NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 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.
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
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).
Correct Answer: A
Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.
Question 4 of 5
The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?
Correct Answer: B
Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes.
Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.
Question 5 of 5
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
Correct Answer: D
Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (
Choice
A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (
Choice
B) is not required for early decelerations. Notifying the physician (
Choice
C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.