NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
Correct Answer: B
Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.
Question 2 of 5
Which action by a graduate nurse would require the charge nurse to intervene?
Correct Answer: A
Rationale: The correct answer is walking in the hallway outside the operating room without a hair covering. In healthcare settings, it is crucial to adhere to infection control measures, which include wearing appropriate attire to prevent the spread of pathogens. Walking in the hallway outside the operating room without a hair covering violates these infection control protocols, necessitating immediate intervention by the charge nurse.
Choices B and C are incorrect because putting on surgical attire before entering the operating room and wearing a surgical mask into the holding area are both standard practices that promote patient safety and infection control.
Choice D is also incorrect as wearing scrubs from home into the nursing station, while not ideal, is not a violation that warrants immediate intervention compared to breaching infection control protocols near sensitive areas like the operating room.
Question 3 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 4 of 5
In the Emergency Department (ED), which client should the nurse see first?
Correct Answer: C
Rationale: In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis.
Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening.
Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency.
Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.
Question 5 of 5
For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?
Correct Answer: A
Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat.
To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.