NCLEX RN

Correct Answers:

A. Institute droplet precautions

B. Monitor for signs of airway obstruction

C. Offer small amounts of fluids frequently

Explanation (each correct option in full):

A. Institute droplet precautions

Pertussis spreads via large respiratory droplets from coughing/sneezing. A surgical mask on entry, a private room if available, and masking the child during transport reduce transmission. Maintain droplet precautions until at least 5 days after starting an appropriate macrolide antibiotic (or 21 days from cough onset if not treated). Standard and respiratory hygiene measures (hand hygiene, covering cough) are essential.

B. Monitor for signs of airway obstruction

Paroxysmal coughing, thick secretions, post-tussive vomiting, apnea, cyanosis, and increasing work of breathing signal potential airway compromise. Continuous assessment of respiratory rate/effort, oxygen saturation, color, and hydration status is critical. Have suction available, minimize stimuli that trigger coughing fits, and escalate care promptly for hypoxia, exhaustion, or signs of impending respiratory failure.

C. Offer small amounts of fluids frequently

Frequent, small sips help prevent dehydration and reduce the risk of emesis during coughing paroxysms. Clear fluids and oral rehydration solutions are preferred. Avoid forcing large volumes; pace intake around cough-free intervals. If oral intake is inadequate or vomiting persists, consider IV fluids to maintain hydration.

Why the Other Options Are Wrong:

D. Place the child in a negative-pressure isolation room

Negative-pressure rooms are for airborne pathogens (e.g., tuberculosis, measles, varicella). Pertussis requires droplet (not airborne) precautions. A standard private room with droplet measures is appropriate unless another indication for airborne isolation exists.

E. Request an order for cough suppressant

Antitussives are not recommended in young children with pertussis; they are generally ineffective for the paroxysmal cough and may suppress protective airway clearance or cause sedation. Management focuses on macrolide therapy, hydration, oxygen as needed, gentle suctioning, and supportive care.

Correct Answers: A, B, D

A. Apply a cold cloth to the bridge of the nose

B. Apply continuous pressure to the nose for 10 minutes

D. Keep the child calm and quiet

Why these are correct:

A. Apply a cold cloth to the bridge of the nose

Cold causes local vasoconstriction, helping the bleeding vessels in Kiesselbach’s area to constrict and slow/stop the bleed. A cold pack or cloth to the nasal bridge is appropriate.

B. Apply continuous pressure to the nose for 10 minutes

Pinch the soft lower part of the nose (just below the bony bridge) with the child sitting up and leaning slightly forward. Maintain firm, uninterrupted pressure for a full 10 minutes (use a timer). If still bleeding, repeat another 10 minutes.

D. Keep the child calm and quiet

Crying, talking, coughing, or activity increases blood pressure and can worsen bleeding. Keeping the child still and calm promotes clot formation.

Why the other options are wrong:

C. Have the child lie down and turn to the left side

Lying down or tilting the head back increases swallowing of blood, which can cause nausea/vomiting and airway irritation. The correct position is sit up, lean forward.

E. Take the child to the emergency department

Not immediately necessary for a typical anterior nosebleed that responds to proper first aid. ED/urgent care is indicated if bleeding persists beyond 20 minutes despite correct pressure, is heavy/recurrent, follows significant trauma, or if there are signs of anemia or hemodynamic instability.

Correct Answer A. Lactated Ringer's

Explanation:

For a client with moderate dehydration due to nausea and vomiting, the priority is to replace both fluid and electrolytes. Lactated Ringer’s (LR) is an isotonic solution that contains sodium, potassium, calcium, chloride, and lactate, making it the best choice for restoring hydration and electrolyte balance.

Why the other options are incorrect:

B. Dextrose 1% in water

This is a hypotonic solution and not appropriate for rehydration or electrolyte replacement in moderate dehydration.

C. Three percent normal saline

This is a hypertonic solution used for severe hyponatremia, not for general dehydration. It can cause dangerous fluid shifts if misused.

D. Dextrose 5% /.45% normal saline

This is a hypertonic solution that provides free water and some electrolytes but is generally used for maintenance, not for initial rehydration in dehydration.

Correct Answer B. Stop the transfusion and maintain an IV of normal saline.

Explanation:

The priority action during a transfusion reaction is to immediately stop the transfusion to prevent further infusion of the incompatible blood product. The IV line should be kept open with normal saline using new tubing to maintain venous access for emergency medications or fluids. Once the transfusion is stopped, the physician and blood bank are notified, and appropriate labs are drawn.

