NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
During the admission assessment for a client undergoing breast augmentation, which information should the nurse prioritize reporting to the surgeon before surgery?
Correct Answer: C
Rationale: The most important information for the nurse to report to the surgeon before surgery is the client's statement that her last menstrual period was 8 weeks prior. This information is crucial as the client may be pregnant, and a pregnancy test will need to be completed before administering any anesthetic agents. Reporting this detail ensures patient safety and prevents potential risks associated with anesthesia.
Choices A, B, and D are important aspects of care but do not take precedence over the need to rule out pregnancy before surgery.
Question 2 of 5
The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?
Correct Answer: C
Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.
Question 3 of 5
Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?
Correct Answer: A
Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile.
Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions.
Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks.
Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.
Question 4 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 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.