ASCORERS STUVIA n
NCLEX MANAGEMENT OF CARE EXAM QUESTIONS WITH CO
n n n n n n n n
RRECT ANSWERS n
A 13 year old, found unresponsive in the park, is brought into the emerge
n n n n n n n n n n n n n
ncy department. The nurse sees a medical alert bracelet stating "Diabetic
n n n n n n n n n n
", and notes a fruity smell to the breath. There are no family members ava
n n n n n n n n n n n n n n
ilable to obtain consent for treatment and an attempt to call them has be
n n n n n n n n n n n n n
en unsuccessful. What action should the nurse take?
n n n n n n n
1. Obtain consent from the social worker on duty in the emergency depar
n n n n n n n n n n n n
tment.
2. Begin treatment by inserting two large bore IVs of Normal Saline.
n n n n n n n n n n n
3. Give glucogon IM and wait for the arrival of a parent to consent to furth
n n n n n n n n n n n n n n n
er treatment.
n
4. Withhold treatment until a parent arrives to the emergency departme
n n n n n n n n n n
nt. ANS: 2. Begin treatment by inserting two large bore IVs of Normal
nnnnnn nn n n n n n n n n n n n
Saline.
(2. Correct: In emergencies, if it is impossible to obtain consent from the
n n n n n n n n n n n n n
client or an authorized person, a health care provider may perform a pro
n n n n n n n n n n n n
cedure required to benefit the client or save a life without liability for fail
n n n n n n n n n n n n n
ure to obtain consent. In such cases the law assumes that the client woul
n n n n n n n n n n n n n
d wish to be treated. Begin treatment for diabetic ketoacidosis (DKA).
n n n n n n n n n n
1. Incorrect: Consent for a minor is not needed in the event of an emerge
n n n n n n n n n n n n n n
ncy. The social worker does not give consent in this situation.
n n n n n n n n n n
,ASCORERS STUVIA n
3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not nee
n n n n n n n n n n n n n
ded. Emergency treatment can be provided without parental consent.
n n n n n n n n
4. Incorrect: Consent for a minor is not needed in the event of an emerge
n n n n n n n n n n n n n n
ncy. This is an emergency, so begin treatment for DKA.)
n n n n n n n n n
A 70 year old client was admitted to the vascular surgery unit during the
n n n n n n n n n n n n n n
night shift with chronic hypertension. At 0830, the unlicensed nursing as
n n n n n n n n n n
sistant (UAP) reports that the client's BP is 198/94. What would be the b
n n n n n n n n n n n n n
est action for the charge nurse to delegate at this time?
n n n n n n n n n n
1. Ask the UAP to put the client back in bed immediately.
n n n n n n n n n n n
2. Tell the UAP to take the BP in the opposite arm in 15 minutes.
n n n n n n n n n n n n n n
3. Have the LPN/LVN administer the 0900 furosemide and enalapril now.
n n n n n n n n n n
4. Ask the LPN/LVN to assess the client for pain. ANS: 3. Have the LPN
n n n n n n n n n nnnnnn nn n n n
/LVN administer the 0900 furosemide and enalapril now.
n n n n n n n
(3. Correct: The nurse should recognize the need for measures to reduce
n n n n n n n n n n n n
the blood pressure. Administering the client's blood pressure medicine i
n n n n n n n n n
s aimed at correcting the problem. It is appropriate to administer the me
n n n n n n n n n n n n
dications at this time in relation to the time that the next dose is due.
n n n n n n n n n n n n n n
1., 2., & 4. Incorrect: This is an appropriate action, but does not address t
n n n n n n n n n n n n n n
he problem of lowering the client's blood pressure.)
n n n n n n n
,ASCORERS STUVIA n
A case manager is assessing an unresponsive client diagnosed with termi
n n n n n n n n n n
nal hepatic encephalopathy for equipment needs upon discharge home f
n n n n n n n n n
or hospice care. Which equipment should the case manager obtain for thi
n n n n n n n n n n n
s client?
