NCLEX-PN
Nclex Questions Management of Care
1. After receiving a recent tattoo, someone should be screened for:
- A. tuberculosis.
- B. herpes.
- C. hepatitis.
- D. syphilis.
Correct answer: C
Rationale: After receiving a recent tattoo, screening for hepatitis is crucial due to the risk of blood-borne hepatitis B or C if strict sterile procedures are not followed during the tattooing process. Tuberculosis is an airborne pathogen and is not directly related to receiving a tattoo. Herpes and syphilis are infections spread through direct contact, such as sexual contact, and are not typically associated with tattooing.
2. Following abdominal surgery, a client has a nasogastric (NG) tube in place. What is the purpose of this tube immediately after surgery?
- A. simplify medication administration
- B. measure accurate input and output
- C. prevent accumulation of fluids and gas
- D. facilitate collection of specimens
Correct answer: C
Rationale: The correct answer is to prevent accumulation of fluids and gas. Immediately after abdominal surgery, the NG tube is used to keep the stomach decompressed, preventing the accumulation of fluids and gas. This helps in maintaining decompression to prevent surgical-site disruption and fluid loss through vomiting. Choices A, B, and D are incorrect because the primary purpose of the NG tube following abdominal surgery is to prevent complications related to fluid and gas build-up rather than simplifying medication administration, measuring input and output, or collecting specimens.
3. In an emergency situation where a client is unconscious and requires immediate surgery, what action is necessary with regard to informed consent?
- A. The healthcare team will proceed with the surgery as consent is not needed in emergencies.
- B. The healthcare team will wait until the client's family can be contacted for consent.
- C. The healthcare team will contact the hospital clergy to provide informed consent.
- D. The healthcare team will obtain consent from the client's legal guardian before proceeding.
Correct answer: A
Rationale: In emergency situations where obtaining consent is not possible due to the client's condition, healthcare providers are allowed to perform life-saving procedures without informed consent. It is assumed that the client would want to receive necessary treatment to save their life. Therefore, the correct action is for the healthcare team to proceed with the surgery as consent is not needed. Waiting to contact the client's family for consent can delay life-saving treatment, risking the client's life. Contacting the hospital clergy for consent is unnecessary and can cause further delays. Obtaining consent from the client's legal guardian is not feasible in this critical situation and may lead to a delay in providing essential care.
4. 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 action the nurse should take after the baby delivers is to suction the baby's mouth and nose to ensure the infant can breathe properly. This helps clear any potential obstructions and establish a clear airway. Cutting the umbilical cord (Choice B) and wrapping the baby in a clean blanket (Choice D) are important steps but should come after ensuring the baby's airway is clear. Placing extra padding under the mother (Choice A) is not a priority in this emergency situation as the focus should be on the baby's immediate needs for breathing and airway clearance.
5. Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night starting at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct answer: D
Rationale: Getting a back rub and drinking a glass of warm milk are appropriate measures to promote sleep as they can help relax the body and induce sleepiness. Exercising vigorously, as suggested in choice A, can be counterproductive as it stimulates the body rather than relaxing it, making it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, may also increase alertness due to the temperature changes and the caffeine in tea, which can interfere with falling asleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, making it harder to fall asleep. Therefore, choice D is the best option to promote sleep in this scenario.
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