NCLEX-PN
Nclex Questions Management of Care
1. A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?
- A. 'I need to reapply spermicidal cream with repeated intercourse.'
- B. 'The diaphragm needs to be filled with spermicidal cream before insertion.'
- C. 'I can leave the diaphragm in place as long as I want after intercourse.'
- D. 'The diaphragm can be inserted as long as 6 hours before intercourse.'
Correct answer: C
Rationale: The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome. Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy. Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness. Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.
2. Which of the following provides the framework for confidentiality and the client's right to privacy?
- A. Health Insurance Portability and Accountability Act
- B. CDC Surveillance Programs
- C. American Nurses Association Code of Ethics
- D. Durable Power of Attorney for Health Care
Correct answer: A
Rationale: The correct answer is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is the federal statute that outlines client confidentiality and the client's right to privacy. It establishes national standards to protect individuals' medical records and personal health information. The American Nurses Association Code of Ethics emphasizes principles of nursing ethics but does not serve as a legal framework for confidentiality and privacy. CDC Surveillance Programs focus on disease surveillance and control at a public health level and are not directly related to individual client privacy. The durable power of attorney for health care pertains to granting legal decision-making authority to another individual in healthcare matters, rather than addressing confidentiality and privacy rights.
3. 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.
4. What is the purpose of the hydraulic lift (Hoyer lift)?
- A. To assist clients who have had orthopedic surgery.
- B. To assist clients who are unable to stand and extremely obese clients.
- C. To assist clients of all ages in a hospital setting.
- D. To assist clients with special needs.
Correct answer: B
Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.
5. 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.
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