NCLEX-PN
Kaplan NCLEX Question of The Day
1. Because of the possible nervous system side-effects that occur with isoniazid (Nydrazid) therapy, which supplementary nutritional agent would the nurse teach the client to take as a prophylaxis?
- A. Alpha tocopherol (vitamin E)
- B. Ascorbic acid (vitamin C)
- C. Calcitriol (vitamin D)
- D. Pyridoxine (vitamin B6)
Correct answer: D
Rationale: Pyridoxine is the correct choice in this scenario because it is used as a prophylaxis to prevent neuritis, a possible nervous system side-effect of isoniazid therapy. Neuritis is a condition that involves inflammation of the nerves and can be a side effect of isoniazid. Pyridoxine, also known as vitamin B6, helps prevent this side effect. Vitamin E (Alpha tocopherol), vitamin C (Ascorbic acid), and vitamin D (Calcitriol) do not specifically address the nervous system side-effects associated with isoniazid therapy, making them incorrect choices.
2. A nurse is instructing a patient about the warning signs of Digitalis side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?
- A. Seizures
- B. Muscle weakness
- C. Depression
- D. Anxiety
Correct answer: B
Rationale: The correct answer is 'Muscle weakness.' Palpitations and muscle weakness are commonly associated with excessive levels of Digitalis. Seizures, depression, and anxiety are not typically linked to Digitalis toxicity. Seizures could be more related to other medications or conditions, while depression and anxiety are not commonly reported side effects of Digitalis.
3. A nurse is caring for a client with an elevated cortisol level. The nurse can expect the client to exhibit symptoms of:
- A. urinary excess
- B. hyperpituitarism
- C. urinary deficit
- D. hyperthyroidism
Correct answer: C
Rationale: Elevated cortisol levels can lead to sodium and fluid retention and potassium deficit, resulting in urinary deficit. This imbalance in electrolytes and fluid can cause a decrease in urinary output. Choices B, hyperpituitarism, and D, hyperthyroidism, are incorrect as they do not directly relate to the symptoms expected with elevated cortisol levels. Option A, urinary excess, is also incorrect as high cortisol levels typically lead to fluid retention and urinary deficit, not excess.
4. How can the nurse promote relief of muscle pain, spasms, and tension?
- A. Encouraging the client to continue their activities as usual.
- B. Immobilizing the client.
- C. Applying heat, cold, pressure, or vibration to the painful area.
- D. Administering pain medication as needed to ease the muscle.
Correct answer: C
Rationale: To promote relief of muscle pain, spasms, and tension, the nurse should consider applying heat, cold, pressure, or vibration to the painful area. These interventions can help alleviate pain associated with muscle tension, pain, or spasms. Choice A is incorrect because encouraging the client to continue their activities as usual may exacerbate the pain. Choice B is incorrect as immobilizing the client may not address the underlying issue and could potentially lead to further complications. Choice D is also incorrect because while pain medication can be used, it is not the first-line treatment for muscle pain, spasms, and tension.
5. The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time?
- A. Warm the room
- B. Submerge the hand in warm water
- C. Order a K pad and apply to hand
- D. Have the client exercise the fingers to increase blood flow
Correct answer: A
Rationale: The correct action for the nurse to take when caring for a burn victim with a skin graft to the hand, exhibiting pale and mottled skin but good capillary refill, is to warm the room. By warming the room, the nurse helps promote circulation and maintain a conducive environment for healing. Submerging the hand in warm water can pose a risk of injury or infection to the graft site. Ordering a K pad and applying it to the hand may not be necessary at this time and could potentially cause harm. Having the client exercise the fingers to increase blood flow is also not recommended as it may interfere with the healing process of the skin graft.
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