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. Why would a nurse employed at a hospital be asked by a nurse manager to review the organizational chart?
- A. To be aware of the geographic area that the organization serves
- B. To be familiar with the organization's line of authority
- C. To understand the organization's reason for existence
- D. To be familiar with the beliefs and values of the organization
Correct answer: B
Rationale: The correct answer is 'To be familiar with the organization's line of authority.' Organizational charts provide a visual representation of the chain of command, reporting relationships, and structure within an organization. This helps employees understand who they report to, who reports to them, and the overall hierarchy. Choice A is incorrect because understanding the geographic area served is more about the organization's scope, not depicted in an organizational chart. Choice C is incorrect as it relates to the organization's reason for existence, usually found in its mission statement. Choice D is incorrect as beliefs and values are linked to the organization's culture, not typically shown in an organizational chart.
3. A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?
- A. "Because it gives you comfort, you may wear it."?
- B. "It is a violation of religious rights to forbid it."?
- C. "I am sorry, but it is not safe for you to wear the crucifix during this test."?
- D. "You may wear it because it is important to you."?
Correct answer: C
Rationale: No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.
4. Which of the following client statements indicates adequate understanding of preparation for electroencephalography?
- A. "I don't need to eat or drink after midnight."?
- B. "I need to wash my hair before the test."?
- C. "I need to remove metal jewelry."?
- D. "I can't take aspirin before the test."?
Correct answer: B
Rationale: The correct statement is, 'I need to wash my hair before the test.' Washing the hair is necessary to remove hair products that could interfere with electrode attachment to the scalp. Restricting food or drink is not required, except for avoiding caffeinated beverages. Removing metal jewelry is unnecessary for an electroencephalography procedure. Aspirin does not need to be avoided before the test; medications like anticonvulsants, tranquilizers, barbiturates, and sedatives are the ones that might need to be held.
5. What should be included in the assessment of a client with a cast?
- A. capillary refill, warm toes, no discomfort.
- B. posterior tibial pulses, warm toes.
- C. moist skin essential, pain threshold.
- D. discomfort of the metacarpals.
Correct answer: A
Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.
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