NCLEX-PN
Nclex Questions Management of Care
1. Which of the following tests is commonly performed on newborns with jaundice?
- A. blood urea nitrogen
- B. magnesium
- C. bilirubin
- D. prolactin
Correct answer: C
Rationale: The correct answer is C: bilirubin. A high bilirubin level is found in newborns with hepatic immaturity, leading to jaundice. Testing bilirubin levels is crucial in diagnosing and monitoring jaundice in newborns. Choices A, B, and D (blood urea nitrogen, magnesium, and prolactin) are not commonly performed tests for evaluating jaundice in newborns. Blood urea nitrogen is a measure of kidney function, magnesium levels are usually checked in metabolic disorders, and prolactin is a hormone related to lactation, none of which are directly relevant to assessing jaundice in newborns.
2. When providing perineal care to a female client, how should the nurse perform the procedure?
- A. with gloves, washing the perineal area from front to back
- B. without gloves, having the client perform all care
- C. with gloves, washing the perineal area from back to front
- D. without gloves, pouring water from a sterile bottle
Correct answer: A
Rationale: When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention. Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.
3. 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.
4. Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?
- A. Impaired Physical Mobility
- B. Dysreflexia
- C. Hypothermia
- D. Impaired Dentition
Correct answer: A
Rationale: The correct answer is 'Impaired Physical Mobility.' As Parkinson's disease progresses, clients may experience a shuffling gait and rigidity, leading to impaired physical mobility. This nursing diagnosis is relevant to address the functional limitations that may arise. 'Dysreflexia' is not typically associated with Parkinson's disease but rather with spinal cord injuries. 'Hypothermia' is a condition of abnormally low body temperature and is not a common complication of Parkinson's disease. 'Impaired Dentition' refers to dental issues and is not directly related to the progression of Parkinson's disease.
5. The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills.
- B. contact with hot surfaces such as stoves and fireplaces.
- C. contact with flammable liquids or gases resulting in flash burns.
- D. sunburn from lack of protection and overexposure.
Correct answer: D
Rationale: The correct answer is 'sunburn from lack of protection and overexposure.' First-degree burns primarily affect the outer layer of the skin and are commonly caused by overexposure to the sun without adequate protection, making it a significant concern for parents of small children. Choices A, B, and C describe other types of burns (scalding, contact with hot surfaces, and contact with flammable substances) that can cause more severe burns beyond the first-degree level. It is crucial for parents to be educated about sun safety measures to prevent sunburns in children.
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