NCLEX-PN
NCLEX Question of The Day
1. What is the best position for a client immediately following a bilateral salpingooophorectomy?
- A. Fowler's
- B. Modified Sims
- C. Side lying
- D. Flat supine
Correct answer: C
Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (Choice A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (Choice B) is typically used for rectal examinations, not for post-surgical management. Flat supine (Choice D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.
2. The client develops a tension pneumothorax. Assessment is expected to reveal?
- A. Sudden hypertension and bradycardia
- B. Productive cough with yellow mucus
- C. Tracheal deviation and dyspnea
- D. Sudden development of profuse hemoptysis and weakness
Correct answer: C
Rationale: In a tension pneumothorax, the trachea deviates to the unaffected side due to increased pressure in the affected pleural space, causing respiratory distress. Dyspnea is a hallmark symptom as the lung on the affected side collapses, leading to difficulty in breathing. Sudden hypertension and bradycardia (Choice A) are not typical findings of tension pneumothorax. Productive cough with yellow mucus (Choice B) is more suggestive of respiratory infections rather than a tension pneumothorax. Sudden development of profuse hemoptysis and weakness (Choice D) is not characteristic of tension pneumothorax presentation.
3. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?
- A. Decrease the stimuli and observe frequently
- B. Administer the PRN sedative
- C. Call the physician immediately
- D. Administer the PRN pain medication
Correct answer: D
Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.
4. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:
- A. Obtaining Intake and Output.
- B. Frequent lung assessments.
- C. Vital signs every shift.
- D. Monitoring the IV site for infiltration.
Correct answer: D
Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.
5. Which client should be seen first by the Emergency Department nurse?
- A. A six-year-old with a femur fracture.
- B. A two-year-old with a fever of 102 degrees F.
- C. A three-year-old with wheezes in the right lower lobe.
- D. A two-year-old whose gastrostomy tube came out.
Correct answer: C
Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.
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