NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 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 2 of 5
What is the most common cause of acute renal failure?
Correct Answer: A
Rationale: The most common cause of acute renal failure is shock. In cases of shock, such as hypovolemic shock where there is low blood volume, the kidneys receive inadequate blood flow leading to acute renal failure. This can result in the kidneys starting to die within 20 minutes of low pressure. While nephrotoxic drugs can also cause acute renal failure, shock is more commonly associated with this condition. An enlarged prostate can lead to urinary retention but is not the most common cause of acute renal failure. Diabetes, on the other hand, can cause chronic kidney disease over time but is not typically the primary cause of acute renal failure.
Question 3 of 5
The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?
Correct Answer: C
Rationale: Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option
A) is essential but not the priority in this situation. While airway assessment (Option
B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option
D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.
Question 4 of 5
Which symptom is the client who self-administered an overdose of acetaminophen most likely to exhibit?
Correct Answer: C
Rationale: When a client self-administers an overdose of acetaminophen, the liver is primarily affected. Jaundiced conjunctiva, which is yellowing of the eyes, is a common symptom of liver damage. Pink frothy sputum is typically associated with conditions like pulmonary edema, not acetaminophen overdose. Seizure activity is not a common symptom of acetaminophen overdose but can be seen in other toxicities. Diaphoresis and fever are more generalized symptoms and not specific to acetaminophen overdose.
Question 5 of 5
Which hormone is responsible for amenorrhea in the pregnant woman?
Correct Answer: A
Rationale: Correct! Progesterone is the hormone responsible for amenorrhea in pregnant women. Progesterone plays a crucial role in maintaining the uterine lining for implantation and supporting early pregnancy. High levels of progesterone during pregnancy suppress the normal menstrual cycle, leading to amenorrhea. Estrogen, FSH, and hCG do not directly cause amenorrhea in pregnant women. Estrogen is involved in the development of female secondary sexual characteristics, FSH is involved in the growth and maturation of ovarian follicles, and hCG is produced by the placenta to support the production of progesterone during pregnancy.