NCLEX-PN
Nclex Questions Management of Care
1. Following abdominal surgery, a client has a nasogastric (NG) tube in place. What is the purpose of this tube immediately after surgery?
- A. simplify medication administration
- B. measure accurate input and output
- C. prevent accumulation of fluids and gas
- D. facilitate collection of specimens
Correct answer: C
Rationale: The correct answer is to prevent accumulation of fluids and gas. Immediately after abdominal surgery, the NG tube is used to keep the stomach decompressed, preventing the accumulation of fluids and gas. This helps in maintaining decompression to prevent surgical-site disruption and fluid loss through vomiting. Choices A, B, and D are incorrect because the primary purpose of the NG tube following abdominal surgery is to prevent complications related to fluid and gas build-up rather than simplifying medication administration, measuring input and output, or collecting specimens.
2. A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should provide the client with which information?
- A. Oral consent is not sufficient, and the client's request will be honored by all healthcare providers.
- B. Consent must be obtained from the family.
- C. The DNR request should be discussed with the healthcare provider, who will write the order.
- D. The healthcare provider makes the final decision about a DNR request.
Correct answer: C
Rationale: When a client requests a DNR order, the nurse should contact the healthcare provider so that the provider may discuss the request with the client. A DNR order should be written, not verbal, following agency and state guidelines. Therefore, the correct answer is that the DNR request should be discussed with the healthcare provider, who will write the order. Option A is incorrect as oral consent is not sufficient for a DNR order. Option B is incorrect because the client, not the family, has the authority to request a DNR order. Option D is incorrect because the healthcare provider discusses the request with the client but does not make the final decision.
3. While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.
- A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
- B. The client had an allergy to cefazolin sodium.
- C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
- D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.
Correct answer: D
Rationale: Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.
4. 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.
5. Ethics committees typically do not handle which of the following issues?
- A. Nonpayment of bills.
- B. Euthanasia.
- C. Starting or stopping treatment.
- D. Use of feeding tubes.
Correct answer: A
Rationale: Ethics committees primarily focus on addressing ethical dilemmas in healthcare. Issues like euthanasia, decisions regarding starting or stopping treatment, and the use of feeding tubes for nutritional support involve complex ethical considerations related to patient care and end-of-life decisions, which are commonly deliberated by ethics committees. However, nonpayment of bills is a financial matter and falls outside the typical scope of ethics committees' functions.
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