2024 NCLEX Daily Ten Question Practical Exercise 3

1. The nurse is caring for an infant with tetralogy of Fallot when the infant begins crying inconsolably and becomes cyanotic.
Which of the following actions should the nurse take first?

A. Administer intravenous morphine.
B. Notify the health care provider about the episode.
C. Comfort infant and place in the knees-to-chest position.
D. Start an intravenous 0.9% sodium chloride (normal saline) bolus.

Correct Answer: C

Answer Explanation:

Hypercyanotic spells, also known as “tet” spells, are frequently observed in tetralogy of Fallot (TOF) and other heart defects that reduce pulmonary blood flow. These spells occur when oxygen demands rise, such as during stress, crying, or feeding, leading to infundibular spasm. This spasm augments right-to-left shunting of blood away from the pulmonary circulation, resulting in hypoxia. During a hypercyanotic episode, the nurse should implement interventions aimed at increasing oxygenation and pulmonary blood flow, starting with the fastest and least invasive action. This typically involves placing the infant in the knees-to-chest position to increase systemic vascular resistance. Additionally, calming the infant by providing a dim, quiet environment, swaddling, and encouraging caregiver participation can help decrease oxygen demand. Finally, administering oxygen is essential to improve oxygenation.

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2. The nurse is caring for a client who is diagnosed with intussusception and observes that the client is hypotensive, tachycardic, and has a rigid abdomen.
Which of the following actions should the nurse take?

A. Administer lv fluids.
B. Perform gastric lavage.
C. Prepare for an air enema.
D. Prepare for a pyloromyotomy.

Correct Answer: A

Answer Explanation:

Intussusception involves the telescoping of a proximal portion of the intestine into a distal portion, which can lead to decreased circulation, necrosis, and bowel perforation. Manifestations of bowel perforation include abdominal rigidity, irritability, and early signs of shock. In the event of bowel perforation, IV fluids should be promptly administered to replace intravascular fluid loss and improve perfusion. Additionally, IV antibiotics, gastric decompression, and oxygen therapy are initiated until the client undergoes surgery to decontaminate the peritoneum and repair the bowel.

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3. The nurse reviews the initial arterial blood gas Laboratory Results for a client with chronic obstructive pulmonary disease (COPD) who is intubated and receiving mechanical ventilation.
Which of the following interventions does the nurse anticipate to follow up on this client’s acid-base imbalance?

A. Administer lv fluids.
B. Perform gastric lavage.
C. Prepare for an air enema.
D. Prepare for a pyloromyotomy.

Correct Answer: D

Answer Explanation:

Acid-base imbalances are classified as respiratory or metabolic and occur due to shifts in acidic (e.g., carbon dioxide [CO2]) and alkaline (e.g., bicarbonate [HCO3−]) compounds in the body. In arterial blood gas interpretation, a low pH indicates acidosis, while a high PaCO2 suggests a problem with gas exchange in the lungs or a respiratory issue. Respiratory acidosis occurs when there is a buildup of CO2 in the body, often seen in conditions such as chronic obstructive pulmonary disease (COPD), where airflow obstruction leads to inadequate carbon dioxide expulsion. Increasing the respiratory rate helps eliminate excess CO2 from the body, improving ventilation and correcting acidosis.

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4. The nurse is observing an unlicensed assistive personnel (UAP) assisting various clients with activities of daily living (ADLs).
Which of the following actions by the UAP would require the nurse to intervene?

A. Assists a client with diabetes mellitus to soak the feet in warm water
B. Transfers a client with one-sided weakness to the wheelchair using a gait belt
C. Provides a client taking apixaban with a soft-bristled toothbrush to brush the teeth
D. Instructs a client who is 3 days post-mastectomy to brush her hair using the affected arm

Correct Answer: A

Answer Explanation:

When assisting clients with activities of daily living (ADLs), it’s crucial for the nurse to consider any precautions or contraindications. In the case of diabetes mellitus, peripheral neuropathy can lead to decreased sensation in the feet. Consequently, soaking the feet in warm water poses a risk for burns or infection. Due to decreased sensation, the client may not be able to feel if the water is too hot, increasing the risk for burns. Prolonged moisture can also elevate the risk for infection, which is particularly concerning for clients with diabetes due to their delayed wound healing.

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5. The nurse has taught a female client newly diagnosed with chlamydia about sexually transmitted infections (STIs).
Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.

A. “My partner needs to be treated.”
B. “l can’t get an STl from having oral sex.
C. “Not everyone with an STl will have symptoms.
D. “Birth control pills will protect me from another STl.”
E. ” will need to take an antibiotic to treat my chlamydia infection.”
F. “lf l don’t treat my chlamydia, l could have trouble getting pregnant later on.”

Correct Answer: A C E F

Answer Explanation:

Sexually transmitted infections (STIs) (e.g., chlamydia, gonorrhea) are spread through bodily fluids and skin-to-skin contact during sexual activity. STI education focuses on transmission, prevention, treatment, and complications.