Why the other options are incorrect:

A. Notify the physician and the nursing supervisor

This is important but must occur after the transfusion is stopped to prevent further harm.

C. Call the lab for verification of type and cross match

Verification is important for investigation, but it is not the immediate action in response to a reaction.

D. Prepare an injection of Benadryl (diphenhydramine)

Medication may be given later depending on the type of reaction, but the first step is to stop the transfusion and maintain IV access.

Correct Answer D. Ask the nurse if she has ever had the chickenpox.

Explanation:

The first step is to determine the nurse’s immunity status. If the nurse has had chickenpox in the past or has been vaccinated, she is immune and poses no risk to the immunocompromised client with leukemia. If she has never had chickenpox, she could be incubating the virus after exposure from her child, which would put the client at significant risk of severe or fatal varicella infection. The charge nurse must assess immunity before deciding on reassignment.

Why the other options are incorrect:

A. Change the nurse's assignment to another client.

This may eventually be necessary if the nurse is not immune, but it is not the initial action. The nurse’s immunity status must first be assessed.

B. Explain to the nurse that there is no risk to the client.

This is incorrect because a leukemia client is severely immunocompromised and highly susceptible to infection. Risk assessment must be done first.

C. Ask the nurse if the chickenpox have crusted.

This question applies to whether the child is contagious, but the focus should be on the nurse’s immunity, not the child’s infection stage. The child having crusted lesions does not eliminate the nurse’s potential exposure risk.

Correct Answer C. Buck's traction

Explanation:

For an adult client with a suspected femur fracture, Buck’s traction is often used. It is a form of skin traction applied to the lower extremity to reduce muscle spasms, immobilize the limb, and prevent further injury until surgical repair can be performed. It helps maintain alignment and control pain before definitive treatment.

Why the other options are incorrect:

A. Bryant's traction

This is used for young children with femur fractures, not for adults. It involves both legs being suspended vertically.

B. Ice to the entire extremity

Applying ice may be part of initial management for swelling and pain, but it is not the primary immobilization method for a femur fracture.

D. An abduction pillow

An abduction pillow is typically used after hip replacement surgery to prevent hip dislocation, not for femur fractures.

Correct Answer B. I have trouble seeing.

Explanation:

Clients with diabetes are at high risk for vision problems, such as retinopathy, cataracts, and glaucoma. Difficulty seeing can interfere with their ability to draw up insulin, read medication labels, monitor blood glucose, and safely prepare meals. This statement requires follow-up to ensure the client has appropriate support and adaptive strategies at home.

Why the other options are incorrect:

A. I live by myself.

Living alone is not necessarily unsafe if the client is otherwise independent and has adequate resources for self-care.

C. I have a cat in the house with me.

Having a pet does not interfere with diabetes self-care. This statement does not raise concern.

D. I usually drive myself to the doctor.

Driving independently shows functional ability and does not indicate a need for follow-up unless vision or neuropathy impairs driving safety.

Correct Answer B. Pain

Explanation:

In modern nursing practice, pain is recognized as the fifth vital sign. It is assessed routinely along with temperature, pulse, respirations, and blood pressure. For a client with pancreatic cancer, monitoring pain is especially critical because it is often severe and requires consistent evaluation and management to ensure comfort and quality of life.

Why the other options are incorrect:

A. Anorexia

Loss of appetite is a common symptom in cancer but is not considered a vital sign.

C. Insomnia

Difficulty sleeping may affect quality of life but is not classified as a vital sign.

D. Fatigue

Fatigue is common in cancer patients but, like anorexia, is not considered a vital sign.

Correct Answer B. If bleeding occurs, I should place an ice bag on the site for 10 minutes.

Explanation:

The correct response is B because bleeding after a cardiac catheterization requires immediate firm pressure applied directly to the site and calling emergency services if it does not stop. Placing an ice bag is not appropriate and could delay life-saving intervention. Proper instructions include avoiding strenuous activity for at least a day, reporting fever as a possible sign of infection, and consulting the doctor about return-to-work clearance.

Why the other options are incorrect:

A. I should not bend, strain, or lift heavy objects for one day.

This is correct teaching. Patients should avoid strenuous activity for at least 24 hours after the procedure to prevent bleeding from the catheter insertion site.

C. I need to call the doctor if my temperature goes above 101°F.

This is correct teaching. A fever may indicate infection at the insertion site or systemic infection, which requires prompt medical attention.

D. I should talk to the doctor to find out when I can go back to work.

This is correct teaching. Return to normal activities, including work, depends on the patient’s recovery and the physician’s assessment, so consulting the doctor is appropriate.