NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?
Correct Answer: C
Rationale: Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (
Choice
A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (
Choice
B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (
Choice
D) is not the priority at this stage as assessing for any physical changes is more crucial.
Question 2 of 5
To determine the standards of care for the institution, the nurse should consult?
Correct Answer: C
Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols.
Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.
Question 3 of 5
A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?
Correct Answer: A
Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.
Question 4 of 5
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?
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.
Question 5 of 5
What is the best position for a client immediately following a bilateral salpingooophorectomy?
Correct Answer: C
Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (
Choice
A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (
Choice
B) is typically used for rectal examinations, not for post-surgical management. Flat supine (
Choice
D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.