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. A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?
- A. Transferring the patient to the shower.
- B. Ambulating the patient for the first time.
- C. Taking the patient's breath sounds.
- D. Educating the patient on monitoring fatigue.
Correct answer: A
Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.
3. A healthcare professional is reviewing a patient's current Lithium levels. Which of the following values is outside the therapeutic range?
- A. 1.0 mEq/L
- B. 1.1 mEq/L
- C. 1.2 mEq/L
- D. 1.3 mEq/L
Correct answer: D
Rationale: The correct answer is 1.3 mEq/L. The therapeutic range for Lithium levels typically falls between 0.6 to 1.2 mEq/L. Values below or above this range can lead to suboptimal treatment outcomes or toxicity. Choices A, B, and C are within the therapeutic range of 1.0-1.2 mEq/L, making them appropriate levels for patient care.
4. Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?
- A. mycobacterium tuberculosis
- B. clostridium tetani
- C. staphylococcus aureus
- D. human immunodeficiency virus
Correct answer: C
Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.
5. A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct answer: B
Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.
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