Effective teaching: 
Clients treated for STIs should tell recent sex partners so the partner can be tested. This improves awareness of STI exposure and prevents further STI transmission.
Many clients with STIs are asymptomatic. Some symptoms may not appear until days or years after infection.
Chlamydia is a bacterial infection caused by Chlamydia trachomatis that is treated with antibiotics (e.g., doxycycline, azithromycin).
If left untreated, chlamydia can lead to pelvic inflammatory disease (PID), which can cause a build-up of scar tissue, leading to infertility and ectopic pregnancy.

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6. The nurse is screening clients for those at risk for hypokalemia.
At highest risk for hypokalemia is the client who

A. takes enalapril for hypertension
B. has severe vomiting and diarrhea
C. missed a hemodialysis session
D. has a diagnosis of acute adrenal insufficiency

Correct Answer: B

Answer Explanation:

Potassium is essential for proper muscle function, nerve function, and several biochemical processes in the body. Several factors can lead to hypokalemia (low serum potassium). Common causes of hypokalemia include:
Excessive potassium loss from the gastrointestinal tract (e.g., vomiting, diarrhea), which is a major route of potassium excretion.
Renal losses through medications (e.g., loop diuretics) that promote potassium excretion.
Hormonal imbalances, such as hyperaldosteronism (e.g., Conn syndrome), which increases renal potassium excretion.

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7. The nurse in the pediatric unit is preparing to admit a client with pertussis.
The nurse should assign the client to a

A. private room with airborne precautions
B. shared room with a client with pertussis
C. private room with filtered positive pressure airflow
D. shared room with a client with respiratory syncytial virus

Correct Answer: B

Answer Explanation:

Pertussis, or whooping cough, is a highly contagious, acute bacterial respiratory infection that causes coryza (nasal congestion), sneezing, and paroxysmal coughing episodes with an inspiratory “whooping” sound, frequently followed by vomiting. Pertussis is spread by airborne droplets and requires droplet precautions. Although a private room is preferred, clients requiring droplet precautions with the same droplet illness (e.g., pertussis, influenza, rubella) can safely room together since the risk of reinfection is minimal compared to airborne illnesses.

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8. The charge nurse is observing the following client situations.
Which of the following actions by a staff member would require the charge nurse to intervene?

A. A nurse secures a soft wrist restraint to the raised side rail using a quick-release knot.
B. An assistive personnel elevates the head of the bed for a client in ankle restraints.
C. An assistive personnel temporarily removes mitten restraints to assist a client with toileting
D. A nurse places 2 fingers between the restraint and the client’s skin while applying soft wrist restraints.

Correct Answer: A

Answer Explanation:

Restraints can be physical (e.g., mittens, soft extremity) or chemical (e.g., sedatives) and are prescribed to promote safety when less restrictive measures fail (e.g., reorienting). A soft wrist restraint is a cuff placed around the wrist and secured to a non-movable part of the bed frame using a quick-release knot (slipknot) to immobilize the upper extremities. The nurse should avoid securing restraints to the side rails because the restraint will tighten if the rail is lowered.

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9. The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following tasks would be appropriate for the nurse to assign to UAP?

A. Checking the dressing site of a client who underwent closed liver biopsy 3 days ago
B. Sitting at the bedside of an older adult client who is confused and at high risk for falls
C. Demonstrating incentive spirometer use for a client who is 1 day post cholecystectomy
D. Measuring a client’s vital signs 15 minutes after beginning a transfusion of red blood cells

Correct Answer: B

Answer Explanation:

Registered nurses (RNs) should only delegate tasks that satisfy the five rights of delegation and are within the delegatee’s scope of practice. Sitting at the bedside of an older adult client who is confused and at high risk for falls requires ensuring client safety and providing reorientation. This task does not require nursing judgment or critical decision-making, so it is appropriate to delegate to UAP, who are trained to support basic safety measures.

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10. The nurse is planning a staff education program about client confidentiality.
Which of the following scenarios should the nurse include as an example of a violation of client confidentiality?

A. Faxing a report sheet to an inpatient unit prior to transporting the client to the unit.
B. Contacting the local health department to report the client tested positive for chlamydia.
C. Sharing information regarding a mechanically ventilated client with their power of attorney.
D. Asking the client’s family member to translate treatment information to the client’s language.

Correct Answer: D

Answer Explanation:

Nurses must ensure client confidentiality to reduce liability and preserve client dignity. This is done by only sharing relevant information with the appropriate parties, which includes healthcare team members who are directly involved in the client’s care, individuals authorized by the client, or when mandatory reporting is required. If a language barrier exists, the nurse should utilize a professional interpreter. Asking a family member to serve as an interpreter is inappropriate because sharing health information with the family without first obtaining consent violates confidentiality.

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