NCLEX-PN
Kaplan NCLEX Question of The Day Questions
Extract:
Question 1 of 5
Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?
Correct Answer: B
Rationale: When a client is being treated with antiepileptic drugs (AEDs), it is essential to monitor for potential side effects on blood parameters. Some AEDs can lead to blood dyscrasia, which includes conditions like aplastic anemia and megaloblastic anemia.
Therefore, drawing a complete blood count and differential helps in identifying these adverse effects early.
Choices A, C, and D are incorrect because the primary concern when monitoring blood parameters in clients on AEDs is the risk of blood dyscrasia, not changes in hematocrit due to vascular volume, white blood cell reduction, or immune modulation.
Question 2 of 5
The nurse has just received a change-of-shift report. Which client should the nurse assess first?
Correct Answer: A
Rationale: The nurse should assess the client 2 hours post-lobectomy with 150cc drainage first because postoperative assessments are crucial during the immediate postoperative period. This client may be at higher risk for complications, such as bleeding or infection, requiring immediate attention. Clients in choices B, C, and D are relatively stable and can be assessed after the immediate postoperative client has been evaluated.
Question 3 of 5
A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
Correct Answer: A
Rationale: Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body.
Choices B, C, and D are not associated with unilateral neglect.
Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body.
Choice C describes a visual field cut, which is a different visual deficit.
Choice D relates to dual-task interference, not specific to ignoring one side of the body.
Question 4 of 5
One week ago, a client was involved in a motor vehicle crash (MVC) and was brought to the Emergency Department (ED). In the emergency department, the client received two stitches to the forehead and was sent home. Today, the client's spouse notes that the client 'acts like he is drunk' and cannot control his right foot and arm. The nurse will suspect?
Correct Answer: C
Rationale: Yes! The nurse will suspect a subdural hematoma. In this case, the client's presentation of acting intoxicated and experiencing loss of motor control in the right foot and arm is indicative of an acute subdural hematoma. This condition can occur after a head injury with a slow venous bleed, where symptoms may not show until compensation mechanisms are overwhelmed. Meningitis (choice
A) usually presents with fever, headache, and neck stiffness. Absence seizure (choice
B) is characterized by brief periods of unconsciousness without convulsions. Meniere's disease (choice
D) manifests with symptoms like vertigo, hearing loss, and tinnitus, which do not match the client's current symptoms.
Question 5 of 5
When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
Correct Answer: B
Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.