NCLEX-PN
Kaplan NCLEX Question of The Day
1. The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority?
- A. Continue to monitor urine output
- B. Check a pulse
- C. Check a blood pressure
- D. Check level of consciousness (LOC)
Correct answer: C
Rationale: The correct answer is to check a blood pressure. Diabetes insipidus can lead to dehydration and potential hypovolemic shock due to excessive urine output. Monitoring blood pressure is crucial to assess the client's circulatory status and detect signs of shock early. Checking the blood pressure will provide essential information on perfusion, which is vital in this situation. Continuing to monitor urine output, checking a pulse, or assessing the level of consciousness are important but not as high a priority as evaluating the blood pressure in a potentially critical situation like suspected diabetes insipidus.
2. The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?
- A. Client with irritable bowel syndrome
- B. Family history of colon polyps
- C. Client with cirrhosis of the liver
- D. History of colon surgery
Correct answer: B
Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.
3. A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).
- A. Weight gain
- B. Fatigue
- C. Bloody sputum
- D. Diaphoresis during sleep
Correct answer: A
Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.
4. A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?
- A. Transferring the patient to the shower.
- B. Ambulating the patient for the first time.
- C. Taking the patient's breath sounds.
- D. Educating the patient on monitoring fatigue.
Correct answer: A
Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.
5. 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.
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