Integrated Management-of-Care Questions for the NCLEX® Examination
1. The home health nurse is assigned to visit all of the following clients when a change in agency
staffing requires that one of the clients be resched
...
Integrated Management-of-Care Questions for the NCLEX® Examination
1. The home health nurse is assigned to visit all of the following clients when a change in agency
staffing requires that one of the clients be rescheduled for a visit on the following day. Which
of the following clients would be best to reschedule?
a. A client with emphysema who has been on home oxygen for a month and has SpO2
levels of 91% to 93%
b. A client with lung cancer who has recurrent pleural effusions and called in
complaining of increased dyspnea
c. A client with newly diagnosed heart failure who needs an admission visit and
initial intake assessment
d. A client with a history of a cough, weight loss, and night sweats who has just had a
positive Mantoux test
ANS: A
This client has appropriate SpO2 levels for a client using oxygen at home. The other three clients
need more immediate assessment and interventions.
2. A 42-year-old client who has fallen off a roof arrives in the ED with possible head and neck,
chest, and abdominal trauma. All of the following orders are received. Which action will the
nurse take first?
a. Immobilize the neck with a cervical collar.
b. Infuse normal saline IV at 200 mL/hr.
c. Give oxygen to keep O2 saturation greater than 93%.
d. Obtain computed tomography scan of head, neck, chest, and abdomen.
ANS: C
The other orders are also of high importance, but the priority in any traumatic injury is to assess
and maintain airway patency and oxygenation.
3. The change of shift report on the hospital medical surgical unit has just been completed. Which
of these clients will the oncoming nurse need to assess first?
a. An asthmatic client who was admitted 1 hour ago with expiratory wheezes and a
respiratory rate of 34 breaths/min
b. A client with lung cancer who needs an IV antibiotic administered before going to
surgery
c. A hospice client with terminal pulmonary fibrosis and an oxygen saturation of 89%
d. A client with COPD who is ready for discharge, but is not able to pay for the
prescribed home medications
ANS: A
This client is having an acute asthma attack and should be assessed immediately. The other
clients also require complex nursing care, but are more stable than the client admitted with
asthma.
4. All of the following information is obtained by the nurse who is admitting a client for a coronary
arteriogram. Which information is most important to report to the physician before the
procedure begins?
1
This study source was downloaded by 100000839121131 from CourseHero.com on 08-23-2022 23:58:00 GMT -05:00
https://www.coursehero.com/file/21221213/NCLEX-Practice-Test-question
[Show More]
.png)
