NCLEX-PN
Nclex Questions Management of Care
1. In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?
- A. Place extra padding under the mother to absorb blood from the delivery.
- B. Cut the umbilical cord using sterile scissors.
- C. Suction the baby's mouth and nose.
- D. Wrap the baby in a clean blanket to preserve warmth.
Correct answer: C
Rationale: In an obstetrical emergency, the immediate priority after the baby delivers is to clear the baby's airway by suctioning the mouth and nose to ensure effective breathing. This action helps prevent potential complications like meconium aspiration. Cutting the umbilical cord, wrapping the baby in a blanket, or placing extra padding under the mother can follow once the baby's airway is clear. Therefore, suctioning the baby's mouth and nose is the most critical and time-sensitive intervention in this scenario. Placing extra padding under the mother is not the immediate priority as ensuring the baby's airway is clear. Cutting the umbilical cord and wrapping the baby in a clean blanket are important but can wait until after ensuring the baby's breathing is not compromised.
2. An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
- A. internationally.
- B. in the state of Colorado only.
- C. in the continental United States.
- D. in the county of origination only.
Correct answer: B
Rationale: The correct answer is 'in the state of Colorado only.' Advance directive protocols and documents are specific to each state's laws and regulations. Choice A is incorrect as advance directives are not universally recognized internationally. Choice C is incorrect as the legal validity of an advance directive is limited to the state in which it was created. Choice D is incorrect as the legal reach of an advance directive typically extends throughout the state of origination, not just the county.
3. A client is having an abortion in a women's clinic, and the nurse caring for the client does not think the reasoning is appropriate. The nurse asks, "Are you sure you want to do this? It can't be undone. Have you read about your other options? Adoption is always a good choice."? The client states she understands all options and is comfortable with her choice. The nurse nods and leaves the room to discuss the procedure with the physician. Which client right did the nurse violate with her actions?
- A. the client's right to make personal health decisions without interference, as the nurse tried to sway the client's decision-making and healthcare choice in the direction of not having an abortion
- B. the client's right to be left alone without unsolicited attention, as the nurse inserted herself in the client's healthcare scenario and offered uninvited advice
- C. the client's right to confidentiality, as the nurse is talking to the physician about the client and the abortion
- D. the client's right to respectful care, as the nurse clearly made it known that she did not approve of the abortion
Correct answer: A
Rationale: A client has the right to make decisions about their healthcare without interference from healthcare team members. In this scenario, the nurse violated the client's right to make personal health decisions without interference by trying to influence the client's decision-making and healthcare choice in the direction of not having an abortion. It is essential for healthcare providers to respect patients' autonomy and decisions, regardless of personal beliefs. Choices B, C, and D are incorrect because the primary violation in this situation is related to the client's right to make their own healthcare decisions without interference.
4. Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs?
- A. epilepsy
- B. Parkinson's
- C. multiple sclerosis
- D. Huntington's chorea
Correct answer: D
Rationale: Huntington's chorea is characterized by writhing, twisting movements of the face and limbs, known as chorea. This disorder is caused by a genetic mutation affecting specific brain cells. Epilepsy presents with seizures, Parkinson's with tremors and rigidity, and multiple sclerosis with central nervous system issues. The specific description of writhing and twisting movements aligns with Huntington's chorea, making it the correct answer. Choices A, B, and C are incorrect as they describe different neurological disorders with distinct symptoms that do not match the writhing, twisting movements characteristic of Huntington's chorea.
5. All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct answer: C
Rationale: The correct answer is 'a client with an old injury.' Emergency assessments are required for immediate and life-threatening situations. Clients A, B, and D are in need of emergency assessments due to their critical conditions. Choice C, a client with an old injury, does not require an emergency assessment as it is not an acute or life-threatening situation. While the client with an old injury may still need medical attention, it does not necessitate an emergency assessment as the condition is not currently life-threatening or in need of immediate intervention.
Similar Questions
Access More Features
NCLEX PN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access
NCLEX PN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access