NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
Correct Answer: D
Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (
Choice
A) or turning the client on her left side (
Choice
B) is not indicated for early decelerations. Notifying the physician (
Choice
C) is unnecessary for this type of deceleration.
Question 2 of 5
The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:
Correct Answer: D
Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts.
Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself.
Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression.
Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.
Question 3 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 4 of 5
One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
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.
Question 5 of 5
Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?
Correct Answer: B
Rationale: The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (
Choice
A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (
Choice
C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (
Choice
D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.