NCLEX-PN
Nclex Questions Management of Care
1. 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.
2. 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.
3. What intervention should the nurse take for a client who has sustained a hyphema?
- A. Instruct the client to wear eye protectors in the future
- B. Keep the client at bed rest, typically with the head of the bed propped up
- C. Apply atropine eyedrops
- D. Apply an ice pack to the site of injury
Correct answer: B
Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (Choice A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (Choice C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (Choice D) is not recommended for a hyphema as it can increase the risk of rebleeding. Therefore, the correct answer is to keep the client at bed rest.
4. A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?
- A. 'I need to reapply spermicidal cream with repeated intercourse.'
- B. 'The diaphragm needs to be filled with spermicidal cream before insertion.'
- C. 'I can leave the diaphragm in place as long as I want after intercourse.'
- D. 'The diaphragm can be inserted as long as 6 hours before intercourse.'
Correct answer: C
Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome. Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy. Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness. Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.
5. To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?
- A. flexion, extension, hyperextension
- B. flexion, extension, abduction, adduction
- C. external rotation, internal rotation
- D. extension, flexion, inversion, eversion
Correct answer: D
Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.
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