a nurse discharge planner is preparing a client for discharge from an acute care setting the nurse assesses that skilled home care services are clini
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Nursing Elites

NCLEX-PN

Nclex Questions Management of Care

1. A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:

Correct answer: V

Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.

2. A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?

Correct answer: A

Rationale: The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone. Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team. Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse. Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.

3. An LPN is caring for a primarily bedridden client. Which finding should be of least concern?

Correct answer: D

Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.

4. Quality is defined as a combination of all of the following except:

Correct answer: B

Rationale: Quality in any context is about meeting or exceeding customer requirements and exceeding customer expectations. It also involves conforming to standards to ensure consistency and reliability. Merely performing at the minimally acceptable level does not encompass the essence of quality, as it sets the bar at the lowest level of acceptability rather than aiming for excellence or customer satisfaction. Therefore, the correct answer is 'performing at the minimally acceptable level,' as this choice falls short in capturing the comprehensive definition of quality.

5. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?

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.

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