NCLEX Question of The Day - Nurselytic

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.

Correct Answer: A

Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself.
Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger.
Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety.
Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.

Correct Answer: C

Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (
Choice
A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (
Choice
B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (
Choice
D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.

Correct Answer: B

Rationale: The correct answer is B: Denial. Individuals with alcohol addiction often deny that they have a drinking problem and may become defensive when confronted about it. This sense of denial can be a significant barrier to seeking treatment. Co-dependency, referred to in choice A, is a relationship dynamic and is not the primary reason for avoiding treatment. Depression, as mentioned in choice C, is a common co-occurring condition with alcohol addiction but is not typically the main factor preventing treatment-seeking. Stigma, as in choice D, can act as a deterrent, but denial of the problem itself is usually the primary obstacle to seeking help.

Correct Answer: D

Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain.
Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.