NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 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 2 of 5
The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice until the client regains full consciousness?
Correct Answer: C
Rationale: The correct answer is 'Lateral.' When a client is very drowsy or sedated, placing them in the lateral position is important to maintain an open airway and allow for drainage of secretions. This position helps prevent airway obstruction and aspiration.
Choice A, 'Supine,' is lying flat on the back and may not be ideal for a drowsy client due to the risk of airway compromise.
Choice B, 'Fowlers,' is a semi-sitting position that is beneficial for clients with respiratory distress, but it may not be the best choice for a very drowsy individual.
Choice D, 'High Fowlers,' is a more upright sitting position, which again may not be suitable for a drowsy client as it does not facilitate airway patency as effectively as the lateral position.
Question 3 of 5
A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?
Correct Answer: B
Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (
Choice
B) are more commonly associated with a myocardial infarction.
Choices A and D are not typical symptoms of either angina or myocardial infarction.
Question 4 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 5 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.