NCLEX-PN
Nclex Questions Management of Care
1. What is involved in client education by the nurse?
- A. Telling the client everything about their disease, what will happen in the course of the disease, and the outcome.
- B. Giving information to the client that is accurate and understandable.
- C. Informing the client that the pain they experience might not be real.
- D. Administering medication to the client when they experience pain.
Correct answer: B
Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.
2. Which of the following is not one of the four categories related to client care plans?
- A. privacy
- B. evaluation
- C. diagnosis
- D. outcome
Correct answer: A
Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.
3. A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:
- A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
- B. eat foods low in fat.
- C. empty his bladder prior to the procedure.
- D. assume the prone position.
Correct answer: C
Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.
4. A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of?
- A. positive
- B. false positive
- C. negative
- D. false negative
Correct answer: B
Rationale: The correct answer is 'false positive.' A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. In this scenario, the client received a positive test result incorrectly, as he does not have the disease being tested for. Choice A ('positive') is too vague and does not specify that the result was incorrect. Choice C ('negative') is the opposite of what happened in the scenario. Choice D ('false negative') refers to a situation where a test result is labeled negative incorrectly, which is not the case in this scenario.
5. Which action exemplifies the use of evidence-based practice in the delivery of client care?
- A. Advising a client to agree to the treatment recommended by their healthcare provider
- B. Taking a rectal temperature from a client for whom bleeding precautions have been instituted
- C. Donning sterile gloves to change an abdominal wound dressing
- D. Encouraging a client to take an herbal substance to treat their insomnia
Correct answer: C
Rationale: Evidence-based practice is an approach to client care where the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing exemplifies evidence-based practice as it prevents the entrance of harmful bacteria into the wound, following best practice guidelines. The other options do not align with evidence-based practice. Advising a client to agree to a treatment does not involve integrating research evidence. Taking herbal substances may not be supported by strong research evidence and can pose risks. Additionally, rectal temperature-taking in a client with bleeding precautions can increase the risk of injury to the rectal mucosa, not aligning with best practices in care delivery.
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