NCLEX-PN
Nclex Questions Management of Care
1. Which of the following is not an indication for pelvic ultrasonography?
- A. to measure uterine size
- B. to detect multiple pregnancies
- C. to measure renal size
- D. to detect foreign bodies
Correct answer: C
Rationale: Pelvic ultrasonography is commonly used to assess various conditions. Choices A, B, and D are all valid reasons for performing pelvic ultrasonography. Measuring uterine size helps evaluate conditions like fibroids, while detecting multiple pregnancies is essential for prenatal care. Furthermore, identifying foreign bodies can aid in diagnosing certain conditions. However, assessing renal size is typically not a primary reason for pelvic ultrasonography, making choice C the correct answer.
2. A client is having an abortion in a women's clinic, and the nurse caring for the client does not think the reasoning is appropriate. The nurse asks, "Are you sure you want to do this? It can't be undone. Have you read about your other options? Adoption is always a good choice."? The client states she understands all options and is comfortable with her choice. The nurse nods and leaves the room to discuss the procedure with the physician. Which client right did the nurse violate with her actions?
- A. the client's right to make personal health decisions without interference, as the nurse tried to sway the client's decision-making and healthcare choice in the direction of not having an abortion
- B. the client's right to be left alone without unsolicited attention, as the nurse inserted herself in the client's healthcare scenario and offered uninvited advice
- C. the client's right to confidentiality, as the nurse is talking to the physician about the client and the abortion
- D. the client's right to respectful care, as the nurse clearly made it known that she did not approve of the abortion
Correct answer: A
Rationale: A client has the right to make decisions about their healthcare without interference from healthcare team members. In this scenario, the nurse violated the client's right to make personal health decisions without interference by trying to influence the client's decision-making and healthcare choice in the direction of not having an abortion. It is essential for healthcare providers to respect patients' autonomy and decisions, regardless of personal beliefs. Choices B, C, and D are incorrect because the primary violation in this situation is related to the client's right to make their own healthcare decisions without interference.
3. What is a predisposing factor for cancer of the tongue?
- A. tobacco use
- B. obesity
- C. sun exposure
- D. eating sweets
Correct answer: A
Rationale: Tobacco use is a well-established predisposing factor for cancer of the tongue. Smoking or chewing tobacco can lead to the development of oral cancers, including those affecting the tongue. Obesity, sun exposure, and eating sweets are not directly linked to an increased risk of tongue cancer. Obesity may be associated with other types of cancer, sun exposure can lead to skin cancer, and eating sweets is not a known risk factor for tongue cancer. Therefore, the correct answer is tobacco use, as it has a strong association with the development of tongue cancer, making it a significant predisposing factor.
4. All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct answer: C
Rationale: The correct answer is 'a client with an old injury.' Emergency assessments are required for immediate and life-threatening situations. Clients A, B, and D are in need of emergency assessments due to their critical conditions. Choice C, a client with an old injury, does not require an emergency assessment as it is not an acute or life-threatening situation. While the client with an old injury may still need medical attention, it does not necessitate an emergency assessment as the condition is not currently life-threatening or in need of immediate intervention.
5. Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?
- A. "Make it a stat delivery."?
- B. "Please do it as soon as you can after break."?
- C. "This client is delirious, and we're worried about urinary sepsis."?
- D. "Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately."?
Correct answer: D
Rationale: Effective delegation depends on clear, concise direction that leaves no room for question or interpretation on the part of the one being delegated to. In this scenario, the most appropriate direction is to ensure the urine specimen is collected promptly and delivered to the lab immediately. Choice A is too vague and does not specify the urgency required. Choice B does not emphasize the immediate need for the specimen to be delivered. Choice C introduces unnecessary medical information that is beyond the scope of a nursing assistant and may cause confusion. Therefore, choice D is the correct answer as it provides clear instructions for immediate action without room for misunderstanding.
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