the emergency department charge nurse is reviewing the clients triaged in the last 30 minutes the nurse is required to obtain a social service consult

NCLEX-PN

NCLEX Question of The Day

1. The emergency department charge nurse is reviewing the clients triaged in the last 30 minutes. The nurse is required to obtain a social service consult from which of the following clients?

A. A 6-year-old who drank some diluted bleach.
B. A 10-year-old who suffered burns in a house fire.
C. A 12-year-old who fractured his arm in a fight at school.
D. A 12-month-old without any oral intake for the last 12 hours.

Correct answer: A

Rationale: For children under 7 years, most states have laws that mandate reporting certain situations to social services or child protection, such as ingestions of toxic substances, fractures, suspected neglect, or abuse, and burns. In this scenario, the 6-year-old who drank diluted bleach falls under the category that requires a social service consult. The other choices involve injuries or conditions that may warrant medical attention but do not necessarily mandate a social service consult based on age-related legal requirements.

2. The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?

A. Hypocalcemia.
B. Hyponatremia.
C. Hyperkalemia.
D. Hypophosphatemia.

Correct answer: A.

Rationale: The correct answer is Hypocalcemia. In hypoparathyroidism, where the parathyroid glands are not producing sufficient parathyroid hormone, calcium levels become inadequate. This leads to hypocalcemia, characterized by symptoms such as muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia are not typically associated with hypoparathyroidism. While hyperphosphatemia can be seen in hypoparathyroidism due to decreasing calcium levels, the question specifically asks about the primary electrolyte imbalance closely related to hypoparathyroidism, which is hypocalcemia.

3. Which type of hepatitis is transmitted via the fecal-oral route?

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D

Correct answer: A

Rationale: Hepatitis A is the correct answer because it is transmitted via the fecal-oral route, often through contaminated food or water. Hepatitis B is transmitted through exposure to infectious blood, semen, and other body fluids, not through the fecal-oral route. Hepatitis C is transmitted through blood-to-blood contact, not via the fecal-oral route. Hepatitis D occurs only in individuals infected with Hepatitis B. Therefore, the correct choice for the type of hepatitis transmitted via the fecal-oral route is Hepatitis A.

4. After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?

A. Have the client take slow deep breaths in through their mouth and out through their nose.
B. Post signs indicating that oxygen is in use on the client's door and in their room
C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

Correct answer: A

Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.

5. Acyclovir is the drug of choice for:

A. HIV
B. HSV 1 and 2 and VZV
C. CMV
D. influenza A viruses

Correct answer: C

Rationale: Acyclovir (Zovirax) is specifically used to treat infections caused by herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) and varicella-zoster virus (VZV). These include conditions like cold sores, genital herpes, and shingles. Acyclovir works by inhibiting viral DNA replication, leading to the formation of shorter, ineffective DNA chains. It is important to note that acyclovir is not effective against other viruses like HIV, cytomegalovirus (CMV), or influenza A viruses. Therefore, the correct answer is HSV 1 and 2 and VZV.