n
Select all that apply. n n n
1. Alternating pressure mattress
n n n
2. Hospital bed
n n
3. Walker
n
4. Suction equipment
n n
5. Oxygen
n nnnnnn ANS: 1. Alternating pressure mattress
nn n n n
2. Hospital bed
n n
4. Suction equipment
n n
5. Oxygen
n
(1., 2., 4., & 5. Correct: An alternating pressure mattress will help to preve
n n n n n n n n n n n n n
nt pressure ulcers. The risk of respiratory compromise increases as the n
n n n n n n n n n n n
eurologic status deteriorates. A hospital bed is needed so that the head of
n n n n n n n n n n n n
nthe client's bed can be elevated to 30 degrees to ease respirations and de
n n n n n n n n n n n n n
, ASCORERS STUVIA n
crease the work of breathing. The client with hepatic encephalopathy is u
n n n n n n n n n n n
nresponsive due to accumulation of toxins and may need suctioning if un
n n n n n n n n n n n
able to clear secretions from the oropharynx. Hepatic encephalopathy fre
n n n n n n n n n
quently has associated bleeding varices. The increasing ascites leads to h
n n n n n n n n n n
ypovolemia. Both of these conditions can result in hypoxemia for the clie
n n n n n n n n n n n
nt at the end stages of liver disease; therefore, oxygen therapy is provide
n n n n n n n n n n n n
d.
3. Incorrect: As hepatic encephalopathy progresses and toxins accumulat
n n n n n n n n
e, the client lapses into a coma. Therefore, the unresponsive client will no
n n n n n n n n n n n n
t be ambulatory and would not need a walker.)
n n n n n n n n
A case manager is assessing an unresponsive client diagnosed with termi
n n n n n n n n n n
nal hepatic encephalopathy to determine equipment needs upon dischar
n n n n n n n n
ge to home for hospice care. Which equipment should the case manager
n n n n n n n n n n n n
obtain for this client? n n n
Select all that apply. n n n
1. Alternating pressure mattress
n n n
2. Hospital bed
n n
3. Walker
n
4. Suction equipment
n n
5. Oxygen
n nnnnnn ANS: 1. Alternating pressure mattress
nn n n n
2. Hospital bed
n n
NCLEX MANAGEMENT OF CARE EXAM QUESTIONS WITH CO
n n n n n n n n
RRECT ANSWERS n
A 13 year old, found unresponsive in the park, is brought into the emerge
n n n n n n n n n n n n n
ncy department. The nurse sees a medical alert bracelet stating "Diabetic
n n n n n n n n n n
", and notes a fruity smell to the breath. There are no family members ava
n n n n n n n n n n n n n n
ilable to obtain consent for treatment and an attempt to call them has be
n n n n n n n n n n n n n
en unsuccessful. What action should the nurse take?
n n n n n n n
1. Obtain consent from the social worker on duty in the emergency depar
n n n n n n n n n n n n
tment.
2. Begin treatment by inserting two large bore IVs of Normal Saline.
n n n n n n n n n n n
3. Give glucogon IM and wait for the arrival of a parent to consent to furth
n n n n n n n n n n n n n n n
er treatment.
n
4. Withhold treatment until a parent arrives to the emergency departme
n n n n n n n n n n
nt. ANS: 2. Begin treatment by inserting two large bore IVs of Normal
nnnnnn nn n n n n n n n n n n n
Saline.
(2. Correct: In emergencies, if it is impossible to obtain consent from the
n n n n n n n n n n n n n
client or an authorized person, a health care provider may perform a pro
n n n n n n n n n n n n
cedure required to benefit the client or save a life without liability for fail
n n n n n n n n n n n n n
ure to obtain consent. In such cases the law assumes that the client woul
n n n n n n n n n n n n n
d wish to be treated. Begin treatment for diabetic ketoacidosis (DKA).
n n n n n n n n n n
1. Incorrect: Consent for a minor is not needed in the event of an emerge
n n n n n n n n n n n n n n
ncy. The social worker does not give consent in this situation.
n n n n n n n n n n
,ASCORERS STUVIA n
3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not nee
n n n n n n n n n n n n n
ded. Emergency treatment can be provided without parental consent.
