NCLEX-PN
Nclex Questions Management of Care
1. A child comes to the clinic with a skin rash. The maculopapular lesions are distributed around the mouth and have honey-colored drainage. The caregiver states that the rash is getting worse and seems to spread with the child's scratching. Which of the following advisory comments should be given?
- A. The history and presentation might indicate chickenpox, a highly contagious disease.
- B. The lesions might indicate a noncontagious infection that does not require isolation.
- C. The history and presentation might indicate an infectious illness called impetigo.
- D. The lesions are not contagious unless others have open wounds or lesions themselves.
Correct answer: C
Rationale: The scenario describes classic impetigo, characterized by maculopapular lesions with honey-colored drainage, typically caused by Staphylococcus aureus or Streptococcus pyogenes. Antibiotic therapy is usually indicated for impetigo. Chickenpox, a highly contagious disease, presents with a history of high fever followed by a vesicular rash, different from the described maculopapular lesions with honey-colored drainage. Choice A is incorrect as the presentation is not consistent with chickenpox. Choice B is incorrect because impetigo is contagious, especially through direct contact. Choice D is also incorrect as impetigo is a contagious skin infection regardless of others having open wounds or lesions.
2. Under what circumstances can an individual receive medical care without giving informed consent?
- A. when the durable power of attorney for health care is not available
- B. in an emergency, life-or-death situation
- C. when the physician is not available for discussion with the client
- D. when they (clients) are not able to speak for themselves
Correct answer: B
Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.
3. When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?
- A. 2 seconds
- B. 10 seconds
- C. 20 seconds
- D. 30 seconds
Correct answer: B
Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma. Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.
4. What is the most appropriate feeding method for a client who is unable to swallow?
- A. Nothing by mouth
- B. Nasogastric feedings
- C. Clear liquids
- D. Total parenteral nutrition
Correct answer: B
Rationale: Nasogastric feedings are the most appropriate feeding method for a client who is unable to swallow. Providing nothing by mouth can lead to nutritional deficiencies, while clear liquids might cause aspiration. Total parenteral nutrition is not necessary if the gastrointestinal tract is functional. Nasogastric feedings are preferred as they can safely provide nutrition without the risks associated with not eating or aspirating.
5. How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
- A. 1 foot
- B. 2 feet
- C. 4 feet
- D. 6 feet
Correct answer: D
Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger. Choice A, 1 foot, is incorrect because it is too close to the fire and can expose the nurse to unnecessary risk. Choice B, 2 feet, is also too close to the fire and may lead to potential harm. Similarly, choice C, 4 feet, is not the ideal distance as it is still within the range of potential danger. The correct answer is D, 6 feet, which is a safe distance for the nurse to extinguish the fire effectively without risking personal safety.
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