the nurse should see the client with which problem first

NCLEX-PN

NCLEX Question of The Day

1. Which client should the nurse see first?

A. Recurring crushing chest pain
B. Needing an IV for surgery in 5 minutes
C. Needing PCA morphine for pain control post-hysterectomy
D. Waiting to get back to bed after sitting in a chair for 30 minutes

Correct answer: A

Rationale: The client presenting with recurring crushing chest pain should be seen first as this symptom could indicate a myocardial infarction (MI), which is a life-threatening condition requiring immediate attention. Assessing and managing potential cardiac issues take priority over other concerns like needing an IV for surgery, pain control post-hysterectomy, or assistance with mobility. While all clients require care, addressing the chest pain promptly is crucial to ensure the client's safety and well-being.

2. What is the preferred position for a client post liver biopsy procedure?

A. Fowler's
B. Right side
C. Left side
D. Prone

Correct answer: B

Rationale: The correct position for a client post liver biopsy procedure is the right side. Placing the client on the right side helps apply pressure to the liver area, which can help in holding pressure and stopping bleeding. Placing the client on the left side may not be as effective in providing direct pressure on the liver. The prone position is also not ideal for post-liver biopsy care as it does not target the liver area directly. Fowler's position, a semi-sitting position, is not typically recommended post liver biopsy as it does not provide the necessary pressure on the liver site.

3. A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?

A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.

Correct answer: A

Rationale: The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.

4. 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.

5. A 28-year-old male has a diagnosis of AIDS. The patient has had a two-year history of AIDS. The most likely cognitive deficits include which of the following?

A. Disorientation
B. Sensory changes
C. Inability to produce sound
D. Hearing deficits

Correct answer: A

Rationale: In individuals with AIDS, cognitive deficits commonly manifest as confusion and disorientation, making choice A, 'Disorientation,' the correct answer. Sensory changes (choice B) and hearing deficits (choice D) are more related to sensory processing rather than cognitive impairment. 'Inability to produce sound' (choice C) is more indicative of a speech or language deficit rather than a cognitive impairment typically seen in AIDS patients.