NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit?
Correct Answer: C
Rationale: The most important goal for a client admitted to the cardiac rehabilitation unit is the identification of lifestyle changes. This is crucial in promoting cardiovascular health and preventing future cardiac issues. Lifestyle changes such as diet modifications, exercise routines, smoking cessation, and stress management play a significant role in improving the overall cardiovascular well-being of the patient. While reducing anxiety, referring to community resources, and verbalizing energy-conservation techniques are all important aspects of care, identifying lifestyle changes is the primary focus in helping the client achieve long-term cardiovascular wellness.
Question 2 of 5
The emergency department charge nurse is reviewing the clients triaged in the last 30 minutes. The nurse is required to obtain a social service consult from which of the following clients?
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.
Question 3 of 5
A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?
Correct Answer: C
Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.
Question 4 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 5 of 5
The client develops a tension pneumothorax. Assessment is expected to reveal?
Correct Answer: C
Rationale: In a tension pneumothorax, the trachea deviates to the unaffected side due to increased pressure in the affected pleural space, causing respiratory distress. Dyspnea is a hallmark symptom as the lung on the affected side collapses, leading to difficulty in breathing. Sudden hypertension and bradycardia (
Choice
A) are not typical findings of tension pneumothorax. Productive cough with yellow mucus (
Choice
B) is more suggestive of respiratory infections rather than a tension pneumothorax. Sudden development of profuse hemoptysis and weakness (
Choice
D) is not characteristic of tension pneumothorax presentation.