NCLEX-PN
Nclex Questions Management of Care
1. When are pressure ulcers most likely to occur?
- A. when clients are left in one position in bed for extended periods of time.
- B. when clients are underweight.
- C. when clients are overweight.
- D. only in underweight and overweight clients.
Correct answer: A
Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client. Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.
2. What is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct answer: B
Rationale: Mammography is a diagnostic imaging technique specifically designed to detect tumors, cysts, or other abnormalities in breast tissue. It is not used to detect pain, edema, or epilepsy. Pain is a symptom, not a condition that mammography can detect. Edema refers to swelling and is not detectable through mammography. Epilepsy is a neurological disorder, not a condition detected by mammography.
3. How should an infant be secured in a car?
- A. To hold the infant while sitting in the middle of the back seat of the car
- B. To place the infant in the front seat in a rear-facing infant safety seat if the car has passenger-side air bags
- C. To place the infant in a booster seat in the front seat with the shoulder and lap belts secured around the infant
- D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat
Correct answer: D
Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants. Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.
4. When managing time effectively, which of the following stimuli should the nurse respond to first?
- A. the physician's loud verbal direction
- B. the nursing supervisor who is going to a meeting
- C. unit staff leaving on a break
- D. the care needs of the returning postoperative client just exiting the elevator
Correct answer: D
Rationale: The correct answer is to attend to the care needs of the returning postoperative client just exiting the elevator first. In a healthcare setting, patient care should always take precedence, especially for complex or unstable clients requiring immediate assessment and care. The physician's loud verbal direction, the nursing supervisor going to a meeting, and unit staff leaving on a break are important but do not involve direct patient care. Therefore, the nurse should prioritize responding to the returning postoperative client to ensure their immediate needs are met.
5. After delivery, a newborn undergoes an Apgar assessment. What does this scoring system evaluate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct answer: B
Rationale: The Apgar scoring system, developed by Virginia Apgar, an anesthesiologist, evaluates newborns based on five criteria: heart rate, respiratory effort, color, muscle tone, and reflex irritability. These parameters provide a quick and simple assessment of a newborn's overall condition and the need for immediate medical attention. Choices B, C, and D are incorrect as they do not encompass the essential elements evaluated by the Apgar scoring system.
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