NCLEX-PN
Nclex Questions Management of Care
1. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?
- A. To comply with legal requirements for documenting lesions.
- B. To meet hospital policies for documenting lesions.
- C. To fulfill physician's documentation requirements for lesions.
- D. Because the nursing assessment of ulcers is a standard of nursing practice.
Correct answer: D
Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.
2. The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask them to see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct answer: A
Rationale: The most appropriate action in this scenario is to call the surgeon and ask them to see the client to clarify the information. It is the responsibility of the physician to explain and clarify the procedure to the client, ensuring informed consent. Answer B is incorrect as nurses should not provide detailed medical explanations beyond their scope of practice. Answer C is incorrect as the physician's notes may not capture the client's current understanding accurately. Answer D is incorrect because the client's own understanding, not the family's, is crucial for informed decision-making regarding the surgery.
3. When working with elderly clients, the healthcare provider should keep in mind that falls are most likely to happen to the elderly who are:
- A. in their 80s.
- B. living at home.
- C. hospitalized.
- D. living on only Social Security income.
Correct answer: C
Rationale: The correct answer is 'hospitalized.' Elderly individuals are at a higher risk of falls, especially when they are in new environments like hospitals due to unfamiliarity with the surroundings, medications, and potential mobility challenges. Being in a hospital can disrupt their usual routines and increase the risk of falls. Choice A ('in their 80s') is not as directly related to the increased risk of falls in a hospital environment. Choice B ('living at home') is a common setting for the elderly but does not address the specific risk associated with being hospitalized. Choice D ('living on only Social Security income') is unrelated to the risk of falls based on the environment.
4. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
- A. Notify maintenance to come and check the pump immediately.
- B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
- C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
- D. Tag the equipment for maintenance.
Correct answer: C
Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.
5. What are the hazards of improper splinting?
- A. Aggravation of a bone or joint injury
- B. Reduced distal circulation
- C. Delay in transporting a client with a life-threatening injury
- D. All of the above
Correct answer: D
Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.
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