NCLEX-PN
Nclex Questions Management of Care
1. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?
- A. ability to speak
- B. ability to hear
- C. oxygen saturation
- D. adventitious breath sounds
Correct answer: A
Rationale: In an emergency situation, assessing the client's ability to speak is crucial in determining airway obstruction. If a client can speak, it indicates that the airway is patent and not completely obstructed. Choices B and C, assessing the ability to hear and oxygen saturation, are not directly indicative of an airway obstruction. Choice D, adventitious breath sounds, may be present in conditions like asthma or pneumonia but are not specific to determining an airway obstruction.
2. Which is the proper hand position for performing chest percussion?
- A. Use the side of the hands
- B. Flatten the hands
- C. Spread the fingers of both hands
- D. Cup the hands
Correct answer: D
Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.
3. A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?
- A. The client's wound is healing well.
- B. The client seems anxious.
- C. The client's intake was 360 mL
- D. The client is voiding large amounts
Correct answer: C
Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.
4. People living in poverty are most likely to obtain health care from:
- A. their primary care physician (family doctor)
- B. a neighborhood clinic
- C. specialists
- D. Emergency Departments or urgent care centers
Correct answer: D
Rationale: People living in poverty often face barriers to accessing regular healthcare services, leading them to seek care in Emergency Departments or urgent care centers. These facilities are more accessible and do not require appointments or insurance, making them a common choice for individuals with limited resources. Neighborhood clinics, while a good option, may not always be available or affordable for those in poverty. Specialists provide specialized care but usually require a referral from a primary care provider, which individuals in poverty may not have consistent access to. Therefore, Emergency Departments or urgent care centers are the most likely sources of healthcare for people living in poverty.
5. The nurse is educating a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?
- A. "Do not sit on toilet seats without protection."?
- B. "Oral sex can transmit the virus."?
- C. "This infection can be transmitted via intercourse even when you do not feel ill."?
- D. "Try to drink plenty of fluids after sex to flush the reproductive tract."?
Correct answer: C
Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It is crucial to educate the patient that the infection can be transmitted via intercourse even when asymptomatic to prevent its spread. Choice A is incorrect as sitting on toilet seats without protection does not transmit genital herpes. Choice B is incorrect because oral sex can transmit the virus. Choice D is also incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.
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