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. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms.
- B. nutritional status.
- C. bleeding problems.
- D. availability of insulin.
Correct answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse needs to consider various factors. Diabetic signs and symptoms, nutritional status, and availability of insulin are crucial aspects to assess for appropriate management during a crisis. However, bleeding problems are not directly related to diabetes or insulin therapy. Therefore, assessing for bleeding problems is not a priority in this context. Choice C, bleeding problems, is the correct answer as it is not typically associated with diabetes, unlike the other options provided.
3. A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for:
- A. solutions administered in obstetrics.
- B. dilute antibiotics.
- C. large volumes of IV solutions.
- D. the neonatal and pediatric populations.
Correct answer: D
Rationale: The correct answer is 'the neonatal and pediatric populations.' Syringe pumps are commonly used in neonatal and pediatric populations because they allow for precise infusion of small volumes of medications or fluids at controlled rates. This is crucial for ensuring safety and accuracy in these delicate populations. Choice A is incorrect because syringe pumps are not limited to obstetrics; they are used in various healthcare settings. Choices B and C are incorrect because syringe pumps are not typically used for dilute antibiotics or large volumes of IV solutions. Instead, they are preferred for delivering small volumes accurately, making them ideal for neonatal and pediatric care.
4. The client with a diagnosis of hepatitis is experiencing pruritus. Which would be the most appropriate nursing intervention?
- A. Suggest that the client take warm showers once a day.
- B. Add baby oil to the client's bath water.
- C. Apply powder to the client's skin.
- D. Suggest a cool-water rinse after bathing.
Correct answer: B
Rationale: Pruritus, or itching, in clients with hepatitis can be alleviated by adding moisturizing agents to bath water. Baby oil helps soothe and moisturize the skin, reducing dryness and itching. Warm showers, as in choice A, can be drying to the skin if taken too frequently, making it less suitable than adding oil to the bath water. Applying powder, as mentioned in choice C, can exacerbate dryness rather than alleviate it. Choice D suggests a cool-water rinse after bathing, which can help in retaining moisture and is less drying compared to hot water rinses.
5. When assessing a client's mobility status, the physical examination should start with:
- A. examining their gait.
- B. orienting to time, place, and person.
- C. performing the Romberg test.
- D. conducting the Tandem Walk test.
Correct answer: A
Rationale: When assessing a client's mobility status, it is crucial to start by examining their gait. Gait assessment is usually conducted as the client walks into the room. Normal gait is described as smooth, flowing, and rhythmic without the need for assistive devices. Choices B, C, and D are incorrect as they do not represent the standard practice of beginning the assessment of mobility status with gait examination.
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