NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
Correct Answer: B
Rationale: The correct answer is covering the affected leg with a blanket to avoid chills. Covering the leg with a blanket can prevent the evaporation of heat from the new cast, which can lead to skin irritation or discomfort. Lifting the affected leg with the palms of the hand is appropriate as it helps in providing support and prevents unnecessary pressure on the cast. Placing plastic over the groin prior to bathing is also acceptable to protect the area from getting wet. Elevating the cased leg on two pillows helps reduce swelling and promotes circulation, making it a suitable action.
Question 2 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 3 of 5
A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:
Correct Answer: A
Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity.
Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation.
Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose.
Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.
Question 4 of 5
A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?
Correct Answer: A
Rationale: In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis.
Therefore, the correct answer is Respiratory acidosis.
Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.
Question 5 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.