NCLEX NCLEX-PN
NCLEX Question of The Day
1. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?
- A. Decrease the stimuli and observe frequently
- B. Administer the PRN sedative
- C. Call the physician immediately
- D. Administer the PRN pain medication
Correct answer: D
Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.
2. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?
- A. Left upper quadrant
- B. Left lower quadrant
- C. Right upper quadrant
- D. Right lower quadrant
Correct answer: Right lower quadrant
Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.
3. The client should include all of the following in teaching an obese client about nutritional needs and weight loss except:
- A. knowledge of food and food products
- B. development of a positive mental attitude
- C. adequate exercise
- D. starting a fast weight-loss diet
Correct answer: starting a fast weight-loss diet
Rationale: When educating an obese client about nutritional needs and weight loss, it is crucial to emphasize a holistic approach that involves understanding food and food products, fostering a positive mental attitude, and incorporating adequate exercise. Initiating a fast weight-loss diet is not advisable due to potential health risks and lack of long-term sustainability. Therefore, this option stands out as the exception and should not be part of the client's learning. Choices A, B, and C are essential components of a healthy weight-loss plan and should be included in the client's education.
4. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63 mmHg, HCO3 23, and oxygenation saturation (SaO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?
- A. tuberculosis (TB)
- B. pneumonia
- C. pleural effusion
- D. hypoxia
Correct answer: hypoxia
Rationale: A combined low PO2 and low SaO2 indicate hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low due to hypoxia stimulating hyperventilation, but the given ABG values specifically point to hypoxia as the primary issue.
5. When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. When started, therapy must not be interrupted to prevent viral resistance.
- B. When started, therapy must not be interrupted to prevent opportunistic infection.
- C. Therapy should not be interrupted for one day each month to prevent toxicity.
- D. Therapy should not be interrupted for one week every three months to prevent toxicity.
Correct answer: When started, therapy must not be interrupted to prevent viral resistance.
Rationale: When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness. Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections. Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.
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