the nurse has just received a change of shift report which client should the nurse assess irst
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. The nurse has just received a change-of-shift report. Which client should the nurse assess first?

Correct answer: A

Rationale: The nurse should assess the client 2 hours post-lobectomy with 150cc drainage first because postoperative assessments are crucial during the immediate postoperative period. This client may be at higher risk for complications, such as bleeding or infection, requiring immediate attention. Clients in choices B, C, and D are relatively stable and can be assessed after the immediate postoperative client has been evaluated.

2. Post thyroidectomy the nurse assesses for complications by performing which of the following assessments?

Correct answer: B

Rationale: The correct answer is Chvostek's. A positive Chvostek's and Trousseau's sign is indicative of tetany, which is associated with low calcium levels. This can occur if parathyroid glands are accidentally removed during thyroidectomy. Accu-Chek is a brand of blood glucose monitor used for checking blood sugar levels and is not relevant in this context. Ballottement is a technique used in physical examination to assess for fluid in the body, typically in the abdomen or joints. Ice water colonic is not a standard medical assessment and is not relevant to post-thyroidectomy complications.

3. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.

4. A client who is newly diagnosed with Parkinson's disease and beginning medication therapy asks the nurse, 'How soon will I see improvement?' The nurse's best response is:

Correct answer: D

Rationale: In the case of Parkinson's disease, improvement in symptoms may take several weeks of therapy to become noticeable. Therefore, the correct answer is to inform the client that it might take several weeks before they notice improvement. Choice A acknowledges individual variability but does not provide a specific timeframe, making it less reassuring. Choice B suggests deferring the question to the physician, which is not the most supportive response. Choice C is incorrect because improvement in Parkinson's disease symptoms typically does not occur within a few days.

5. The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?

Correct answer: D

Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.

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