NCLEX-PN
Nclex Questions Management of Care
1. The method of splinting is always dictated by:
- A. location of the injury and whether it is open or closed.
- B. the severity of the client's condition and the priority decision.
- C. the number of available rescuers and the type of splints.
- D. all of the above.
Correct answer: B
Rationale: The correct answer is 'the severity of the client's condition and the priority decision.' When determining the method of splinting, it is crucial to consider the severity of the client's condition and make decisions based on their priority. Choice A is incorrect because while the location of the injury and whether it is open or closed are important factors, they do not always dictate the method of splinting. Choice C is incorrect as the number of available rescuers and the type of splints may impact the execution of splinting but do not solely dictate the method. Choice D is incorrect as it suggests that all the factors mentioned dictate the method, but in reality, the severity of the client's condition and the priority decision are the primary factors.
2. When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?
- A. 2 seconds
- B. 10 seconds
- C. 20 seconds
- D. 30 seconds
Correct answer: B
Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma. Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.
3. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
- A. Performing a physical assessment prior to administration
- B. Obtaining the most recent lab values regarding renal function
- C. Reviewing peaks and troughs for the past few days
- D. Ensuring the client is not allergic to the medication
Correct answer: D
Rationale: Before administering any medication, including IV Vancomycin, it is crucial to ensure that the client is not allergic to the medication. This is the most critical action to prevent any potential allergic reactions. While performing a physical assessment is important, it may not be as time-sensitive as checking for allergies. Obtaining lab values related to renal function is also significant with Vancomycin due to its potential nephrotoxicity, but ensuring the client's safety by checking for allergies takes precedence. Reviewing peaks and troughs is important for monitoring drug levels, but it is a secondary step compared to checking for allergies prior to administration.
4. Which NSAID is comparable to morphine in efficacy?
- A. Feldene
- B. Stodal
- C. Toradol
- D. Elavil
Correct answer: C
Rationale: The correct answer is Toradol. Toradol is the first injectable NSAID that has been found to be comparable to morphine in terms of efficacy. Feldene (choice A) is not known for being comparable to morphine in efficacy. Stodal (choice B) is a homeopathic cough syrup and not an NSAID. Elavil (choice D) is a tricyclic antidepressant and not an NSAID, so it is not comparable to morphine in efficacy. Therefore, Toradol is the most appropriate choice as it matches the description provided in the question.
5. Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct answer: A
Rationale: Clients with major burns are in a hypermetabolic state, leading to increased protein catabolism. Therefore, a high-protein diet is essential to help them maintain a positive nitrogen balance and support wound healing. High carbohydrate diets do not directly contribute to achieving a positive nitrogen balance, making choice B incorrect. Similarly, low carbohydrate diets are not recommended for clients with major burns as carbohydrates provide essential energy needed for healing. Low protein diets are contraindicated for clients with major burns as they require higher protein intake to support tissue repair and prevent further breakdown.
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