NCLEX-PN
Nclex Questions Management of Care
1. The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?
- A. Car safety seat in the back seat in a face-forward position
- B. Booster seat with one of the car's seat belts placed over the child
- C. Booster seat in a rear-facing position in the front seat
- D. Car safety seat in a face-forward position in the front seat
Correct answer: B
Rationale: The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.
2. A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions, and he says, "I don't want to bother the surgeon."? The nurse should ____.
- A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
- B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
- C. go get the surgeon to answer all of the client's questions
- D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed
Correct answer: D
Rationale: In this scenario, the nurse should prioritize the client's understanding and comfort. While acknowledging the client's wish not to bother the surgeon is important, it is equally crucial to ensure that the client's questions are answered appropriately and thoroughly. Choice A is correct as it respects the client's initial sentiment and offers the client the opportunity to ask questions later if needed. Choice B is incorrect as it suggests answering all questions immediately, without considering the client's feelings. Choice C is incorrect as it bypasses the nurse's role in addressing the client's concerns. Choice D, the correct answer, balances respecting the client's wish and ensuring that all questions are appropriately addressed, even if it involves the surgeon returning.
3. After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct answer: C
Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.
4. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:
- A. hypothalamus.
- B. thalamus.
- C. cortex.
- D. medulla.
Correct answer: A
Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.
5. What condition is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct answer: B
Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.
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