NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 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 2 of 5
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse anticipates that this client would be in which acid-base imbalance?
Correct Answer: B
Rationale: The correct answer is respiratory alkalosis. Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. In this scenario, the client is extremely anxious and crying uncontrollably, indicating an increased respiratory rate and CO2 loss. Respiratory acidosis (choice
A) is incorrect as it is characterized by an increase in CO2 levels, not a loss. Metabolic acidosis (choice
C) involves a decrease in blood pH due to an accumulation of acids or loss of bicarbonate, which is not the case here. Metabolic alkalosis (choice
D) results from excess bicarbonate or a loss of acids, not from increased CO2 loss due to hyperventilation.
Question 3 of 5
The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?
Correct Answer: B
Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced.
Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.
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 with decreased cardiac output secondary to heart failure with fluid volume overload. The effects of diminished renal perfusion will have which physiologic response?
Correct Answer: B
Rationale: When there is diminished renal perfusion due to decreased cardiac output, the kidneys receive less blood flow. This leads to a decrease in urine output and an increase in fluid retention, as the kidneys are not able to effectively filter and excrete excess fluid. Elevated bicarbonate level and paroxysmal idiopathic narcosis are not typically associated with diminished renal perfusion in heart failure.
Therefore, the correct answer is 'Increased fluid retention.'