NCLEX-PN
NCLEX Question of The Day
1. A child with newly diagnosed leukemia is receiving chemotherapy. Which would be included in his plan of care by the nurse?
- A. Place the child in a negative pressure isolation room
- B. Administer prophylactic IV antibiotics
- C. Avoid high protein food intake
- D. Teach family and visitors handwashing techniques
Correct answer: D
Rationale: The correct answer is to teach family and visitors handwashing techniques. Any client on chemotherapy should have good infection control measures in place, such as handwashing by all who they encounter. Placing the child in a negative pressure isolation room (Choice A) is not necessary unless specifically indicated for a certain condition. Administering prophylactic IV antibiotics (Choice B) may not be part of the standard care plan for a child with leukemia receiving chemotherapy. Avoiding high protein food intake (Choice C) is not directly related to infection control and may not be necessary unless there are specific dietary restrictions.
2. A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?
- A. Request a private room on the GYN floor
- B. Assign her to a private room on the postpartum unit
- C. Discharge her home as soon as her condition is stable
- D. Room her with another client who experienced a pregnancy loss
Correct answer: A
Rationale: In this situation, the most appropriate room assignment for the client who delivered a stillborn infant would be to request a private room on the GYN floor. This client needs privacy to grieve, and having a private space allows for family members to offer support. Placing her in a GYN unit ensures that she is away from the maternity unit's sights and sounds, which could be painful reminders for her. Assigning her to a postpartum unit may cause distress due to the presence of other mothers and newborns. Discharging her home too early may not allow her sufficient time for emotional and physical recovery. Rooming her with another client who experienced a pregnancy loss may not provide the necessary privacy and space she needs for her emotional well-being.
3. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?
- A. Decrease the stimuli and observe frequently
- B. Administer the PRN sedative
- C. Call the physician immediately
- D. Administer the PRN pain medication
Correct answer: D
Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.
4. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?
- A. Nasal congestion
- B. Hiccups
- C. Blood glucose of 150
- D. Muscle spasms
Correct answer: D
Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.
5. The newborn nursery is filled to capacity. Which newborn should the nurse assess first?
- A. A three-hour-old just waking up after a period of sleep
- B. A two-day-old crying loudly
- C. A three-day-old two hours after circumcision
- D. A one-hour-old sucking his fist
Correct answer: A
Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.
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