NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
A client complaining of chest pain is prescribed an intravenous infusion of nitroglycerin (Nitro-Bid). After the infusion is initiated, the occurrence of which symptom warrants the nurse discontinuing an intravenous infusion of nitroglycerin?
Correct Answer: D
Rationale: The correct answer is 'Cool clammy skin.' This assessment finding indicates decreased cardiac output that could result from excessive vasodilation. Cool clammy skin is a sign of poor perfusion, suggesting that the blood pressure might be dropping too low. Discontinuing the nitroglycerin infusion is crucial to prevent further complications.
Choice A, 'Frontal headache,' is a common side effect of nitroglycerin but not a reason to discontinue the infusion unless severe or persistent.
Choice B, 'Orthostatic hypotension,' may occur as a side effect of nitroglycerin but does not necessarily warrant discontinuation unless severe.
Choice C, 'Decrease in intensity of chest pain,' is actually an expected therapeutic response to nitroglycerin and indicates improved myocardial perfusion, so it is not a reason to stop the infusion.
Question 2 of 5
One week ago, a client was involved in a motor vehicle crash (MVC) and was brought to the Emergency Department (ED). In the emergency department, the client received two stitches to the forehead and was sent home. Today, the client's spouse notes that the client 'acts like he is drunk' and cannot control his right foot and arm. The nurse will suspect?
Correct Answer: C
Rationale: Yes! The nurse will suspect a subdural hematoma. In this case, the client's presentation of acting intoxicated and experiencing loss of motor control in the right foot and arm is indicative of an acute subdural hematoma. This condition can occur after a head injury with a slow venous bleed, where symptoms may not show until compensation mechanisms are overwhelmed. Meningitis (choice
A) usually presents with fever, headache, and neck stiffness. Absence seizure (choice
B) is characterized by brief periods of unconsciousness without convulsions. Meniere's disease (choice
D) manifests with symptoms like vertigo, hearing loss, and tinnitus, which do not match the client's current symptoms.
Question 3 of 5
Which hormone is responsible for amenorrhea in the pregnant woman?
Correct Answer: A
Rationale: Correct! Progesterone is the hormone responsible for amenorrhea in pregnant women. Progesterone plays a crucial role in maintaining the uterine lining for implantation and supporting early pregnancy. High levels of progesterone during pregnancy suppress the normal menstrual cycle, leading to amenorrhea. Estrogen, FSH, and hCG do not directly cause amenorrhea in pregnant women. Estrogen is involved in the development of female secondary sexual characteristics, FSH is involved in the growth and maturation of ovarian follicles, and hCG is produced by the placenta to support the production of progesterone during pregnancy.
Question 4 of 5
When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
Correct Answer: B
Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.
Question 5 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.