NCLEX-PN
Nclex Questions Management of Care
1. What is a significant point about Shigella that the nurse should acknowledge upon identifying it in a stool culture?
- A. People who have been in contact with the client need to be tested.
- B. Shigella is an airborne infection.
- C. Shigella is a bacteria sometimes found in stagnant water.
- D. The nurse should wear a one-way breathing apparatus when giving client care.
Correct answer: C
Rationale: Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states. Choices A, B, and D are incorrect. While it is important for close contacts to be aware and practice good hygiene, testing is not routinely indicated. Shigella is not an airborne infection; it is transmitted through contaminated food or water. A one-way breathing apparatus is not necessary for caring for a patient with Shigella; standard precautions, including handwashing and gloves, are sufficient.
2. A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
- A. Linens from the client's bed should be double-bagged.
- B. Meals should be served on washable dishes.
- C. Extensive isolation rarely causes psychological problems.
- D. Paper trays and plastic utensils do not prevent disease transmission.
Correct answer: A
Rationale: Isolation techniques are used to prevent or limit the spread of infection. Special handling of articles and linens soiled by any body fluid is essential. Linens should be placed in impervious bags before being removed from the client's bedside to prevent exposure of personnel and contamination of the environment. Double-bagging is required if the outside of the bag becomes contaminated. This practice ensures that potentially infectious materials are properly contained and disposed of. Choices B, C, and D are incorrect because the focus in this scenario is on proper handling and disposal of soiled linens to prevent the spread of infection, not on serving meals, psychological effects of isolation, or the use of paper trays and plastic utensils.
3. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS?
- A. Nucleoside reverse transcriptase inhibitors
- B. Protease inhibitors
- C. HIV fusion inhibitors
- D. All of the above
Correct answer: D
Rationale: The correct answer is 'All of the above.' Nucleoside reverse transcriptase inhibitors inhibit the enzyme reverse transcriptase, protease inhibitors block the activity of the HIV-1 protease enzyme, and HIV fusion inhibitors prevent HIV from entering human cells. Therefore, all the choices provided are valid antiviral drug classes for managing HIV/AIDS. Nucleoside reverse transcriptase inhibitors, protease inhibitors, and HIV fusion inhibitors play crucial roles in combating the virus at different stages. Nucleoside reverse transcriptase inhibitors target an early stage, protease inhibitors act on a later stage, and HIV fusion inhibitors prevent viral entry. Thus, 'All of the above' is the correct and comprehensive answer encompassing different mechanisms of action in managing HIV/AIDS.
4. How many temporary teeth should the nurse expect to find in a 5-year-old client's mouth?
- A. up to 10
- B. up to 15
- C. up to 20
- D. up to 32
Correct answer: C
Rationale: A 5-year-old child can have up to 20 temporary (deciduous or baby) teeth. The first tooth usually erupts by age 6 months, and the last by age 30 months. All temporary teeth are usually shed between 6 and 13 years of age. Therefore, a 5-year-old child should have up to 20 temporary teeth. The correct answer is 'up to 20.' Choices A, B, and D are incorrect because the correct number of temporary teeth in a 5-year-old child's mouth is up to 20, not 10, 15, or 32.
5. The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills.
- B. contact with hot surfaces such as stoves and fireplaces.
- C. contact with flammable liquids or gases resulting in flash burns.
- D. sunburn from lack of protection and overexposure.
Correct answer: D
Rationale: The correct answer is 'sunburn from lack of protection and overexposure.' First-degree burns primarily affect the outer layer of the skin and are commonly caused by overexposure to the sun without adequate protection, making it a significant concern for parents of small children. Choices A, B, and C describe other types of burns (scalding, contact with hot surfaces, and contact with flammable substances) that can cause more severe burns beyond the first-degree level. It is crucial for parents to be educated about sun safety measures to prevent sunburns in children.
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