NCLEX-PN
NCLEX Question of The Day
1. While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?
- A. Recommend a dermatological consult to the physician.
- B. Note the location of the mole and contact the physician via telephone.
- C. Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
- D. Remove the mole with a sharp debridement technique, following approval from the charge nurse.
Correct answer: C
Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.
2. A nurse is covering a pediatric unit and is responsible for a 15-year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls."? The most appropriate course of action for the nurse is to respond by stating:
- A. "I will talk to the doctor about it."?
- B. "Has this been going on for a while?"?
- C. "How do you know this?"?
- D. "Teenagers often exhibit signs of sexual interest in females."?
Correct answer: D
Rationale: The most appropriate response for the nurse in this situation is to acknowledge that teenagers often exhibit signs of sexual interest in females. This response normalizes the mother's concern and provides reassurance that such behavior is typical during adolescence. Option A deflects the conversation to the doctor without addressing the mother's concern directly. Option B focuses on the duration rather than addressing the mother's statement. Option C may come off as defensive or dismissive, questioning the mother's observation. Therefore, the best response is to acknowledge the normalcy of teenage behavior regarding sexual interest.
3. A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct answer: D
Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.
4. During a stress test, a patient complains of severe chest pain. Which of the following medications is the most appropriate to relieve this discomfort?
- A. Aspirin
- B. Diazoxide
- C. Procardia
- D. Mannitol
Correct answer: C
Rationale: In this scenario, the most appropriate medication to relieve severe ischemic chest pain during a stress test is Procardia. Procardia, a calcium channel blocker, is effective in quickly alleviating chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Aspirin, although important for antiplatelet effects, is not the best choice for immediate relief of severe chest pain. Diazoxide is a vasodilator used in hypertensive emergencies, not for acute chest pain. Mannitol is an osmotic diuretic used to reduce intracranial pressure, not for chest pain relief.
5. In the Emergency Department (ED), which client should the nurse see first?
- A. COPD client with a non-productive cough
- B. Diabetic client who has an infected sore on the foot
- C. Client with adrenal insufficiency who feels weak
- D. Client with a fracture of the forearm in an air splint
Correct answer: C
Rationale: In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis. Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening. Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency. Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.
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