NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?
Correct Answer: C
Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DK
A). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones.
Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis.
Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction.
Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis.
Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.
Question 2 of 5
A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
Correct Answer: A
Rationale: Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body.
Choices B, C, and D are not associated with unilateral neglect.
Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body.
Choice C describes a visual field cut, which is a different visual deficit.
Choice D relates to dual-task interference, not specific to ignoring one side of the body.
Question 3 of 5
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
Correct Answer: B
Rationale: The correct answer is 'Pain felt during a bowel movement.' Endoscopy is used to examine the upper gastrointestinal tract, which includes the esophagus, stomach, and duodenum. Pain during a bowel movement would suggest an issue in the lower gastrointestinal tract, which is typically examined with a colonoscopy.
Choices A, C, and D are not probable reasons for an endoscopy procedure as they relate to symptoms in the upper gastrointestinal tract or are not specific to gastrointestinal issues. Aspiration noted on a honey-thick diet could indicate a risk of aspiration pneumonia related to swallowing difficulties, which can be assessed through an endoscopy. Pain felt in the left upper quadrant may be related to conditions like gastritis or peptic ulcers that can be investigated using an endoscopy. Right shoulder pain can be a referred pain from conditions like gallbladder disease that can also be evaluated with an endoscopy.
Question 4 of 5
When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?
Correct Answer: B
Rationale: The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.
Question 5 of 5
Which medication should the nurse withhold if the client's blood pressure is 88/50?
Correct Answer: B
Rationale: Enalapril (Vasotec) is the correct answer. It is an angiotensin-converting enzyme (ACE) inhibitor that can further lower blood pressure. Given that the client's blood pressure is already low at 88/50, administering Enalapril could exacerbate hypotension and compromise perfusion to vital organs. Rosuvastatin (Crestor), Digoxin (Lanoxin), and Clopidogrel (Plavix) are not contraindicated in the context of low blood pressure and may be administered safely.