cause high ammonia levels. Renal failure affects kidney function, while psoriasis and lupus are autoimmune conditions that do not directly impact ammonia metabolism.
5. A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?
- A. The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge
- B. The care map is a plan that is used only by the nurse to provide client care
- C. The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis
- D. The care map is developed by a nurse and identifies nursing diagnoses
Correct answer: A
Rationale: The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone. Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team. Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse. Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.
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