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. When a client has a chest drainage system in place, where should the system be placed?
- A. above the level of the client's chest
- B. at the level of the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct answer: D
Rationale: A chest drainage system should be placed below the level of the client's chest to ensure proper drainage of fluid from the chest. Placing the system above the level of the chest or at the shoulders would not allow gravity to assist in the drainage process, potentially leading to complications such as fluid accumulation. Similarly, placing it at the level of the chest would not create the necessary gravity-dependent flow for effective drainage, which is crucial for the proper functioning of the chest drainage system.
3. A 10-year-old boy has been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?
- A. Increased body weight
- B. Elevated heart rate
- C. Lower extremity edema
- D. Compulsive behavior
Correct answer: D
Rationale: Compulsive behavior is not a clinical sign typically associated with congestive heart failure (CHF). CHF commonly presents with symptoms such as increased body weight due to fluid retention, elevated heart rate as the heart works harder to pump blood effectively, and lower extremity edema caused by fluid buildup. While behavioral changes can occur in response to illness, compulsive behavior is not a typical indicator of CHF. Choices A, B, and C are more commonly linked to CHF and should be monitored in patients with this condition.
4. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?
- A. "I should make sure he gets plenty of rest."?
- B. "I should get him a medical alert bracelet."?
- C. "I should lay him on his back during a seizure."?
- D. "I should loosen his clothing during a seizure."?
Correct answer: C
Rationale: The correct answer is '"I should lay him on his back during a seizure."?' When a client is having a seizure, it is crucial to turn them onto their side to prevent aspiration of secretions. Placing them on their back can lead to potential airway compromise. Choices A, B, and D are correct statements that indicate a good understanding of caring for a child with a seizure disorder: ensuring rest, getting a medical alert bracelet for identification, and loosening clothing to facilitate breathing during a seizure.
5. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?
- A. corner of the mouth to tragus of the ear
- B. corner of the eye to top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: D
Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.
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