NCLEX-PN
Nclex Questions Management of Care
1. After securing the client's safety from a faulty electric bed, what should the nurse do next?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct answer: D
Rationale: After ensuring the client's safety from the faulty electric bed, the nurse should prioritize preparing an incident report. This report documents the details of what happened and is crucial for quality improvement and risk management. Choice A, discussing the matter with the client's significant others, may be important in some cases but is not the immediate priority after a safety incident. Choice B, documenting the incident in the client's record, is necessary but should be preceded by preparing an incident report. Choice C, notifying the physician, is important but not as urgent as preparing the incident report to ensure timely reporting and investigation of the safety issue.
2. What is the appropriate ratio of cardiac compressions to ventilations in an adult client for one-person CPR?
- A. 5:01
- B. 1:05
- C. 15:02
- D. 2:15
Correct answer: C
Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation. Choice A (5:1) and Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR. Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.
3. When providing perineal care to a female client, how should the nurse perform the procedure?
- A. with gloves, washing the perineal area from front to back
- B. without gloves, having the client perform all care
- C. with gloves, washing the perineal area from back to front
- D. without gloves, pouring water from a sterile bottle
Correct answer: A
Rationale: When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention. Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.
4. Where do the vast majority of deaths resulting from unintentional poisoning occur?
- A. Infants
- B. Toddlers
- C. Teens
- D. Adults
Correct answer: B
Rationale: The correct answer is 'Toddlers.' Toddlers are at the highest risk of unintentional poisoning due to their natural curiosity, explorative behavior, and lack of awareness of potential dangers. Infants are typically closely monitored, teens are more aware of risks, and adults generally have better judgment and understanding of hazardous substances, making them less susceptible to unintentional poisoning. Therefore, toddlers, being inquisitive and unaware of risks, are the most vulnerable group in terms of unintentional poisoning incidents.
5. 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: A
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.
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