NCLEX Daily Ten Question Practical Exercise 6

6. The nurse is caring for a client who reports vomiting for the last week. Which of the following findings would be a priority for the nurse to report to the primary health care provider?

A. Client has no appetite.
B. Dizziness upon standing
C. Urine output of 20 mL/hr
D. Temperature of 100.2 F (37.9 C)

Correct Answer: C

Answer Explanation:

Circulating intravascular volume is decreased with prolonged vomiting and poor fluid intake. Low intravascular volume causes decreased renal blood flow and prerenal azotemia (i.e., increased blood urea nitrogen [BUN] and creatinine).
Oliguria, or low urine output (i.e., <30 mL/hr), indicates inadequate renal perfusion and suggests that acute kidney injury (AKI) is developing. Without prompt medical evaluation and treatment, AKI can quickly progress to permanent renal damage.
The nurse should anticipate administering IV fluids to improve renal perfusion along with monitoring kidney function for improvement or worsening (e.g., BUN, creatinine).

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7. The nurse is caring for a client who sustained burn injuries to the neck, chest, and around the entire left leg. The nurse observes the client is restless, has a hoarse voice, and has decreased pedal pulses in the left foot. Which of the following actions should the nurse take first?

A. Provide a dose of fentanyl 25 mg via IV push.
B. Prepare the client for an escharotomy of the left leg.
C. Start an IV bolus of warmed lactated Ringer’s solution.
D. Administer high-flow oxygen via a non-rebreather mask.

Correct Answer: D

Answer Explanation:

Airway management is a priority for clients with suspected inhalation injuries (e.g., hoarse voice, restlessness, singed nasal hair). Clients with large burns or burns to the face or neck are at high risk for life-threatening airway inflammation due to smoke and heat inhalation. The nurse should first administer high-flow oxygen via a non-rebreather mask. A non-rebreather mask rapidly delivers high-flow oxygen to improve oxygenation until the client is stabilized. Clients with suspected inhalation injuries are often prophylactically intubated to maintain airway patency even if they do not demonstrate signs of respiratory distress.

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8. The nurse is administering a vaccine to an 18-month-old child. Which of the following statements by the nurse demonstrates appropriate communication with a toddler-aged client?

A. “We are all done! Would you like a yellow or orange bandage?”
B. “Don’t cry! I promise that this won’t hurt at all. It is just a little poke.”
C. “I am going to use an antibacterial wipe to kill all of the bacteria on your skin!”
D. “Imagine you’re an astronaut getting a special shot to help you on your space mission!”

Correct Answer: A

Answer Explanation:

Medical procedures, like vaccinations, can be painful and stressful for young clients (e.g., toddlers [1-3 years old]). Toddlers think literally and desire independence and control over their surroundings. This is expected in Erikson’s psychosocial development stage, autonomy vs. shame and doubt. Offering choices empowers toddlers and helps them feel in control of the situation, reducing anxiety. Allowing the toddler to complete age-appropriate tasks independently should also be encouraged.

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9. The nurse is caring for a 17-year-old client who was brought to the emergency department by his mother after sustaining head and neck trauma. Which of the following actions should the nurse take first?

A. Immobilize the cervical spine.
B. Provide supplemental oxygen.
C. Obtain a thorough history of injury.
D. Complete a neurological assessment.

Correct Answer: A

Answer Explanation:

The nurse should prioritize immediately stabilizing the neck in a neutral position until further assessment is completed. Immobilizing the cervical spine prevents movements that can harm the spinal cord and cause permanent loss of sensory and motor function below the level of injury. Rigid cervical collars prevent flexion, extension, and rotation of the spine with the goal of minimizing further injury to the spinal cord. Additional interventions can be completed once the cervical spine is immobilized.

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10. The nurse is educating a client with insomnia about the importance of sleep hygiene. Which client statements indicate that the teaching was effective? Select all that apply.

A. “I shouldn’t lift weights late in the evening.”
B. “A light snack before bed is okay if I’m feeling hungry.”
C. “When I read at night, I should sit in my chair and not in my bed.”
D. “I can take diphenhydramine every night to ensure quality sleep.”
E. “I should go to bed by 9 p.m. and lay there to help make myself sleepy.”

Correct Answer: A B C

Answer Explanation:

Sleep hygiene refers to positive habits that promote consistent, good-quality sleep. Teaching was effective if the client understands the following teaching points:
Adequate physical activity is important for maintaining good sleep quality; however, exercising within 3 hours of bedtime can interfere with the ability to fall asleep.
Eating a light snack before sleep prevents hunger, which can cause insomnia. Clients should avoid large meals before bed as digestion can last several hours, disrupting sleep.
The bed should only be used for sleep and sexual activity to promote restfulness. Clients should avoid reading and watching television in the bedroom as this associates wakefulness with being in bed.

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