NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 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.
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 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.'
Question 4 of 5
Which symptoms is the client who overdosed on barbiturates most likely to exhibit?
Correct Answer: A
Rationale: The correct answer is bradypnea and bradycardia. Barbiturates are central nervous system (CNS) depressants, which will slow down the respiratory rate (bradypnea) and heart rate (bradycardia).
Choice B, hyperthermia and drowsiness, is incorrect as barbiturate overdose typically does not cause hyperthermia but rather hypothermia. Hyperreflexia and slurred speech (
Choice
C) are more indicative of stimulant overdoses rather than CNS depressants like barbiturates. Tachycardia and psychosis (
Choice
D) are also not typically seen in barbiturate overdose, as these drugs tend to depress the CNS rather than cause symptoms of increased heart rate or psychosis.
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.