NCLEX-RN Daily Ten Question Practical Exercise 57

Welcome to our NCLEX-RN Daily Ten Practice! This practice is designed to help you solidify your knowledge, improve your skills, and prepare thoroughly for the NCLEX-RN exam. With ten questions to tackle each day, you’ll have the opportunity to review a broad range of subjects covered in the NCLEX-RN exam.

 

1. In a busy urban emergency department during a holiday weekend, a triage nurse is faced with six clients arriving simultaneously, each presenting with distinct symptoms. The waiting room is crowded, and the nurse is aware that the ER is currently short-staffed. Given the symptoms, potential severity of each case, and the current ER situation, which client should the triage nurse prioritize to be seen first?

Correct Answer: B

Answer Explanation:

This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs has no nerve fibers so the client will not be aware of swelling.

2. You’re a pediatric nurse working with a family who has recently adopted a 2-year-old child named Mia. This is the family’s first time adopting, and they are particularly concerned about ensuring they provide the right environment for her developmental needs. Mia is an active toddler who loves exploring but has had minor falls. During your nursing education session, you emphasized the importance of balancing safety, exploration, and skill development at this stage of Mia’s life. Which of the following statements made by Mia’s mother indicates that she has a clear understanding of her daughter’s developmental needs at this age?

Correct Answer: C

Answer Explanation:

Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child must use motor skills to explore the environment and develop autonomy.

Option A: The statement in Option A is correct but pertains to the risks associated with a toddler.
Option B: Setting limits on a toddler may cause frustration instead of independence.
Option D: Controlling the child may harm her development as toddlers should develop autonomy at this stage.

3. In a specialized medical-surgical unit, you’re assigned to care for Mr. Johnson, a 72-year-old male who recently suffered a cerebrovascular accident (stroke) that has led to dysphagia. He is being temporarily nourished through a nasogastric (NG) feeding tube. His current medications include anticoagulants, and he has a history of peptic ulcer disease. Given the patient’s complex medical condition, what is the most important action for the nurse to take before administering an enteral feeding via the nasogastric feeding tube?

Correct Answer: A

Answer Explanation:

Proper placement of the tube prevents aspiration and entrance of food content into the lungs. Ensuring the correct placement of the NG tube is critical to prevent complications such as aspiration, which can be life-threatening, especially given Mr. Johnson’s history of stroke and anticoagulant use. The definitive way to ascertain the position of the nasogastric tube is through visualization by an x-ray. Another method is to aspirate stomach contents and check their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm it is placed in the stomach.

Option B: It is also important to check that the feeding solution matches the dietary order to ensure the client gets proper nutrition.
Option C: Aspirating the gastric contents is one of the methods used to determine the last feeding amount in the stomach, but it is not the most important action the nurse should take.
Option D: Keep it at room temperature so it will not upset the stomach.

4. You are a nurse in the cardiac care unit caring for Mrs. Thompson, a 62-year-old female with a history of chronic kidney disease and hypertension. She has been admitted for acute heart failure and has a serum potassium level of 3.5 mEq/L, on the lower end of the normal range (3.5-5.0 mEq/L). Considering her clinical history and current condition, she is placed on a cardiac monitor and starts receiving an infusion of 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. While monitoring her EKG, which of the following patterns should prompt you to discontinue the potassium infusion immediately?

Correct Answer: C

Answer Explanation:

Tall peaked “T” waves are a classic sign of hyperkalemia. Given Mrs. Thompson’s chronic kidney disease and acute heart failure, continuing to infuse potassium with this EKG finding could be dangerous. The infusion should be discontinued immediately.

Option A: Narrow QRS complex indicates fast cardiac rhythms (generally more than 100 beats/min) with a QRS duration of 100 ms or less.
Option B: A short PR interval (<120 ms) is seen with preexcitation syndromes and AV nodal (junctional) rhythm.
Option D: Prominent U waves are characteristic of hypokalemia.

5. While working in the pediatric oncology ward, Nurse Ramirez manages care for Leo, a 4-year-old boy newly diagnosed with rhabdomyosarcoma. Leo’s parents are anxious, as they’ve been reading extensively online and are overwhelmed with information. They express concerns about potential metastasis and how the cancer may affect Leo’s overall function. Given the primary site of rhabdomyosarcoma, Nurse Ramirez should emphasize monitoring the function of which area of the body and educate the family about its relevance.

Correct Answer: A

Answer Explanation:

Rhabdomyosarcoma is the most common children’s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. Symptoms of rhabdomyosarcoma include if the cancer is in the head or neck area, sudden bulging or swelling of the eyes, conjunctival chemosis, and headache. It can also affect the urinary or reproductive system. Its common site of metastasis is the lung. Leo’s muscle strength, function, and any pain in areas of striated muscles should be continuously assessed. Educating the family about the origin of this cancer can help them understand the primary areas of concern.

Option B: The cerebellum is not affected in rhabdomyosarcoma.
Option C: The kidneys are not directly affected by the disease.
Option D: Bones are not directly affected by the disease.

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