NCLEX-PN
Nclex Questions Management of Care
1. A test that can correctly identify those who do not have a given disease is:
- A. specific.
- B. sensitive.
- C. negative culture
- D. marginal finding.
Correct answer: A
Rationale: The correct answer is 'specific.' Specificity refers to the ability of a test to correctly identify individuals who do not have a particular disease. In this case, when the client's lab culture report is negative for the suspected infection, a specific test would correctly identify that the client does not have the disease. 'Sensitive' (Choice B) is incorrect as sensitivity refers to the ability of a test to correctly identify individuals who do have the disease. 'Negative culture' (Choice C) is incorrect as it does not describe the test's ability but rather the result itself. 'Marginal finding' (Choice D) is irrelevant to the concept being tested in this question.
2. The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask them to see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct answer: A
Rationale: The most appropriate action in this scenario is to call the surgeon and ask them to see the client to clarify the information. It is the responsibility of the physician to explain and clarify the procedure to the client, ensuring informed consent. Answer B is incorrect as nurses should not provide detailed medical explanations beyond their scope of practice. Answer C is incorrect as the physician's notes may not capture the client's current understanding accurately. Answer D is incorrect because the client's own understanding, not the family's, is crucial for informed decision-making regarding the surgery.
3. Which of the following is not considered one of the five rights of medication administration?
- A. client
- B. drug
- C. dose
- D. routine
Correct answer: D
Rationale: The five rights of medication administration are dose, client, drug, route, and time. The correct answer is 'routine' as it is not commonly recognized as one of the essential rights in medication administration. Choice A, client, is necessary to ensure the right medication is administered to the right individual. Choice B, drug, is crucial to confirm the correct medication is given. Choice C, dose, is essential to ensure the right amount of medication is administered. Choice D, routine, is not typically included in the five rights of medication administration and is therefore the correct answer.
4. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?
- A. Begin client data collection before receiving the physician's order for the referral.
- B. Use documents to provide information for the referral.
- C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
- D. Participate in the client referral process.
Correct answer: C
Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.
5. An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?
- A. "You really need to listen to what the physician says."?
- B. "You will get too tired to take care of him at home."?
- C. "What can I do to assist you to care for him at home?"?
- D. "You are too busy to be taking care of an elderly person."?
Correct answer: C
Rationale: The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.
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