NCLEX-PN
Nclex Questions Management of Care
1. Which of the following isoenzymes is elevated in a client who has had a myocardial infarction?
- A. CPK-BB
- B. CPK-MM
- C. CPK-MB
- D. CPK-MI
Correct answer: C
Rationale: CPK-MB is the correct answer as it is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients with brain damage, and CPK-MM is elevated in clients with skeletal muscle damage. CPK-MI, mentioned in the rationale, does not exist, making it an incorrect choice.
2. The client has asked if you would be able to offer any alternative or complementary therapy during their hospitalization. Which of the following would be appropriate to suggest?
- A. Physical therapy
- B. Music therapy
- C. Psychiatric therapy
- D. Occupational therapy
Correct answer: B
Rationale: Music therapy is an appropriate suggestion as an alternative or complementary therapy during hospitalization. Music therapy can help improve the client's condition and comfort level by providing emotional support and reducing stress. Physical therapy and occupational therapy are crucial for rehabilitation and improving physical function, while psychiatric therapy focuses on mental health treatment. These therapies are essential components of care but are not typically considered alternative or complementary therapies in this context.
3. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:
- A. the client reports no episodes of awakening during the night.
- B. the client falls asleep within 1 hour of going to bed.
- C. the client reports satisfaction with their amount of sleep.
- D. the client rates sleep as an 8 or more on the visual analog scale.
Correct answer: B
Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.
4. Which of the following client statements indicates adequate understanding of preparation for electroencephalography?
- A. "I don't need to eat or drink after midnight."?
- B. "I need to wash my hair before the test."?
- C. "I need to remove metal jewelry."?
- D. "I can't take aspirin before the test."?
Correct answer: B
Rationale: The correct statement is, 'I need to wash my hair before the test.' Washing the hair is necessary to remove hair products that could interfere with electrode attachment to the scalp. Restricting food or drink is not required, except for avoiding caffeinated beverages. Removing metal jewelry is unnecessary for an electroencephalography procedure. Aspirin does not need to be avoided before the test; medications like anticonvulsants, tranquilizers, barbiturates, and sedatives are the ones that might need to be held.
5. After assigning tasks, what is the nurse's primary responsibility?
- A. Assigning any tasks that were not completed to the next nursing shift
- B. Documenting completion of each task
- C. Allowing each staff member to make judgments when performing the tasks
- D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task
Correct answer: D
Rationale: The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.
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