NCLEX Daily Ten Question Practical Exercise 5

6. The nurse has attended a staff education program about healthcare workplace safety. It would indicate a correct understanding of the teaching if the nurse is observed

A. recapping a medication syringe before placing it in the sharps container
B. carrying blood-stained sheets down the hallway to the unit’s biohazard closet
C. unplugging the client’s IV pump by pulling the power cord away from the wall
D. instructing visitors to maintain a 6-foot (1.8 meters) distance from client with internal radioactive implant

Correct Answer: D

Answer Explanation:

Internal radiation (i.e., brachytherapy) involves placing a radioactive implant close to a tumor to treat cancer, which minimizes exposure to healthy tissue. Clients with implants in place are considered radioactive. The nurse should monitor exposure time and wear a shield to limit radiation exposure. Additionally, the nurse should ensure visitors maintain a 6-foot distance from the client to minimize exposure.

7. A client with a new diagnosis of congestive heart failure (CHF) is being admitted to the telemetry unit. Which staff member is most appropriate to assign to complete the admission assessment and develop the client’s plan of care?

A. A registered nurse (RN) who has worked on the telemetry unit for 1 year
B. A registered nurse (RN) who has been floated to the telemetry unit from the neuroscience intensive care unit (ICU)
C. A licensed practical nurse (LPN) who has worked on the telemetry unit for 10 years and has taken a course on CHF management
D. A registered nurse (RN) who has worked on the telemetry unit for 3 months and has just completed the organization’s new-hire training program

Correct Answer: A

Answer Explanation:

When making assignments, the nursing staff’s scope of practice, skills, and experience must be considered. For a client with a new diagnosis, substantial client education on disease management will be needed. Therefore, the most appropriate nurse to assign to this client is the RN with 1 year of telemetry experience. This nurse has experience working with cardiac conditions and has specialized knowledge of congestive heart failure (CHF).

8. The nurse is caring for an alert and oriented 32-year-old client with terminal cancer who states, “If something happens to me, don’t resuscitate me. Just let me go.” Which of the following actions should the nurse take?

A. Update the client’s health record to ensure the client’s decision is honored.
B. Contact the health care provider to notify them of the client’s updated decision.
C. Contact the client’s power of attorney to discuss updating the client’s resuscitation status.
D. Explain to the client that advance directives are permanent and to wait to make a decision.

Correct Answer: B

Answer Explanation:

Advance directives are documents that outline a client’s medical treatment decisions. These directives typically include a client’s code status decision. If a client wants to modify advance directives, the nurse should immediately notify the health care provider. The health care provider is responsible for writing a do-not-resuscitate (DNR) order. A DNR order is a health care provider’s directive stating a client’s choice to decline CPR during cardiac or respiratory arrest. It does not exclude other treatments such as medications or nutrition.

9. The nurse has been made aware of the following client situations. Which of the following nursing actions should recieve the highest priority?

A. Administer labetalol that was due 1 hour ago to a client with hypertension.
B. Comfort a client who is crying and upset following a diagnosis of a terminal illness.
C. Assess the client who reports mild burning with initial urination following indwelling catheter removal.
D. Provide discharge education to a frustrated client who has been requesting discharge paperwork for 3 hours.

Correct Answer: A

Answer Explanation:

The nurse should prioritize clients experiencing complications or those that are unstable. However, if all clients are stable, the nurse should prioritize tasks that can place the client at risk for immediate complications. Delaying administration of medications that help maintain hemodynamic stability and adequate circulation can have immediate health implications. The nurse should first administer an overdue antihypertensive medication (e.g., labetalol, lisinopril). Delaying administration could worsen hypertension and potentially cause life-threatening complications (e.g., stroke, myocardial infarction).

10. The nurse is caring for a newborn who is 3 hours old and has bluish mucous membranes, a respiratory rate of 70 breaths per min, an axillary temperature of 97.7 F (36.5 C), and mild intercostal retractions. The newborn is continuously grunting and has a weak cry. Which of the following actions should the nurse take?

A. Place the newborn skin to skin.
B. Apply oxygen via nasal cannula.
C. Document the findings as acrocyanosis.
D. Initiate continuous positive airway pressure.

Correct Answer: D

Answer Explanation:

Respiratory distress syndrome (RDS) in newborns can occur from insufficient surfactant, excess lung fluid not adequately cleared after birth, or aspiration (e.g., meconium-stained amniotic fluid). Grunting, retractions, nasal flaring, central cyanosis, tachypnea, and apnea >20 seconds indicate increased work of breathing, necessitating prompt intervention to prevent respiratory failure. Initiating continuous positive airway pressure (CPAP) is necessary for a newborn experiencing RDS to maintain lung function and improve oxygenation. CPAP provides constant positive pressure to the airways, keeping alveoli open and reducing the work of breathing.