NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?
Correct Answer: D
Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (
Choice
A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (
Choice
B) may delay necessary treatment. Increasing IV fluids (
Choice
C) is unlikely to address the urgent vascular issue indicated by the symptoms described.
Question 2 of 5
Which intervention should the nurse stop the nursing assistant from performing?
Correct Answer: C
Rationale: Placing traction weights on the bed to transfer the client to X-ray is an intervention that the nurse should stop the nursing assistant from performing. Traction should never be relieved without a doctor's order as it can result in muscle spasm and tissue damage. The other choices are appropriate nursing interventions and should not be stopped. Emptying the Jackson-Pratt drainage, performing passive range of motion, and collecting the first urine void for a 24-hour urine test are all within the scope of practice and do not pose immediate risks to the client's well-being.
Question 3 of 5
While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?
Correct Answer: C
Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (
Choice
A) might delay the evaluation and management of the mole. Contacting the physician via telephone (
Choice
B) may not provide a documented record of the observation. Removing the mole without proper evaluation (
Choice
D) could be dangerous and is not within the nurse's scope of practice.
Question 4 of 5
For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?
Correct Answer: A
Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat.
To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.
Question 5 of 5
The newborn nursery is filled to capacity. Which newborn should the nurse assess first?
Correct Answer: A
Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first.
Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress.
Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.