that because of the infants weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of

NCLEX-PN

Nclex Questions Management of Care

1. How should an infant be secured in a car?

A. To hold the infant while sitting in the middle of the back seat of the car
B. To place the infant in the front seat in a rear-facing infant safety seat if the car has passenger-side air bags
C. To place the infant in a booster seat in the front seat with the shoulder and lap belts secured around the infant
D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat

Correct answer: D

Rationale: The recommended way to secure an infant in a car is to place them in the middle of the back seat in a rear-facing infant safety seat. Option A is incorrect because infants should never be held while in a moving vehicle due to safety concerns. Option B is incorrect because placing an infant in the front seat with a rear-facing safety seat can be risky if the car has passenger-side airbags. Option C is incorrect as booster seats are not suitable for infants. Therefore, the correct choice is to secure the infant in the middle of the back seat in a rear-facing infant safety seat.

2. Which sign might a healthcare professional observe in a client with a high ammonia level?

A. coma
B. edema
C. hypoxia
D. polyuria

Correct answer: A

Rationale: A high ammonia level can lead to hepatic encephalopathy, which includes symptoms like confusion, disorientation, and can progress to coma. Coma is a severe condition of unconsciousness. Edema is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia is a condition of inadequate oxygen supply to tissues and organs, not directly related to high ammonia levels. Polyuria is excessive urination, which is not a typical sign of high ammonia levels.

3. Upon admission, the client expresses a desire for an extra oxygen tank in their room due to a previous breathing issue. What is the most appropriate response?

A. "I will make sure there is always an extra oxygen tank in your room."?
B. "I will ask the previous nurse if the extra tank was needed."?
C. "I will need to check if your insurance benefits would cover an additional oxygen tank."?
D. "The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby."?

Correct answer: D

Rationale: The appropriate response in this situation is to prioritize the availability of oxygen tanks for all patients in need. While it is understandable that the client may desire an extra tank for reassurance, the healthcare facility must ensure equitable distribution based on clinical need. Option A is incorrect because promising an always available extra tank may not be feasible and can set unrealistic expectations. Option B is not the best response as it focuses on past actions rather than addressing the current situation. Option C is not the most appropriate response at this time as the client's immediate need for an extra oxygen tank is the primary concern. Therefore, the best response is to emphasize the importance of equitable distribution of resources while acknowledging the client's request for an extra tank.

4. 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.

5. Which hormone in the urine is specifically indicative of pregnancy?

A. estrogen
B. progesterone
C. testosterone
D. human chorionic gonadotropin

Correct answer: D

Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.