NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?
Correct Answer: A
Rationale: In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis.
Therefore, the correct answer is Respiratory acidosis.
Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.
Question 2 of 5
What is most important for the healthcare professional to do prior to initiating peritoneal dialysis?
Correct Answer: D
Rationale: The correct answer is to warm the fluids. Warming the dialysis fluids is crucial before initiating peritoneal dialysis to prevent abdominal discomfort and promote vasodilation, which helps in achieving good exchange in the peritoneum. Aspirating to check placement (
Choice
A) is not typically necessary before initiating peritoneal dialysis. Ensuring the client voids (
Choice
B) is not directly related to the procedure of peritoneal dialysis. Irrigating the catheter to maintain patency (
Choice
C) is usually done as part of routine care but is not specifically required prior to initiating peritoneal dialysis.
Therefore, the most important action to take before starting peritoneal dialysis is to warm the fluids.
Question 3 of 5
The client is wheezing and struggling to breathe. Which of the inhaled medications is indicated at this time?
Correct Answer: D
Rationale: The correct answer is Albuterol (Atrovent) because it is a rapid-acting bronchodilator, essential for a client experiencing wheezing and difficulty breathing. Albuterol acts quickly, dilating the airways and providing immediate relief in cases of respiratory distress. Fluticasone (Flovent) and Salmeterol (Serevent) are maintenance medications for long-term asthma control, not suitable for acute situations described. Theophylline (Theodur) is a bronchodilator but with a slower onset compared to Albuterol, making it less appropriate for a client in immediate distress.
Question 4 of 5
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time?
Correct Answer: A
Rationale: The correct action for the nurse to take when caring for a burn victim with a skin graft to the hand, exhibiting pale and mottled skin but good capillary refill, is to warm the room. By warming the room, the nurse helps promote circulation and maintain a conducive environment for healing. Submerging the hand in warm water can pose a risk of injury or infection to the graft site. Ordering a K pad and applying it to the hand may not be necessary at this time and could potentially cause harm. Having the client exercise the fingers to increase blood flow is also not recommended as it may interfere with the healing process of the skin graft.
Question 5 of 5
After discontinuing a peripherally inserted central line (PICC), what information is most important for the nurse to record?
Correct Answer: B
Rationale: The most important information for the nurse to record after discontinuing a peripherally inserted central line (PIC
C) is the length and intactness of the central line catheter. This is crucial for assessing any potential complications or safety issues post-removal.
Choices A, C, and D are not as critical as ensuring the condition of the central line catheter. While noting the client's tolerance of the procedure is relevant for their care assessment, evaluating the central line's integrity takes precedence in this scenario.