NCLEX-PN
Nclex Questions Management of Care
1. What are the hazards of improper splinting?
- A. Aggravation of a bone or joint injury
- B. Reduced distal circulation
- C. Delay in transporting a client with a life-threatening injury
- D. All of the above
Correct answer: D
Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.
2. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?
- A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
- B. Ask a medical assistant.
- C. Call the nurse in charge of the day shift.
- D. Ask the police officers who brought the client to the center.
Correct answer: A
Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.
3. Which of the following is least important to test when assessing the client’s motor skills?
- A. strength
- B. knowledge of ergonomics
- C. balance
- D. coordination
Correct answer: B
Rationale: When assessing a client’s motor skills, it is crucial to evaluate their strength, balance, and coordination as these directly impact their motor abilities. Strength is essential to perform tasks, balance is required for stability, and coordination is necessary for smooth movements. However, knowledge of ergonomics, while beneficial for overall understanding, is not directly related to assessing motor skills. The focus should be on physical abilities rather than theoretical knowledge of ergonomics. Therefore, testing the client’s knowledge of ergonomics is the least important when evaluating their motor skills.
4. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. measure intake and output.
- B. check albumin levels.
- C. monitor glucose levels.
- D. increase enteral feeding.
Correct answer: A
Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.
5. Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?
- A. Native American
- B. Asian-Pacific
- C. Norwegian
- D. Hispanic
Correct answer: D
Rationale: Hispanic people are at the highest risk in the United States for pesticide-related injuries due to their significant representation among migrant workers in agricultural settings. Working in such environments exposes them to pesticides more frequently, thus elevating their risk compared to other ethnic groups. In contrast, Native American, Asian-Pacific, and Norwegian populations are not as commonly engaged in agricultural work involving pesticide exposure, which makes them less susceptible to pesticide-related injuries. Therefore, the correct answer is Hispanic.
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