NCLEX-PN
Nclex Questions Management of Care
1. Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. butter
- B. oats or barley cereal
- C. fresh vegetables
- D. coffee or tea
Correct answer: B
Rationale: Celiac disease, also known as celiac sprue, is a malabsorption disorder affecting the small intestine due to a problem with ingesting gluten, a protein found in wheat, rye, oats, and barley. Therefore, oats or barley cereal would present a problem for a client with Celiac Disease as they contain gluten. Fresh vegetables, butter, coffee, and tea, on the other hand, do not contain gluten and should not pose any issues for individuals with this disorder. Therefore, the correct answer is oats or barley cereal. Choices A, C, and D are not problematic for clients with Celiac Disease as they are gluten-free.
2. A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for:
- A. solutions administered in obstetrics.
- B. dilute antibiotics.
- C. large volumes of IV solutions.
- D. the neonatal and pediatric populations.
Correct answer: D
Rationale: The correct answer is 'the neonatal and pediatric populations.' Syringe pumps are commonly used in neonatal and pediatric populations because they allow for precise infusion of small volumes of medications or fluids at controlled rates. This is crucial for ensuring safety and accuracy in these delicate populations. Choice A is incorrect because syringe pumps are not limited to obstetrics; they are used in various healthcare settings. Choices B and C are incorrect because syringe pumps are not typically used for dilute antibiotics or large volumes of IV solutions. Instead, they are preferred for delivering small volumes accurately, making them ideal for neonatal and pediatric care.
3. What is the best definition of ethics in nursing?
- A. advocating for the client
- B. knowing your scope of practice
- C. being able to differentiate right from wrong
- D. being willing to report violations
Correct answer: C
Rationale: Ethics in nursing refers to the moral principles that govern a nurse's behavior and decision-making. It involves being able to differentiate right from wrong, making choices that are morally sound, and upholding integrity in patient care. While advocating for the client (choice A) is an important aspect of nursing care, it does not fully encompass the broad concept of ethics. Knowing your scope of practice (choice B) is essential for safe and competent care but is not a comprehensive definition of ethics. Being willing to report violations (choice D) is part of ethical practice, but it is not the core definition of ethics in nursing.
4. When preparing a client for a neck x-ray, what is the most appropriate action for the nurse to take if the client expresses concern about removing a religious medal worn around the neck?
- A. Telling the client that the medal and chain will be kept at the nurse's station for safekeeping while the client is undergoing the x-ray
- B. Asking the client to remove the medal until the x-ray has been completed
- C. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms
- D. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department
Correct answer: C
Rationale: When a client undergoing a neck x-ray expresses concern about removing a religious medal worn around the neck, the nurse should assist the client in pinning the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. This action allows the client to keep the medal close without interfering with the x-ray procedure. It is important to ensure that the radiology department staff is informed about this arrangement. Asking the client to remove the medal, keeping it at the nurse's station, or placing it in the bedside stand is not appropriate. These actions may lead to the loss of the medal and chain and do not address the client's concerns about the religious significance of the item.
5. The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
- A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
- B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
- C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
- D. Proceed with transporting the client to the operating room without obtaining informed consent.
Correct answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
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