NCLEX Question of The Day - Nurselytic

Correct Answer: B

Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.

Correct Answer: A

Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process.
Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering.
Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress.
Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.

Correct Answer: C

Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (
Choice
A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (
Choice
B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (
Choice
D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.

Correct Answer: D

Rationale: The correct answer is to teach family and visitors handwashing techniques. Any client on chemotherapy should have good infection control measures in place, such as handwashing by all who they encounter. Placing the child in a negative pressure isolation room (
Choice
A) is not necessary unless specifically indicated for a certain condition. Administering prophylactic IV antibiotics (
Choice
B) may not be part of the standard care plan for a child with leukemia receiving chemotherapy. Avoiding high protein food intake (
Choice
C) is not directly related to infection control and may not be necessary unless there are specific dietary restrictions.

Correct Answer: A

Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4°F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.