NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse anticipates that this client would be in which acid-base imbalance?
Correct Answer: B
Rationale: The correct answer is respiratory alkalosis. Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. In this scenario, the client is extremely anxious and crying uncontrollably, indicating an increased respiratory rate and CO2 loss. Respiratory acidosis (choice
A) is incorrect as it is characterized by an increase in CO2 levels, not a loss. Metabolic acidosis (choice
C) involves a decrease in blood pH due to an accumulation of acids or loss of bicarbonate, which is not the case here. Metabolic alkalosis (choice
D) results from excess bicarbonate or a loss of acids, not from increased CO2 loss due to hyperventilation.
Question 2 of 5
A client admitted with an episode of bleeding esophageal varices is receiving propranolol (Inderal LA). The nurse knows to monitor for?
Correct Answer: C
Rationale: The correct answer is 'Bradycardia.' Propranolol is a beta-blocking agent used to decrease the heart rate. In the case of bleeding esophageal varices, propranolol is given to reduce the risk of bleeding by keeping the heart rate around 55 beats per minute. Monitoring for bradycardia is essential as the medication's intended effect is to lower the heart rate.
Choices A, B, and D are incorrect because propranolol would not typically cause hypertension, hyperkalemia, or arthralgia.
Question 3 of 5
What essential assessment must be performed for clients with implanted dialysis access devices?
Correct Answer: C
Rationale: Correct! When assessing clients with implanted dialysis access devices, it is crucial to palpate for the thrill, which indicates blood flow, and auscultate for the bruit, a humming sound, to ensure the patency of the access device.
Choices A, B, and D are incorrect as they are not specific assessments related to dialysis access devices. Checking color and capillary refill, pulse, Trousseau's sign, and temperature are important assessments in other contexts but not specifically for monitoring implanted dialysis access devices.
Question 4 of 5
The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:
Correct Answer: C
Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume.
Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.
Question 5 of 5
A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:
Correct Answer: A
Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity.
Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation.
Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose.
Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.