NCLEX-PN
Kaplan NCLEX Question of The Day
1. After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?
- A. Go to the client to assess for signs and symptoms of decreased cardiac output.
- B. Call the physician to inform them of the VF episode for medication adjustments.
- C. Call the 'on-call' person in the cath lab to re-charge the ICD in case of a recurrence.
- D. Document the incident on the code report form and follow up regularly.
Correct answer: A
Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.
2. What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/L?
- A. metabolic alkalosis
- B. homeostasis
- C. respiratory acidosis
- D. respiratory alkalosis
Correct answer: B
Rationale: The correct answer is 'homeostasis.' These ABG values fall within normal ranges, indicating a state of balance in the body's acid-base levels. Choices A, C, and D are incorrect as the ABG values provided do not point towards metabolic alkalosis, respiratory acidosis, or respiratory alkalosis. Instead, the values reflect a state of equilibrium where pH, PO2, PCO2, and HCO3 levels are within the normal range.
3. A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- A. Secure the restraints to the bed rails on all extremities.
- B. Notify the physician that restraints have been placed properly.
- C. Communicate with the patient and family the need for restraints.
- D. Position the head of the bed at a 45-degree angle.
Correct answer: C
Rationale: In cases where restraints are considered necessary for a patient, it is crucial to communicate effectively with both the patient and their family about the reasons for this decision. This helps ensure that all parties involved understand the necessity of restraints and are informed about the potential risks and benefits. Option A, securing restraints to the bed rails on all extremities, is not appropriate as it does not involve proper communication or ethical considerations. Option B, notifying the physician that restraints have been placed properly, overlooks the importance of patient and family involvement in decision-making. Option D, positioning the head of the bed at a 45-degree angle, is unrelated to the use of restraints and does not address the situation at hand.
4. A patient's nurse taking a history notes complaints of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia and hypertension. Which of the following may be occurring?
- A. The patient may be developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct answer: B
Rationale: In this scenario, the patient's symptoms of shortness of breath (SOB) and weakness in the lower extremities, along with a history of hyperlipidemia and hypertension, are suggestive of a myocardial infarction (MI). It is important to note that MI can present with a variety of symptoms, including those affecting the respiratory system and muscle weakness. Choices A, C, and D are incorrect because the patient's symptoms are more indicative of a myocardial infarction rather than congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or peripheral vascular disease (PVD).
5. A patient has experienced a severe third-degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
- A. Shock phase
- B. Emergent phase
- C. Healing phase
- D. Wound proliferation phase
Correct answer: A
Rationale: The correct answer is A: Shock phase. The shock phase occurs within the first 24-48 hours of burn management. During this phase, the focus is on stabilization, fluid resuscitation, and monitoring for potential complications. Choice B, the Emergent phase, is incorrect as it refers to the initial phase of burn care immediately after the injury. Choice C, the Healing phase, occurs later in the treatment process when the wound starts to repair itself. Choice D, the Wound proliferation phase, is not a recognized phase in burn management.
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