NCLEX Question of The Day - Nurselytic

Correct Answer: C

Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (
Choice
A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (
Choice
B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (
Choice
D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.

Correct Answer: C

Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems.
Choice A is incorrect as it immediately involves suspension without investigation or support.
Choice B is not the best course of action as it does not involve direct communication with the staff member in question.
Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.

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.

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.

Correct Answer: C

Rationale: Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (
Choice
A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (
Choice
B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (
Choice
D) is not the priority at this stage as assessing for any physical changes is more crucial.