You decide who to see first, what to delegate, and which order cannot wait. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five management of care questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
A. grief work facilitation
B. vital signs monitoring
C. medication administration: skin
D. anxiety reduction
Show answer and rationale
Correct answer: A — grief work facilitation
The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn.
Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature.
Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity.
Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'
Question 2
What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?
A. Place the client in isolation until further assessment is completed.
B. Seclude the client from other clients and visitors.
C. Perform no intervention until test results confirm a diagnosis.
D. Don personal protective equipment immediately.
Show answer and rationale
Correct answer: B — Seclude the client from other clients and visitors.
The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.
Question 3
A new mother asks the nurse, 'I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?' Which statement should the nurse make in response to the mother?
A. The immune system of an infant is immature, and the infant is at risk for infection.
B. The transfer of your antibodies protects your infant until the infant is 12 months old.
C. Yes, your infant is protected from all infections.
D. If you breastfeed, your infant is protected from infection.
Show answer and rationale
Correct answer: A — The immune system of an infant is immature, and the infant is at risk for infection.
The transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. While the infant starts producing immunoglobulin (Ig) soon after birth, it only reaches about 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level by 1 year of age. Breast milk provides additional IgA protection. Although the immune system matures during infancy, full protection against infections is not achieved until early childhood, putting the infant at risk for infections. Choice B is incorrect because maternal antibody protection typically lasts around 3 to 4 months, not until the infant is 12 months old. Choice C is incorrect as infants are not shielded from all infections due to their immature immune system. Choice D is incorrect because while breastfeeding offers extra protection, it does not guarantee complete immunity against infections.
Question 4
A discharge planning nurse is making arrangements for a client with an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters.
B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.
C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility.
D. None of the above
Show answer and rationale
Correct answer: B — Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital.
In this scenario, the priority is the safety and well-being of the client. The neighborhood facility's lack of experience in caring for a client with an epidural catheter for continuous opioid infusion raises concerns about the quality of care they can provide. Therefore, the most appropriate action for the discharge planning nurse is to explain the situation to the client and family and seek another long-term care facility that can provide the necessary care. Option A, arranging for immediate in-services, may not be feasible or timely, considering the urgent need for appropriate care. Option C, encouraging the family to hire private duty nurses, does not ensure the facility's overall capability to manage the client's complex needs. Option D, 'None of the above,' is not the best choice as the client's safety should be the priority in this situation.
Question 5
The healthcare professional seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function?
A. urinalysis
B. creatinine and blood urea nitrogen
C. chemistry of electrolytes
D. creatinine clearance
Show answer and rationale
Correct answer: D — creatinine clearance
In the context of an elderly client, assessing renal function before administering a nephrotoxic medication is crucial. While urinalysis and blood urea nitrogen provide valuable information on hydration status and overall health clues, they are not specific indicators of renal function. The chemistry of electrolytes may show abnormalities in renal failure, but it does not directly measure the kidneys' ability to eliminate waste. Creatinine clearance, on the other hand, is considered the best indicator for renal function in the elderly. This test accounts for decreases in lean body mass that can affect blood creatinine levels and is widely used to estimate the glomerular filtration rate, reflecting the kidneys' filtration capability. Therefore, creatinine clearance is the most appropriate lab test to assess renal function in this scenario.
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Question 6
A client states, 'I can leave the diaphragm in place as long as I want after intercourse.' Which statement indicates to the nurse that the client needs further information on how to use the diaphragm?
A. 'I need to reapply spermicidal cream with repeated intercourse.'
B. 'The diaphragm needs to be filled with spermicidal cream before insertion.'
C. 'I can leave the diaphragm in place as long as I want after intercourse.'
D. 'The diaphragm can be inserted as long as 6 hours before intercourse.'
Correct answer:
The correct answer is the statement, 'I can leave the diaphragm in place as long as I want after intercourse.' This statement indicates a lack of understanding about the correct use of the diaphragm. The diaphragm must be left in place for at least 6 hours after intercourse to ensure effectiveness and reduce the risk of pregnancy. Leaving the diaphragm in place for an extended period can lead to toxic shock syndrome. Choice A is correct as spermicidal cream needs to be reapplied before each act of intercourse for optimal contraceptive efficacy. Choice B is a correct statement as the diaphragm should be filled with spermicidal cream before insertion to increase its effectiveness. Choice D is also accurate as the diaphragm can be inserted up to 6 hours before intercourse to allow time for proper placement and effectiveness.
A client is diagnosed with HIV. Which of the following antiviral drug classes are used in the treatment of HIV/AIDS?
A. nucleoside reverse transcriptase inhibitors
B. protease inhibitors
C. HIV fusion inhibitors
D. all of the above
Correct answer:
All of the provided choices are antiviral drug classes used in the treatment of HIV/AIDS. Nucleoside reverse transcriptase inhibitors, such as tenofovir and emtricitabine, work by interfering with the virus's ability to replicate. Protease inhibitors, like atazanavir and darunavir, block an enzyme that HIV needs to make copies of itself. HIV fusion inhibitors, for instance, enfuvirtide, prevent HIV from entering human cells. Therefore, 'all of the above' is the correct answer as all the listed drug classes are commonly used in managing HIV infections. Choices A, B, and C are all essential components of antiretroviral therapy for HIV, targeting different stages of the virus's life cycle. The combination of drugs from these classes is often recommended to effectively control HIV replication and reduce viral load.
A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?
