NCLEX NCLEX-PN
NCLEX Question of The Day
1. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary
Correct answer: No action is necessary
Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (Choice A) or turning the client on her left side (Choice B) is not indicated for early decelerations. Notifying the physician (Choice C) is unnecessary for this type of deceleration.
2. When should rehabilitation services begin?
- A. when the client enters the health care system.
- B. after the client requests rehabilitation services.
- C. after the client’s physical condition stabilizes.
- D. when the client is discharged from the hospital.
Correct answer: when the client enters the health care system.
Rationale: Rehabilitation services should begin when the client enters the health care system to ensure early intervention and optimal outcomes. Initiating rehabilitation early can prevent complications, maximize recovery potential, and improve overall health outcomes. Choice B is incorrect because delaying rehabilitation until the client requests it may result in missed opportunities for timely intervention. Choice C is incorrect as waiting for the client's physical condition to stabilize can lead to unnecessary delays in starting the rehabilitation process, potentially slowing down recovery progress. Choice D is incorrect because starting rehabilitation only after discharge can hinder the recovery process by missing out on crucial early stages of intervention and support.
3. A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?
- A. Heart rate
- B. Peripheral pulses
- C. Blood pressure (BP)
- D. Radial pulse rate
Correct answer: Peripheral pulses
Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.
4. After assigning tasks, what is the nurse’s primary responsibility?
- A. Assigning any tasks that were not completed to the next nursing shift
- B. Documenting completion of each task
- C. Allowing each staff member to make judgments when performing the tasks
- D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task
Correct answer: Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task
Rationale: The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.
5. The greatest time savers when planning client care include all of the following except:
- A. reacting to the crisis of the moment
- B. setting goals
- C. planning
- D. specifying priorities
Correct answer: reacting to the crisis of the moment
Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, specifying priorities, planning tasks, delegating where appropriate, reassessment, and ongoing evaluation of needs. Reacting to the crisis of the moment is not a time-saving strategy in client care planning; it can lead to inefficiency, lack of focus, and potentially missing important priority items. Therefore, the correct answer is 'reacting to the crisis of the moment.' Choices B, C, and D are essential components for effective client care planning as they help in organizing and prioritizing tasks, setting objectives, and ensuring a structured approach to care delivery.
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