NCLEX NCLEX-PN
Nclex Questions Management of Care
1. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?
- A. Consider it a normal finding.
- B. Check the system for leaks.
- C. Clamp the chest tube.
- D. Change the drainage system.
Correct answer: Consider it a normal finding.
Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.
2. A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following?
- A. voiding patterns
- B. characteristics of lesions
- C. vaginal discharge
- D. prior history of varicella
Correct answer: prior history of varicella
Rationale: The correct answer is 'prior history of varicella.' When assessing a client with genital herpes, it is important to gather data on voiding patterns, characteristics of lesions, and vaginal discharge as these are pertinent to the disease. However, the prior history of varicella is not directly related to the current diagnosis of genital herpes. Varicella, which refers to chickenpox, is caused by the varicella-zoster virus, a different virus from the herpes simplex virus causing genital herpes.
3. The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?
- A. “I like to soak my feet in the hot tub every day.”
- B. “I walk to the mailbox in my bare feet.”
- C. “I stopped smoking and only use chewing tobacco.”
- D. “I have my wife examine the soles of my feet each day.”
Correct answer: “I have my wife examine the soles of my feet each day.”
Rationale: The correct answer is, “I have my wife examine the soles of my feet each day.” Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.
4. A nurse reviews the health history of a client who will be seeing the health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that the use of a combination oral contraceptive is contraindicated?
- A. The client has type 2 diabetes mellitus.
- B. The client is being treated for hypertension.
- C. The client has been treated for breast cancer.
- D. The client has hyperlipidemia.
Correct answer: The client has been treated for breast cancer.
Rationale: The correct answer is that the client has been treated for breast cancer. Combination oral contraceptives containing estrogen and progestin are contraindicated for women with a history of certain conditions, such as thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. Although having type 2 diabetes mellitus, being treated for hypertension, or having hyperlipidemia are risk factors that require caution when using combination oral contraceptives, they are not absolute contraindications like a history of breast cancer.
5. A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?
- A. "I’m not working overtime today."
- B. "I have plans after work and will not be able to work overtime."
- C. "You know how I hate to work overtime."
- D. "I will if you need me, but I am not happy about this."
Correct answer: "I have plans after work and will not be able to work overtime."
Rationale: The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse should assertively communicate her unavailability for overtime without being confrontational. Option A, "I’m not working overtime today," is too blunt and may come across as rude. Option C, "You know how I hate to work overtime," is not assertive but rather passive-aggressive. Option D, "I will if you need me, but I am not happy about this," is a passive-aggressive response as it implies compliance while expressing discontent. Option B, "I have plans after work and will not be able to work overtime," is the most appropriate response as it clearly states the nurse's unavailability without unnecessary aggression.
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