NCLEX-PN
Nclex Questions Management of Care
1. What is the most appropriate feeding method for a client who is unable to swallow?
- A. Nothing by mouth
- B. Nasogastric feedings
- C. Clear liquids
- D. Total parenteral nutrition
Correct answer: B
Rationale: Nasogastric feedings are the most appropriate feeding method for a client who is unable to swallow. Providing nothing by mouth can lead to nutritional deficiencies, while clear liquids might cause aspiration. Total parenteral nutrition is not necessary if the gastrointestinal tract is functional. Nasogastric feedings are preferred as they can safely provide nutrition without the risks associated with not eating or aspirating.
2. Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?
- A. Native American
- B. Asian-Pacific
- C. Norwegian
- D. Hispanic
Correct answer: D
Rationale: Hispanic people are at the highest risk in the United States for pesticide-related injuries due to their significant representation among migrant workers in agricultural settings. Working in such environments exposes them to pesticides more frequently, thus elevating their risk compared to other ethnic groups. In contrast, Native American, Asian-Pacific, and Norwegian populations are not as commonly engaged in agricultural work involving pesticide exposure, which makes them less susceptible to pesticide-related injuries. Therefore, the correct answer is Hispanic.
3. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
- A. grief work facilitation
- B. vital signs monitoring
- C. medication administration: skin
- D. anxiety reduction
Correct answer: A
Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn. Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature. Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity. Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'
4. The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:
- A. help decrease stimuli from the cerebral cortex.
- B. stimulate hormonal changes in the brain.
- C. help the client's circadian rhythm.
- D. alert the hypothalamus in the brain.
Correct answer: A
Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep. Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.
5. Which of the following represents a normal serum potassium level?
- A. 1.5 mEq/L
- B. 3.0 mEq/L
- C. 4.0 mEq/L
- D. 6.0 mEq/L
Correct answer: C
Rationale: The correct answer is 4.0 mEq/L. Normal serum potassium levels typically range from 3.5-5.5 mEq/L. Choice A (1.5 mEq/L) is below the normal range, Choice B (3.0 mEq/L) is also below the normal range, and Choice D (6.0 mEq/L) is above the normal range. Therefore, the only option within the normal range is Choice C (4.0 mEq/L).
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