NCLEX Question of The Day - Nurselytic

Correct Answer: A

Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process.
Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering.
Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress.
Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.

Correct Answer: A

Rationale: The priority nursing action for a laboring client dilated to 6 cm receiving an epidural is continuous monitoring of maternal blood pressure. This is crucial because epidural anesthesia can lead to a precipitous drop in blood pressure, which can be dangerous for both the mother and fetus by reducing cardiac output and placental perfusion. While frequent auscultation of the fetal heart rate is important, it is not the priority in this situation. Administering an IV fluid bolus of at least 500 cc may not be necessary if the client's blood pressure is stable. Monitoring the maternal temperature is also essential but takes precedence over blood pressure monitoring.

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.

Correct Answer: A

Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (
Choice
D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (
Choice
B) may not effectively address the disruptive behavior. Removing the Bible from the client (
Choice
C) without addressing the underlying issue may escalate the situation further.

Correct Answer: C

Rationale: The most important goal for a client admitted to the cardiac rehabilitation unit is the identification of lifestyle changes. This is crucial in promoting cardiovascular health and preventing future cardiac issues. Lifestyle changes such as diet modifications, exercise routines, smoking cessation, and stress management play a significant role in improving the overall cardiovascular well-being of the patient. While reducing anxiety, referring to community resources, and verbalizing energy-conservation techniques are all important aspects of care, identifying lifestyle changes is the primary focus in helping the client achieve long-term cardiovascular wellness.