NCLEX-PN
NCLEX Question of The Day Questions
Extract:
Question 1 of 5
Which reported symptom would indicate a client with Addison's disease has received too much fludrocortisone (Florinef) replacement?
Correct Answer: B
Rationale: Fludrocortisone (Florinef) replacement in Addison's disease involves mimicking aldosterone to retain sodium and water. This retention can lead to weight gain due to increased fluid retention. Rapid weight gain, such as 6 pounds in one week, is a concerning sign of excessive fluid retention, indicating a potential overdose of fludrocortisone.
Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not specific symptoms of excessive fludrocortisone replacement in Addison's disease.
Question 2 of 5
The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:
Correct Answer: D
Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts.
Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself.
Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression.
Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.
Question 3 of 5
While Fluorouracil (5FU®) is being infused, a client complains of burning at the IV site. What should the nurse do first?
Correct Answer: C
Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (
Choice
A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (
Choice
B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (
Choice
D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.
Question 4 of 5
While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?
Correct Answer: C
Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (
Choice
A) might delay the evaluation and management of the mole. Contacting the physician via telephone (
Choice
B) may not provide a documented record of the observation. Removing the mole without proper evaluation (
Choice
D) could be dangerous and is not within the nurse's scope of practice.
Question 5 of 5
A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?
Correct Answer: C
Rationale: Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (
Choice
A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (
Choice
B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (
Choice
D) is not the priority at this stage as assessing for any physical changes is more crucial.