NCLEX-PN
Nclex Questions Management of Care
1. Under what circumstances can an individual receive medical care without giving informed consent?
- A. when the durable power of attorney for health care is not available
- B. in an emergency, life-or-death situation
- C. when the physician is not available for discussion with the client
- D. when they (clients) are not able to speak for themselves
Correct answer: B
Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.
2. The nurse is teaching a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?
- A. "Do not sit on toilet seats without protection."?
- B. "Oral sex can transmit the virus."?
- C. "This infection can be transmitted via intercourse even when you do not feel ill."?
- D. "Try to drink lots of fluids after sex to flush the reproductive tract."?
Correct answer: C
Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It's crucial to understand that the infection can be spread through intercourse even when symptoms are not present. Option A is incorrect because genital herpes is not transmitted through toilet seats. Option B is correct as oral sex can transmit the virus. Option D is incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.
3. Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct answer: A
Rationale: Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.
4. The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.
5. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?
- A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
- B. Ask a medical assistant.
- C. Call the nurse in charge of the day shift.
- D. Ask the police officers who brought the client to the center.
Correct answer: A
Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.
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