NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?
Correct Answer: B
Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.
Question 2 of 5
Which reported symptom would indicate a client with Addison's disease has received too much fludrocortisone (Florinef) replacement?
Correct Answer: B
Rationale: Fludrocortisone (Florinef) replacement in Addison's disease involves mimicking aldosterone to retain sodium and water. This retention can lead to weight gain due to increased fluid retention. Rapid weight gain, such as 6 pounds in one week, is a concerning sign of excessive fluid retention, indicating a potential overdose of fludrocortisone.
Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not specific symptoms of excessive fludrocortisone replacement in Addison's disease.
Question 3 of 5
When auscultating breath sounds, the nurse auscultates over the following locations:
Correct Answer: B
Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs.
Choices A, C, and D are incorrect.
Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields.
Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section).
Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.
Question 4 of 5
Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
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.
Question 5 of 5
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
Correct Answer: D
Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (
Choice
A) or turning the client on her left side (
Choice
B) is not indicated for early decelerations. Notifying the physician (
Choice
C) is unnecessary for this type of deceleration.