NCLEX-PN
NCLEX Question of The Day
1. The charge nurse is observing a student nurse caring for a 4-month-old infant in isolation diagnosed with RSV. Which of the following would indicate to the charge nurse that the student nurse needs further instruction on isolation standards?
- A. Donning clean gloves each time she goes in the room.
- B. Wearing a clean mask each time she goes in the room.
- C. Labeling the door so staff will use Airborne Precautions.
- D. Wearing a gown when she goes in the room to administer medication.
Correct answer: A
Rationale: The correct answer is 'Donning clean gloves each time she goes in the room.' Sterile gloves are not necessary for standard isolation precautions; clean gloves are sufficient. The student nurse should be instructed to use clean gloves to reduce the risk of spreading infections. Wearing a clean mask each time she goes in the room is a good practice to prevent the spread of respiratory infections like RSV. Labeling the door for Airborne Precautions is appropriate for RSV. Wearing a gown when entering the room to administer medication helps prevent the transmission of infectious agents.
2. The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. He asks to clarify what type of diet he is to follow. Which diet is best for clients with ulcerative colitis?
- A. High vitamin
- B. High calorie
- C. Low sugar
- D. Low fiber
Correct answer: D
Rationale: The correct answer is 'Low fiber.' Clients with ulcerative colitis should follow a low-residue diet, which means consuming low fiber to reduce the frequency and volume of stools, helping to alleviate symptoms such as abdominal pain and diarrhea. High fiber diets can worsen the condition by stimulating bowel movements. Choice A, 'High vitamin,' is incorrect as the focus is on fiber content rather than vitamins. Choice B, 'High calorie,' is not specifically recommended for ulcerative colitis and may not address the symptoms effectively. Choice C, 'Low sugar,' does not directly address the dietary needs of clients with ulcerative colitis as the issue is more related to fiber intake than sugar consumption.
3. The client is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do?
- A. Allow the client to honestly discuss her fears and encourage her to talk more with her physician.
- B. Tell her the good things that she will be able to do without more children and encourage her to make a list of positive things.
- C. Explain to the client that her ovaries can be frozen for egg harvesting at a later time and she can find a surrogate.
- D. Advise the client to put off having the surgery until she is sure that she wants to undergo the procedure and notify the surgeon of the decision.
Correct answer: A
Rationale: In this situation, the most appropriate action for the nurse is to allow the client to express her fears and concerns openly. By encouraging her to talk more with her physician, the nurse is promoting effective communication and ensuring that the client receives adequate information to make an informed decision. Option A is correct because it acknowledges the client's emotions and empowers her to seek clarification and support from her healthcare provider. Options B and C do not address the client's emotional needs or provide a solution to her concerns regarding fertility. Option D is not appropriate as it does not prioritize the client's emotional well-being and delays necessary medical treatment for advanced cervical cancer.
4. The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?
- A. Keep NPO and hold medication.
- B. Hold sedatives, but allow the client to have breakfast and give other medicines.
- C. Administer medications, but hold anticonvulsants.
- D. Give additional fluids and some caffeine prior to the test.
Correct answer: C
Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.
5. Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?
- A. Place the child in a private room
- B. Gowns and masks must be worn by all personnel in the child's room
- C. Visitors are restricted to parents only
- D. Hand washing is required by all personnel and visitors having contact with the child
Correct answer: B
Rationale: The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (Choice A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (Choice C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (Choice D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.
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