NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
The nurse is caring for a client admitted with Class III/IV Pulmonary Hypertension. The nurse explains to the client that Lanoxin is being administered to the client in order to:
Correct Answer: B
Rationale: The correct answer is to improve right ventricular function. Lanoxin, also known as digoxin, is a cardiac glycoside that works by slowing the heart rate and increasing myocardial contractility, especially in the ventricles. This action helps improve the efficiency of the heart's pumping function, particularly the right ventricle in conditions like pulmonary hypertension.
Choice A, managing peripheral edema, is not directly related to Lanoxin's mechanism of action.
Choice C, increasing pulmonary pressure, is incorrect as Lanoxin is not used to increase pressure in the pulmonary circulation.
Choice D, constricting the pulmonary vessels, is incorrect as Lanoxin does not cause vasoconstriction in the pulmonary vessels but rather acts on the heart's contractility.
Question 2 of 5
After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?
Correct Answer: D
Rationale: The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.
Question 3 of 5
Which is an example of a sentinel event?
Correct Answer: D
Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event.
Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.
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
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.