NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
How can a nurse recognize that a chronic renal failure client's AV shunt is patent?
Correct Answer: B
Rationale: The correct assessment to determine the patency of an AV shunt in a chronic renal failure client is the presence of a thrill. A thrill is a vibration or buzzing sensation felt over the shunt site, indicating good blood flow through the shunt. While the presence of a bruit is also important for assessing an AV shunt, a thrill is a more specific indicator of patency. Blood return from the shunt is related to cannulation and not necessarily an indicator of patency. Urine output greater than 30 ml/hr is not directly related to the assessment of an AV shunt's patency.
Question 2 of 5
Which electrolyte imbalance would be the nurse's priority concern in the burn client?
Correct Answer: B
Rationale: The correct answer is hyperkalemia. In a burn client, the nurse's priority concern is hyperkalemia due to cell lysis, which releases potassium into the bloodstream. This can lead to dangerous levels of potassium in the blood. Hypernatremia (
Choice
A) is less likely in burn clients. Hypoalbuminemia (
Choice
C) can occur but is not the priority in the immediate management of a burn client. Hypermagnesemia (
Choice
D) is not typically associated with burn injuries.
Question 3 of 5
A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?
Correct Answer: A
Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.
Question 4 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 5 of 5
The nurse is caring for a client complaining of intense headaches with increasing pain for the past one month. An MRI is ordered. In reviewing the client's information, which piece of information is of concern?
Correct Answer: B
Rationale: The correct answer is 'Has a cardiac pacemaker.' If a client with a cardiac pacemaker undergoes an MRI, the magnetic field can interfere with the pacemaker's function, leading to serious complications or even death. It is crucial to ensure that the pacemaker is compatible with MRI imaging or to consider alternative imaging modalities. The other choices, such as 'Allergy to shellfish,' 'A diabetic,' and 'No IV access,' are not direct contraindications for an MRI scan and do not pose the same level of risk as having a cardiac pacemaker.