NCLEX-PN
NCLEX Question of The Day
1. 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?
- A. A 6-year-old who drank some diluted bleach.
- B. A 10-year-old who suffered burns in a house fire.
- C. A 12-year-old who fractured his arm in a fight at school.
- D. A 12-month-old without any oral intake for the last 12 hours.
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.
2. What task should the RN perform first?
- A. Changing a burn dressing that is scheduled every four hours.
- B. Doing pinsite care on a client in skeletal traction ordered TID.
- C. Teaching a newly diagnosed diabetic about diet and exercise.
- D. Assessing a newly admitted client.
Correct answer: D
Rationale: The correct answer is to assess a newly admitted client first. When a client is newly admitted, it is crucial to perform an assessment promptly. The initial assessment and establishment of a care plan should be completed within a specific timeframe to ensure the client's needs are met effectively. Choices A, B, and C involve important tasks but should be prioritized after the initial assessment of the newly admitted client to ensure timely and appropriate care delivery. Changing a burn dressing (Choice A) and doing pinsite care on a client in skeletal traction (Choice B) are time-sensitive tasks but can be safely delayed briefly to conduct the initial assessment. Teaching a newly diagnosed diabetic about diet and exercise (Choice C) is important for the client's long-term care but can be scheduled after the immediate needs assessment of the newly admitted client.
3. When auscultating breath sounds, the nurse auscultates over the following locations:
- A. Trachea and lateral areas of thoracic cage
- B. Anterior and posterior aspects of all lung fields
- C. The mid section as well as the lateral section of the lungs
- D. The mid-clavicular to mid-axillary lines comparing side to side
Correct answer: B
Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.
4. The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?
- A. Set limits and send the client to their room.
- B. Explain to the client that not all people are Christians.
- C. Remove the Bible from the client and explain that they are not "Jesus"?.
- D. Ask the client to share with the group how he knows that he is "Jesus"?.
Correct answer: A
Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.
5. Which client should be seen first by the Emergency Department nurse?
- A. A six-year-old with a femur fracture.
- B. A two-year-old with a fever of 102 degrees F.
- C. A three-year-old with wheezes in the right lower lobe.
- D. A two-year-old whose gastrostomy tube came out.
Correct answer: C
Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.
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