NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?
Correct Answer: A
Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile.
Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions.
Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks.
Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.
Question 2 of 5
After a client has a tubal ligation in the outpatient surgical clinic, what is the priority for the nurse to determine?
Correct Answer: C
Rationale: The priority for the nurse is to ensure the client has a safe way to get home and adequate care after discharge. It is crucial to determine the client's transportation arrangements and availability of care at home to ensure a smooth transition postoperatively. Options A and B, though important, are not immediate priorities compared to the client's safety and well-being after the procedure. Option D is incorrect as spending the night at the surgical center is not typically part of the plan for outpatient surgery.
Question 3 of 5
The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:
Correct Answer: D
Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts.
Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself.
Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression.
Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.
Question 4 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 5 of 5
The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?
Correct Answer: A
Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (
Choice
B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (
Choice
C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (
Choice
D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.