NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 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.
Question 2 of 5
When dressing a severe burn to the right hand, it is important for the nurse to:
Correct Answer: B
Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.
Question 3 of 5
The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice until the client regains full consciousness?
Correct Answer: C
Rationale: The correct answer is 'Lateral.' When a client is very drowsy or sedated, placing them in the lateral position is important to maintain an open airway and allow for drainage of secretions. This position helps prevent airway obstruction and aspiration.
Choice A, 'Supine,' is lying flat on the back and may not be ideal for a drowsy client due to the risk of airway compromise.
Choice B, 'Fowlers,' is a semi-sitting position that is beneficial for clients with respiratory distress, but it may not be the best choice for a very drowsy individual.
Choice D, 'High Fowlers,' is a more upright sitting position, which again may not be suitable for a drowsy client as it does not facilitate airway patency as effectively as the lateral position.
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
After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?
Correct Answer: A
Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings.
Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen.
Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice.
Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.