NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
Which is an example of a sentinel event?
Correct Answer: D
Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event.
Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.
Question 2 of 5
A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that he lost consciousness for 1-2 minutes. On admission, the client's Glasgow Coma Scale (GCS) was 14. The GCS is now 12. The nurse should:
Correct Answer: D
Rationale: A decrease in the Glasgow Coma Scale (GCS) score from 14 to 12 indicates a significant neurological change in the client's condition. This change can be indicative of a deterioration in the client's neurological status, possibly due to intracranial bleeding or swelling. It is crucial for the nurse to notify the physician immediately to ensure prompt evaluation and intervention. Re-assessing in 15 minutes or stimulating the client with a sternal rub are not appropriate actions in this situation as they do not address the underlying cause of the decrease in GCS. Administering Tylenol with codeine for a headache is also not recommended without further assessment and evaluation of the client's condition.
Question 3 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.
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
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.