n n n n n n n n
4. Incorrect: Consent for a minor is not needed in the event of an emerge
n n n n n n n n n n n n n n
ncy. This is an emergency, so begin treatment for DKA.)
n n n n n n n n n
A 70 year old client was admitted to the vascular surgery unit during the
n n n n n n n n n n n n n n
night shift with chronic hypertension. At 0830, the unlicensed nursing as
n n n n n n n n n n
sistant (UAP) reports that the client's BP is 198/94. What would be the b
n n n n n n n n n n n n n
est action for the charge nurse to delegate at this time?
n n n n n n n n n n
1. Ask the UAP to put the client back in bed immediately.
n n n n n n n n n n n
2. Tell the UAP to take the BP in the opposite arm in 15 minutes.
n n n n n n n n n n n n n n
3. Have the LPN/LVN administer the 0900 furosemide and enalapril now.
n n n n n n n n n n
4. Ask the LPN/LVN to assess the client for pain. ANS: 3. Have the LPN
n n n n n n n n n nnnnnn nn n n n
/LVN administer the 0900 furosemide and enalapril now.
n n n n n n n
(3. Correct: The nurse should recognize the need for measures to reduce
n n n n n n n n n n n n
the blood pressure. Administering the client's blood pressure medicine i
n n n n n n n n n
s aimed at correcting the problem. It is appropriate to administer the me
n n n n n n n n n n n n
dications at this time in relation to the time that the next dose is due.
n n n n n n n n n n n n n n
1., 2., & 4. Incorrect: This is an appropriate action, but does not address t
n n n n n n n n n n n n n n
he problem of lowering the client's blood pressure.)
n n n n n n n
,ASCORERS STUVIA n
A case manager is assessing an unresponsive client diagnosed with termi
n n n n n n n n n n
nal hepatic encephalopathy for equipment needs upon discharge home f
n n n n n n n n n
or hospice care. Which equipment should the case manager obtain for thi
n n n n n n n n n n n
s client?
n
Select all that apply. n n n
1. Alternating pressure mattress
n n n
2. Hospital bed
n n
3. Walker
n
4. Suction equipment
n n
5. Oxygen
n nnnnnn ANS: 1. Alternating pressure mattress
nn n n n
2. Hospital bed
n n
4. Suction equipment
n n
5. Oxygen
n
(1., 2., 4., & 5. Correct: An alternating pressure mattress will help to preve
n n n n n n n n n n n n n
nt pressure ulcers. The risk of respiratory compromise increases as the n
n n n n n n n n n n n
eurologic status deteriorates. A hospital bed is needed so that the head of
n n n n n n n n n n n n
nthe client's bed can be elevated to 30 degrees to ease respirations and de
n n n n n n n n n n n n n
, ASCORERS STUVIA n
crease the work of breathing. The client with hepatic encephalopathy is u
n n n n n n n n n n n
nresponsive due to accumulation of toxins and may need suctioning if un
n n n n n n n n n n n
able to clear secretions from the oropharynx. Hepatic encephalopathy fre
n n n n n n n n n
quently has associated bleeding varices. The increasing ascites leads to h
n n n n n n n n n n
ypovolemia. Both of these conditions can result in hypoxemia for the clie
n n n n n n n n n n n
nt at the end stages of liver disease; therefore, oxygen therapy is provide
n n n n n n n n n n n n
d.
3. Incorrect: As hepatic encephalopathy progresses and toxins accumulat
n n n n n n n n
e, the client lapses into a coma. Therefore, the unresponsive client will no
n n n n n n n n n n n n
t be ambulatory and would not need a walker.)
n n n n n n n n
A case manager is assessing an unresponsive client diagnosed with termi
n n n n n n n n n n
nal hepatic encephalopathy to determine equipment needs upon dischar
n n n n n n n n
ge to home for hospice care. Which equipment should the case manager
n n n n n n n n n n n n
obtain for this client? n n n
Select all that apply. n n n
1. Alternating pressure mattress
n n n
2. Hospital bed
n n
3. Walker
n
4. Suction equipment
n n
5. Oxygen
n nnnnnn ANS: 1. Alternating pressure mattress
nn n n n
2. Hospital bed
n n
