NCLEX NCLEX-PN
Nclex Questions Management of Care
1. A discharge planning nurse is making arrangements for a client with an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
- A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters.
- B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.
- C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility.
- D. None of the above
Correct answer: Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.
Rationale: In this scenario, the priority is the safety and well-being of the client. The neighborhood facility's lack of experience in caring for a client with an epidural catheter for continuous opioid infusion raises concerns about the quality of care they can provide. Therefore, the most appropriate action for the discharge planning nurse is to explain the situation to the client and family and seek another long-term care facility that can provide the necessary care. Option A, arranging for immediate in-services, may not be feasible or timely, considering the urgent need for appropriate care. Option C, encouraging the family to hire private duty nurses, does not ensure the facility's overall capability to manage the client's complex needs. Option D, 'None of the above,' is not the best choice as the client's safety should be the priority in this situation.
2. The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?
- A. Car safety seat in the back seat in a face-forward position
- B. Booster seat with one of the car's seat belts placed over the child
- C. Booster seat in a rear-facing position in the front seat
- D. Car safety seat in a face-forward position in the front seat
Correct answer: Booster seat with one of the car's seat belts placed over the child
Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.
3. While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?
- A. Infection.
- B. Disequilibrium syndrome.
- C. Air embolus.
- D. Infection.
Correct answer: C: Air embolus.
Rationale: In this scenario, the client undergoing hemodialysis is experiencing symptoms like restlessness, a headache, and nausea. These symptoms are indicative of an air embolus, a serious complication that can occur during hemodialysis. Air embolus happens when air enters the bloodstream and can lead to symptoms like restlessness, a headache, and nausea. It is crucial for the nurse to suspect and address this complication promptly to prevent further harm to the client. Choices A and D (Infection) are less likely in this case, as the symptoms presented are more suggestive of an air embolus rather than an infection. Choice B (Disequilibrium syndrome) is also less likely as the symptoms described are not typical of this syndrome. Therefore, the correct answer is C: Air embolus.
4. When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:
- A. The new graduate nurse irrigates the pressure ulcer with 50cc of NS.
- B. The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.
- C. The new graduate packs the wound with sterile kerlix soaked in NS.
- D. The new graduate applies a Duoderm dressing over the wound after cleansing.
Correct answer: The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.
Rationale: The correct answer is that the new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide. Pressure ulcers should not be cleaned with substances that are cytotoxic, such as hydrogen peroxide or betadine. This can cause further damage to the wound and delay the healing process. Choice A is incorrect because irrigating the pressure ulcer with normal saline is an appropriate practice. Choice C is incorrect because packing the wound with sterile kerlix soaked in normal saline is also an appropriate step. Choice D is incorrect because applying a Duoderm dressing after cleansing is a standard procedure in wound care.
5. A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?
- A. 36%
- B. 27%
- C. 18%
- D. 9%
Correct answer: 18%
Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.
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