NCLEX-PN
Kaplan NCLEX Question of The Day
1. When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
- A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
- B. Risk for injury related to active loss of blood from the vascular space
- C. Deficient knowledge related to the client's lack of understanding of the disease process
- D. Impaired skin integrity related to the development of bruises and/or hematoma
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.
2. Which is an example of a sentinel event?
- A. The terminally ill client is referred to hospice and dies 3 months later.
- B. A client receives an unordered mammogram which reveals a small cyst.
- C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
- D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.
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.
3. Which factor in a client’s health history increases their risk for cancer?
- A. Family history and environment
- B. Alcohol and smoking
- C. Alcohol consumption and smoking
- D. Proximity to an electric plant and water source
Correct answer: B
Rationale: The correct answer is 'Alcohol and smoking.' Both alcohol consumption and smoking are well-known risk factors for various types of cancer. They have a synergistic effect, meaning their combined impact raises the risk significantly. Family history and environment (Choice A) may play a role in certain cancers, but alcohol and smoking are more directly linked to increased cancer risk. Proximity to an electric plant and water source (Choice D) is not typically associated with an increased risk of cancer compared to alcohol and smoking.
4. After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?
- A. Infection
- B. Incision
- C. Pain
- D. Tissue perfusion
Correct answer: D
Rationale: The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.
5. Which symptom is the client who self-administered an overdose of acetaminophen most likely to exhibit?
- A. Pink frothy sputum
- B. Seizure activity
- C. Jaundiced conjunctiva
- D. Diaphoresis and fever
Correct answer: C
Rationale: When a client self-administers an overdose of acetaminophen, the liver is primarily affected. Jaundiced conjunctiva, which is yellowing of the eyes, is a common symptom of liver damage. Pink frothy sputum is typically associated with conditions like pulmonary edema, not acetaminophen overdose. Seizure activity is not a common symptom of acetaminophen overdose but can be seen in other toxicities. Diaphoresis and fever are more generalized symptoms and not specific to acetaminophen overdose.
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