NCLEX 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: Prepare an incident report.
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. The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?
- A. 100 mL/hr
- B. 125 mL/min
- C. 125 mL/hr
- D. 80 mL/min
Correct answer: 125 mL/hr
Rationale: To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period. Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information. Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes. Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.
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. Which of the following is not a primary function of the kidneys?
- A. blood pressure control
- B. vitamin D activation
- C. erythropoietin production
- D. reabsorption of waste products
Correct answer: reabsorption of waste products
Rationale: The correct answer is reabsorption of waste products because the kidneys excrete waste products rather than reabsorbing them. Choices A, B, and C are indeed primary functions of the kidneys. The kidneys play a crucial role in regulating blood pressure, activating vitamin D, and producing erythropoietin, which stimulates red blood cell production. Therefore, the primary role of the kidneys is to filter blood, remove waste products, regulate fluid balance, and maintain electrolyte balance.
5. A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
- A. pleurisy.
- B. pleural effusion.
- C. atelectasis.
- D. tuberculosis.
Correct answer: pleurisy.
Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by an abrupt onset of pain. Symptoms of pleurisy include sudden sharp, stabbing pain that is usually unilateral and localized to a specific portion of the chest. The pain can be exacerbated by deep breathing. In contrast, pleural effusion is characterized by fluid accumulation in the pleural space, not sharp pain. Atelectasis involves collapse or closure of a lung leading to reduced gas exchange, but it does not typically present with sharp, stabbing pain. Tuberculosis is a bacterial infection that can affect the lungs but does not typically manifest with sudden sharp pain exacerbated by deep breathing.
Similar Questions
Access More Features
NCLEX Basic
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX Basic
- 5,000 Questions and answers
- Comprehensive NCLEX Coverage
- 90 days access @ $69.99