NCLEX NCLEX-PN
Kaplan NCLEX Question of The Day
1. What is the preferred position for a client post liver biopsy procedure?
- A. Fowler's
- B. Right side
- C. Left side
- D. Prone
Correct answer: Right side
Rationale: The correct position for a client post liver biopsy procedure is the right side. Placing the client on the right side helps apply pressure to the liver area, which can help in holding pressure and stopping bleeding. Placing the client on the left side may not be as effective in providing direct pressure on the liver. The prone position is also not ideal for post-liver biopsy care as it does not target the liver area directly. Fowler's position, a semi-sitting position, is not typically recommended post liver biopsy as it does not provide the necessary pressure on the liver site.
2. The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?
- A. There is less chance of forgetting the medication if taken in the morning.
- B. There will be less fluid retention if taken in the morning.
- C. Prednisone is absorbed best with the breakfast meal.
- D. Morning administration mimics the body’s natural secretion of corticosteroid.
Correct answer: Morning administration mimics the body’s natural secretion of corticosteroid.
Rationale: Taking corticosteroids in the morning mimics the body’s natural release of cortisol, which follows a diurnal pattern with higher levels in the morning. This timing helps regulate the body's inflammatory response and minimizes potential side effects. Answer A is not the primary reason for morning dosing, as adherence concerns can be addressed through other means. Answer B is incorrect since fluid retention is not influenced by the timing of prednisone administration. Answer C is also incorrect as prednisone absorption is not significantly affected by whether it is taken with breakfast or not.
3. 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.
4. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?
- A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
- B. Ask a medical assistant.
- C. Call the nurse in charge of the day shift.
- D. Ask the police officers who brought the client to the center.
Correct answer: Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.
5. A nurse is assisting with developing a plan of care for an older client to help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan?
- A. Encouraging bedtime reading or listening to music
- B. Encouraging at least one daytime nap
- C. Discouraging the use of a nightlight at bedtime
- D. Discouraging social interaction, particularly at bedtime
Correct answer: A: Encouraging bedtime reading or listening to music
Rationale: To help maintain an adequate sleep pattern in older clients, it is essential to include activities that promote relaxation and a conducive sleep environment. Encouraging bedtime reading or listening to music can help the client unwind and prepare for sleep. Daytime naps should be discouraged to ensure a better nighttime sleep. Social interaction, especially positive interactions, can be beneficial and should not be discouraged. The use of a nightlight can create a safe and comfortable environment for the client, so it should not be discouraged unless specifically contraindicated.
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