A. ''Wood surfaces on the crib need to be free of splinters and cracks.''
B. ''I need to keep large toys out of the crib.''
C. ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''
D. ''The drop side needs to be impossible for my infant to release.''
Correct answer:
The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2? inches to prevent entrapment of the infant's head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.
The laws enacted by states to provide immunity from liability to persons who provide emergency care at an accident scene are called:
A. Good Samaritan laws.
B. HIPAA.
C. Patient Self-Determination Act (PSDA).
D. OBRA.
Correct answer:
The correct answer is Good Samaritan laws. These laws protect individuals who provide voluntary emergency care from being held liable for any unintended injury or harm that may occur during the care. Good Samaritan laws encourage individuals to assist in emergencies without fear of legal repercussions. HIPAA, on the other hand, focuses on safeguarding patient information and privacy, ensuring confidentiality. The Patient Self-Determination Act (PSDA) pertains to a patient's rights to make decisions about their medical treatment and advance directives. OBRA, enacted in the late 1980s, aims to improve the quality of care in nursing homes and enhance residents' quality of life, focusing on nursing home reform and standards, which is not directly related to immunity for emergency care providers.
The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat?
A. Car safety seat in the back seat in a face-forward position
B. Booster seat with one of the car's seat belts placed over the child
C. Booster seat in a rear-facing position in the front seat
D. Car safety seat in a face-forward position in the front seat
Correct answer:
The correct answer is to place the child in a booster seat with one of the car's seat belts placed over the child. A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis, providing optimal safety. Placing a child in a booster seat in a rear-facing position in the front seat is incorrect as children should not be seated in the front seat due to potential airbag-related injuries. Additionally, car safety seats are used for children weighing less than 40 lb and are placed in the middle of the back seat in a rear-facing position for maximum protection.
A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?
A. Retape the NG tube.
B. Clamp the NG tube.
C. Remove the NG tube.
D. Check the NG tube placement.
Correct answer:
When a client with a nasogastric (NG) tube begins vomiting, the nurse should first check the NG tube placement. Vomiting can be a sign of tube displacement, which can lead to serious complications. Retaping the tube (Choice A), clamping it (Choice B), or removing it (Choice C) without first assessing its placement can be harmful or ineffective. Checking the NG tube placement is crucial as it ensures that the tube is in the correct position and prevents potential complications. Retaping the NG tube (Choice A) is incorrect because the priority is to check the placement first. Clamping the NG tube (Choice B) or removing it (Choice C) without verifying the placement can be dangerous if the tube is dislodged. Thus, these actions should not be taken before confirming the tube's position.
In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?
A. Place extra padding under the mother to absorb blood from the delivery.
B. Cut the umbilical cord using sterile scissors.
C. Suction the baby's mouth and nose.
D. Wrap the baby in a clean blanket to preserve warmth.
Correct answer:
In an obstetrical emergency, the immediate priority after the baby delivers is to clear the baby's airway by suctioning the mouth and nose to ensure effective breathing. This action helps prevent potential complications like meconium aspiration. Cutting the umbilical cord, wrapping the baby in a blanket, or placing extra padding under the mother can follow once the baby's airway is clear. Therefore, suctioning the baby's mouth and nose is the most critical and time-sensitive intervention in this scenario. Placing extra padding under the mother is not the immediate priority as ensuring the baby's airway is clear. Cutting the umbilical cord and wrapping the baby in a clean blanket are important but can wait until after ensuring the baby's breathing is not compromised.
A. location of the injury and whether it is open or closed.
B. the severity of the client's condition and the priority decision.
C. the number of available rescuers and the type of splints.
D. all of the above.
Correct answer:
The correct answer is 'the severity of the client's condition and the priority decision.' When determining the method of splinting, it is crucial to consider the severity of the client's condition and make decisions based on their priority. Choice A is incorrect because while the location of the injury and whether it is open or closed are important factors, they do not always dictate the method of splinting. Choice C is incorrect as the number of available rescuers and the type of splints may impact the execution of splinting but do not solely dictate the method. Choice D is incorrect as it suggests that all the factors mentioned dictate the method, but in reality, the severity of the client's condition and the priority decision are the primary factors.
What is a significant point about Shigella that the nurse should acknowledge upon identifying it in a stool culture?
A. People who have been in contact with the client need to be tested.
B. Shigella is an airborne infection.
C. Shigella is a bacteria sometimes found in stagnant water.
D. The nurse should wear a one-way breathing apparatus when giving client care.
Correct answer:
Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states. Choices A, B, and D are incorrect. While it is important for close contacts to be aware and practice good hygiene, testing is not routinely indicated. Shigella is not an airborne infection; it is transmitted through contaminated food or water. A one-way breathing apparatus is not necessary for caring for a patient with Shigella; standard precautions, including handwashing and gloves, are sufficient.
A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
A. Linens from the client's bed should be double-bagged.
B. Meals should be served on washable dishes.
C. Extensive isolation rarely causes psychological problems.
D. Paper trays and plastic utensils do not prevent disease transmission.
Correct answer:
Isolation techniques are used to prevent or limit the spread of infection. Special handling of articles and linens soiled by any body fluid is essential. Linens should be placed in impervious bags before being removed from the client's bedside to prevent exposure of personnel and contamination of the environment. Double-bagging is required if the outside of the bag becomes contaminated. This practice ensures that potentially infectious materials are properly contained and disposed of. Choices B, C, and D are incorrect because the focus in this scenario is on proper handling and disposal of soiled linens to prevent the spread of infection, not on serving meals, psychological effects of isolation, or the use of paper trays and plastic utensils.
NCLEX-PN management of care practice questions for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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