a client with a history of peptic ulcer disease arrives to the emergency department complaining of weakness and states that he vomited a lot of dark c
Logo

Nursing Elites

NCLEX-PN

NCLEX Question of The Day

1. A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?

Correct answer: A

Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.

2. A healthcare professional is assessing a patient's right lower extremity. The extremity is warm to touch, red, and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?

Correct answer: D

Rationale: The patient's presentation of a warm, red, swollen extremity with a low fever is indicative of cellulitis, which is inflammation of cellular tissue. Cellulitis is commonly associated with these symptoms due to a bacterial infection in the skin and underlying tissues. Herpes (Choice A) is a viral infection that typically presents with grouped vesicles, not the warm, red, swollen presentation seen in cellulitis. Scleroderma (Choice B) is a chronic autoimmune condition affecting the skin and connective tissue, presenting differently from the acute symptoms of cellulitis. Dermatitis (Choice C) refers to skin inflammation, which does not typically present with the described symptoms of warmth, redness, swelling, and low fever observed in cellulitis.

3. The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse's best response?

Correct answer: A

Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.

4. When a person using over-the-counter nasal decongestant drops experiences unrelieved and worsening nasal congestion, what should be instructed?

Correct answer: B

Rationale: When a person using over-the-counter nasal decongestant drops experiences unrelieved and worsening nasal congestion, it is crucial to discontinue the medication for a few weeks. Prolonged use of decongestant drops can lead to rebound congestion, which is relieved by stopping the medication for a period of time. Nasal congestion occurs due to various factors like infection, inflammation, or allergy, leading to swelling of the nasal cavity. Nasal decongestants work by stimulating alpha-adrenergic receptors, causing vasoconstriction and shrinking of nasal mucous membranes. However, prolonged use can result in vasodilation, worsening nasal congestion. Switching to a stronger dose of the same medication is not recommended as it can exacerbate the issue. Continuing the same medication more frequently or using a combination of medications are also not advised and may lead to side effects. Educating individuals on proper decongestant use and potential risks of prolonged usage is essential, especially for those with specific health conditions.

5. During a home health visit, a nurse consults with a male patient diagnosed with CAD and COPD who is taking Ventolin, Azmacort, Aspirin, and Theophylline and complains of upset stomach, nausea, and discomfort. What should the nurse do?

Correct answer: A

Rationale: The correct answer is to contact the patient's physician immediately. The patient's symptoms of upset stomach, nausea, and discomfort could indicate theophylline toxicity, a potentially serious condition. It is crucial to consult the physician promptly to address this issue. Option B, recommending the patient lie on his right side, is incorrect as it does not address the potential theophylline toxicity and is not a priority. Option C, advising the patient to schedule a doctor's visit the next day, is inappropriate as the symptoms may indicate an urgent concern. Option D, suggesting holding the drug Azmacort, is incorrect as it does not address the potential theophylline toxicity and should not be done without consulting the physician first.

Similar Questions

A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?
Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit?
Support systems during the grieving process include all of the following except:
After experiencing a left frontal lobe CVA, a fifty-five-year-old man is being monitored by a nurse. The patient's family is not present in the room. What should the nurse observe most closely for?
A mother who has never breastfed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses