NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
The nurse is caring for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). In planning the client's care, the nurse should recognize that the child is likely to view this illness as?
Correct Answer: A
Rationale: The correct answer is A: Punishment. Preschool children often see illness as a form of punishment, especially when they are unable to understand the cause of their sickness. This perception is rooted in their limited cognitive abilities and understanding of health concepts.
Choices B, C, and D are incorrect because preschool children are less likely to associate illness with disturbance to body image, rejection from parents, or changes in routine with friends. These options are not developmentally appropriate for how preschoolers typically interpret illness.
Question 2 of 5
While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?
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.
Question 3 of 5
A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?
Correct Answer: A
Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.
Question 4 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.
Question 5 of 5
The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?
Correct Answer: A
Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.