NCLEX-PN
Nclex Questions Management of Care
1. Which of the following clients requires airborne precautions?
- A. a client with fever, chills, vomiting, and diarrhea
- B. a client suspected of varicella (chickenpox)
- C. a client with abdominal pain and purpura
- D. a client diagnosed with AIDS
Correct answer: B
Rationale: The correct answer is 'a client suspected of varicella (chickenpox).' Chickenpox is an acute, infectious airborne illness that requires airborne precautions, including wearing a respirator mask for direct contact with the patient. Choices A, C, and D do not typically require airborne precautions. Choice A describes symptoms that may indicate a gastrointestinal infection but do not require airborne precautions. Choice C mentions abdominal pain and purpura, which are not specific to an airborne illness. Choice D, a client diagnosed with AIDS, does not necessitate airborne precautions unless there are additional infectious conditions present that require such measures.
2. Which of the following is not one of the four categories related to client care plans?
- A. privacy
- B. evaluation
- C. diagnosis
- D. outcome
Correct answer: A
Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.
3. In a disaster triage situation, which of the following should the nurse be least concerned with regarding a client in crisis?
- A. ability to breathe
- B. pallor or cyanosis of the skin
- C. number of accompanying family members
- D. motor function
Correct answer: C
Rationale: During a disaster triage situation where quick decisions are crucial, the nurse's primary focus should be on factors directly related to the patient's immediate condition and survival. The ability to breathe, pallor or cyanosis of the skin, and motor function are critical indicators of a patient's health status and need for urgent intervention. In contrast, the number of accompanying family members, although important for emotional support, is not a priority when assessing and prioritizing care during a crisis. While emotional support is valuable, the focus in triage is on identifying and addressing the most critical and life-threatening issues first to maximize survival chances. Therefore, the nurse should be least concerned with the number of accompanying family members as it does not directly impact the patient's immediate medical needs in a crisis situation. Choices A, B, and D are all crucial factors to assess a client's health status and determine the urgency of intervention during a disaster triage. The ability to breathe indicates respiratory function, pallor or cyanosis of the skin reflect circulatory and oxygenation status, and motor function can hint at neurological impairment or injury, all of which are vital in determining the severity of the crisis and the immediate medical needs of the patient.
4. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?
- A. lettuce
- B. eggs
- C. chocolate
- D. butterscotch
Correct answer: C
Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce and eggs do not significantly affect LES pressure, making them less likely to trigger GERD symptoms. Butterscotch, like lettuce and eggs, does not have a notable effect on LES pressure, so it is not as likely to worsen GERD symptoms as chocolate. Therefore, chocolate is the food to be avoided by clients prone to heartburn due to GERD.
5. During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?
- A. Ask the television crew to interview the individuals attending the program individually.
- B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
- C. Explain to the television crew that videotaping is not allowed.
- D. Allow the television crew to videotape the program.
Correct answer: C
Rationale: Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.
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