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NCLEX Question of The Day
1. One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
- A. cor pulmonale.
- B. atelectasis.
- C. pulmonary embolism.
- D. cardiac tamponade.
Correct answer: atelectasis.
Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.
2. When a 17-year-old client arrives at the clinic suspecting a sexually transmitted infection, what information does the nurse provide concerning informed consent?
- A. She will need to sign an informed consent form.
- B. Her mother or father will need to be contacted for permission to treat her.
- C. A consent form is not needed if the problem is a sexually transmitted infection.
- D. Anyone over the age of 18 years may sign a consent form for her treatment.
Correct answer: She will need to sign an informed consent form.
Rationale: Informed consent is a person’s agreement to allow something, such as a treatment, to be performed. A consent form is required even if the problem is a sexually transmitted infection. If the client is a minor, the minor may sign the informed consent form in specific situations, including seeking treatment for a sexually transmitted infection. In this case, the 17-year-old client is seeking examination and treatment for a sexually transmitted infection, so she will need to sign the informed consent form. Contacting her parents for permission is not required in this situation. Choice C is incorrect because a consent form is necessary regardless of the medical issue. Choice D is incorrect because the individual's age is not the determining factor; rather, it is the nature of the medical service being sought that dictates the need for informed consent.
3. The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 30 minutes if your NG residual is below 50 mL.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct answer: You can lie down in 1 hour.
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications. Therefore, the most appropriate response is to advise the client to lie down in 1 hour. Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes. Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness. Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.
4. A client states, “I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?” The nurse should respond with which of the following statements?
- A. Sleep at least 6–8 hours per night.
- B. Practice monthly self-breast examinations.
- C. Reduce stress.
- D. All of the above.
Correct answer: All of the above.
Rationale: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. Stress can have a physiological response that decreases the immune response and increases the risk of disease. Therefore, all the options mentioned are important for cancer prevention, making 'All of the above' the correct response.
5. Which nursing diagnosis has the highest priority for a client with insomnia?
- A. Ineffective breathing pattern
- B. Disturbed sensory perception
- C. Ineffective coping
- D. Sleep deprivation
Correct answer: A: Ineffective breathing pattern
Rationale: The correct answer is 'A: Ineffective breathing pattern.' When a client presents with insomnia, assessing for underlying causes is crucial. Sleep apnea, an airway issue, may be a contributing factor to the client's insomnia, making 'Ineffective breathing pattern' the priority. 'Disturbed sensory perception' focuses on alterations in touch, taste, or vision, which are not directly related to insomnia. 'Ineffective coping' addresses a client's inability to manage stress, which, although important, is not the priority in this case. 'Sleep deprivation' is a consequence of insomnia rather than a primary nursing diagnosis.
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