NCLEX-PN
Nclex Questions Management of Care
1. The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. pureed canned squash
- B. pureed apples
- C. yogurt
- D. infant rice cereal
Correct answer: D
Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content. Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy. Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.
2. Nonpharmacological pain management involves all of the following except:
- A. hypnosis alone.
- B. psychological care, including support groups.
- C. physical and psychological modalities.
- D. pain-reducing drugs only.
Correct answer: D
Rationale: Nonpharmacological pain management encompasses various strategies like hypnosis, psychological care, and physical and psychological modalities. The correct answer is 'pain-reducing drugs only' because nonpharmacological approaches do not solely rely on medications for pain management. Options A, B, and C are all valid components of nonpharmacological pain management. Hypnosis can help manage pain, psychological care including support groups can provide emotional support and coping strategies, and physical and psychological modalities encompass a wide range of interventions beyond just medication.
3. Which is the proper hand position for performing chest vibration?
- A. cup the hands
- B. use the side of the hands
- C. flatten the hands
- D. spread the fingers of both hands
Correct answer: C
Rationale: The correct hand position for performing chest vibration is to flatten the hands. By flattening the hands over the area of the body where chest percussion is applied, vibrations can be conducted effectively to the chest to help loosen secretions. Cupping the hands may dampen vibrations, using the side of the hands reduces the surface area in contact with the chest, and spreading the fingers can lead to uneven pressure distribution. Therefore, flattening the hands provides the necessary contact and surface area to perform chest vibration efficiently.
4. The LPN is preparing to clean a client's PEG tube.The following tasks should the nurse perform EXCEPT?
- A. Gently remove crusty drainage from the site.
- B. Pull the tube in multiple directions to ensure it is secure.
- C. Thoroughly dry the skin around the tube site with a clean towel.
- D. Use mild soap to clean around the tube site.
Correct answer: B
Rationale: When cleaning a client's PEG tube, the nurse should perform tasks that focus on gentle cleaning and avoiding potential irritants. Choice A is correct as gently removing crusty drainage helps maintain hygiene. Choice C is important to prevent skin irritation and infection. Choice D is appropriate for cleaning the area. Choices B and D are incorrect. Choice B is incorrect because pulling the tube in multiple directions can lead to dislodgement or injury. Choice B is incorrect as talcum powder may irritate the stoma, and it is generally not recommended near PEG tubes.
5. A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?
- A. Assisting a client with dysphagia in eating
- B. Ambulating a client with Parkinson's disease
- C. Providing hygiene to a client with dementia
- D. Assisting a client with an above-the-knee amputation in showering
Correct answer: A
Rationale: The least appropriate assignment for a nursing assistant would be assisting a client with dysphagia in eating. This task requires specialized skills and knowledge to prevent complications such as choking and aspiration. Ambulating a client with Parkinson's disease, providing hygiene to a client with dementia, and assisting a client with an above-the-knee amputation in showering are tasks that a nursing assistant can safely perform without significant risk of complications. Assisting a client with dysphagia in eating involves higher risks and requires specific training, making it the least appropriate choice for a nursing assistant.
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