NCLEX-PN
Nclex Questions Management of Care
1. When managing time effectively, which of the following stimuli should the nurse respond to first?
- A. the physician's loud verbal direction
- B. the nursing supervisor who is going to a meeting
- C. unit staff leaving on a break
- D. the care needs of the returning postoperative client just exiting the elevator
Correct answer: D
Rationale: The correct answer is to attend to the care needs of the returning postoperative client just exiting the elevator first. In a healthcare setting, patient care should always take precedence, especially for complex or unstable clients requiring immediate assessment and care. The physician's loud verbal direction, the nursing supervisor going to a meeting, and unit staff leaving on a break are important but do not involve direct patient care. Therefore, the nurse should prioritize responding to the returning postoperative client to ensure their immediate needs are met.
2. A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?
- A. Retape the NG tube.
- B. Clamp the NG tube.
- C. Remove the NG tube.
- D. Check the NG tube placement.
Correct answer: D
Rationale: When a client with a nasogastric (NG) tube begins vomiting, the nurse should first check the NG tube placement. Vomiting can be a sign of tube displacement, which can lead to serious complications. Retaping the tube (Choice A), clamping it (Choice B), or removing it (Choice C) without first assessing its placement can be harmful or ineffective. Checking the NG tube placement is crucial as it ensures that the tube is in the correct position and prevents potential complications. Retaping the NG tube (Choice A) is incorrect because the priority is to check the placement first. Clamping the NG tube (Choice B) or removing it (Choice C) without verifying the placement can be dangerous if the tube is dislodged. Thus, these actions should not be taken before confirming the tube's position.
3. What is the term for the tendency of a drug to combine with its receptor?
- A. potency
- B. efficacy
- C. kinetics
- D. affinity
Correct answer: D
Rationale: The correct answer is 'affinity.' Affinity refers to the close relationship or mutual attraction between a drug and its receptor, indicating the strength of the drug-receptor bonding. Potency (Choice A) is related to the dose of a drug needed to produce a specific effect. Efficacy (Choice B) refers to a drug's ability to generate the desired effect. Kinetics (Choice C) deals with forces affecting the motion of material bodies or changes in a system, which is not directly associated with the bonding between a drug and its receptor.
4. After securing the client's safety from a faulty electric bed, what should the nurse do next?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct answer: D
Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management. Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident. Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report. Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.
5. A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?
- A. The immune system of an infant is immature, and the infant is at risk for infection.
- B. The transfer of your antibodies protects your infant until the infant is 12 months old.
- C. Yes, your infant is protected from all infections.
- D. If you breastfeed, your infant is protected from infection.
Correct answer: A
Rationale: The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.
Similar Questions
Access More Features
NCLEX PN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX PN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $149.99