NCLEX Question of The Day - Nurselytic

Correct Answer: A

Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction.
Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions.
Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress.
Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.

Correct Answer: A

Rationale: The correct answer is reminding the client to apply the CPAP at bedtime. This task can be safely delegated to a nursing assistant as it involves a simple and routine reminder. Option B, obtaining oxygen saturation levels, requires a higher level of training and interpretation of results, making it more appropriate for an RN. Option C, teaching the client how to turn on the CPAP machine, involves educating the client and ensuring proper use of medical equipment, which is within the RN's scope of practice. Option D, assessing for fatigue or depression, requires a comprehensive evaluation that involves interpreting symptoms and identifying underlying causes, making it more suitable for an RN to address.

Correct Answer: A

Rationale: The correct diet for a client with chronic cirrhosis is high calorie, low protein. Cirrhosis can lead to impaired protein metabolism, making it essential to limit protein intake. High-calorie foods help meet the client's energy needs.
Choice B (High protein, high calorie) is incorrect because high protein intake can worsen hepatic encephalopathy.
Choice C (Low fat, low sodium) is not the most appropriate diet for cirrhosis as the focus should be on calories and protein.
Choice D (High calorie, low sodium) does not address the need to restrict protein intake, which is crucial in cirrhosis.

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.

Correct Answer: C

Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems.
Choice A is incorrect as it immediately involves suspension without investigation or support.
Choice B is not the best course of action as it does not involve direct communication with the staff member in question.
Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.