NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
When dressing a severe burn to the right hand, it is important for the nurse to:
Correct Answer: B
Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.
Question 2 of 5
The client has been taking divalproex (Depakote) for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test?
Correct Answer: A
Rationale: The correct answer is Alanine aminotransferase (ALT). Monitoring ALT levels is crucial when a patient is taking divalproex (Depakote) due to the risk of drug-induced hepatitis. Elevated ALT levels indicate liver damage or disorders, which can be a side effect of Depakote. Serum glucose (choice
B) is not the priority for monitoring in this case, as the medication does not directly affect glucose levels. Serum creatinine (choice
C) is not the most relevant test to monitor for Depakote use; it primarily assesses kidney function. Serum electrolytes (choice
D) are important but do not take precedence over monitoring ALT levels when a patient is on Depakote.
Question 3 of 5
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
Correct Answer: D
Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (
Choice
A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (
Choice
B) is not required for early decelerations. Notifying the physician (
Choice
C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.
Question 4 of 5
When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?
Correct Answer: B
Rationale: The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.
Question 5 of 5
What is most important for the healthcare professional to do prior to initiating peritoneal dialysis?
Correct Answer: D
Rationale: The correct answer is to warm the fluids. Warming the dialysis fluids is crucial before initiating peritoneal dialysis to prevent abdominal discomfort and promote vasodilation, which helps in achieving good exchange in the peritoneum. Aspirating to check placement (
Choice
A) is not typically necessary before initiating peritoneal dialysis. Ensuring the client voids (
Choice
B) is not directly related to the procedure of peritoneal dialysis. Irrigating the catheter to maintain patency (
Choice
C) is usually done as part of routine care but is not specifically required prior to initiating peritoneal dialysis.
Therefore, the most important action to take before starting peritoneal dialysis is to warm the fluids.