NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?
Correct Answer: C
Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.
Question 2 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.
Question 3 of 5
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. Which assessment finding is consistent with a flail chest?
Correct Answer: C
Rationale: The correct assessment finding consistent with a flail chest is paradoxical chest wall movement. This occurs when a segment of the chest wall moves in the opposite direction to the rest of the chest during respiration. Biot's respirations (
Choice
A) are a pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. Sucking sounds during respirations (
Choice
B) may indicate air entering or leaving the chest cavity through a wound. Hypotension and bradycardia (
Choice
D) may be present due to other factors such as shock, but they are not specific to a flail chest.
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
The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?
Correct Answer: B
Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.