Kaplan NCLEX Practice Question of the Day

The nurse in the outpatient clinic has four phone messages. Which message does the nurse return first?

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An older adult client undergoing bowel prep and reporting watery diarrhea.
This client requires teaching, but this client is experiencing expected results from the bowel prep.
A client with a newborn and experiencing breast engorgement.
The client is experiencing an anticipated issue that is not life-threatening. Though further assessment and teaching are required, the client is stable.
A client who had a cataract extraction 3 days ago and reporting nausea.
Vomiting increases intraocular pressure, which may affect the suture line and pose a risk of physical harm to the client. However, there is another client who is more unstable and experiencing an actual (real) problem that is potentially life-threatening.
A client diagnosed with a C6 spinal cord injury and reporting a headache. (Correct Answer)
A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if untreated, can result in intracranial bleeding and death. This client is the most unstable and is experiencing a potentially life-threatening issue that needs to be addressed immediately by the nurse.

Decision Tree:

This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.

This is a "Who Do You See First" Question.

Terminology that is used here is often phrased as, "Who does the nurse see first?" Use these steps, based on the Kaplan Decision Tree, to determine the correct answer.

STEP 1: Can you identify the topic of the question?

Most unstable client.

STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Who Do You See First questions. Move to Step 5.

STEP 5: Read each answer choice and use the Who Do You See First rules.

Who Do You See First Rules:

Is the client stable or unstable? Eliminate the stable clients.
Is the client experiencing an expected or unexpected finding? Eliminate expected findings.
Are the remaining answer options referring to airway, breathing, or circulation (ABCs)? Eliminate each non-priority answer option using the ABCs.
Are the remaining answers options referring to acute or chronic situations? Eliminate the chronic situation answer options.
Are the remaining answer options real (actual) or potential problems? Eliminate the potential problem answer options.
Look at each answer option that remains and ask, what outcome do you want for this client?
- Does this answer option make sense in this situation? If yes, keep this answer option.
- Will this answer option help the client? If yes, keep this answer option.
- Will this answer option hurt the client? If yes, eliminate this answer option.

Unstable vs. Stable

An older adult client undergoing bowel prep and reporting watery diarrhea. Stable (expected results of a bowel prep). Eliminate.
A client with a newborn and experiencing breast engorgement. Stable (non-life-threatening complication for postpartum women). Eliminate.
A client who had a cataract extraction 3 days ago and reporting nausea. Stable (potential problem). If vomiting occurs, suture line may be disrupted. Eliminate.
A client diagnosed with a C6 spinal cord injury and reporting a headache. Unstable

Select the best choice

Is #4 the correct answer? Yes, the client has a circulation issue that must be immediately addressed.

Does #4 make sense? Yes, this ensures the client's current circulatory status is adequate.

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