NCLEX Question of The Day - Nurselytic

Questions 67

NCLEX-PN

NCLEX-PN Test Bank

NCLEX Question of The Day Questions

Extract:


Question 1 of 5

The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?

Correct Answer: C

Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.

Question 2 of 5

The nurse is caring for a client with hyperemesis gravidarum. What is the most likely electrolyte imbalance?

Correct Answer: D

Rationale: In hyperemesis gravidarum, where the client experiences severe nausea and vomiting, the most likely electrolyte imbalance is hypokalemia. Potassium is abundant in the stomach, and excessive vomiting leads to potassium loss. Hypocalcemia (
Choice
A) is not typically associated with hyperemesis gravidarum. Hypomagnesemia (
Choice
B) and Hyponatremia (
Choice
C) are less likely to occur compared to hypokalemia in this condition.

Question 3 of 5

The client develops a tension pneumothorax. Assessment is expected to reveal?

Correct Answer: C

Rationale: In a tension pneumothorax, the trachea deviates to the unaffected side due to increased pressure in the affected pleural space, causing respiratory distress. Dyspnea is a hallmark symptom as the lung on the affected side collapses, leading to difficulty in breathing. Sudden hypertension and bradycardia (
Choice
A) are not typical findings of tension pneumothorax. Productive cough with yellow mucus (
Choice
B) is more suggestive of respiratory infections rather than a tension pneumothorax. Sudden development of profuse hemoptysis and weakness (
Choice
D) is not characteristic of tension pneumothorax presentation.

Question 4 of 5

The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?

Correct Answer: A

Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.

Question 5 of 5

A healthcare professional is reviewing a patient's arterial blood gas values. Which of the following conditions apply under the following values? pH- 7.49 Bicarbonate ion 24 mEq/dl PaCO2 - 31 mmHg PaO2 - 52 mmHg FiO2 - 0.22

Correct Answer: B

Rationale: The given blood gas values indicate respiratory alkalosis. A high pH and low PaCO2 level are consistent with respiratory alkalosis. In this scenario, no compensation for the alkalosis is noted, ruling out metabolic acidosis or alkalosis. Metabolic conditions would usually involve changes in bicarbonate levels, which remain within the normal range in this case.

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