NCLEX NCLEX-PN
NCLEX Question of The Day
1. A 62-year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an overdose?
- A. Lower extremity edema
- B. Sensory changes in the upper extremities
- C. Increased occurrence of fractures
- D. Decreased peripheral blood flow
Correct answer: A: Lower extremity edema
Rationale: Lower extremity edema can indicate an overdose of Premarin. Premarin, an estrogen hormone replacement therapy, can cause fluid retention leading to edema in the lower extremities. Sensory changes in the upper extremities, increased occurrence of fractures, and decreased peripheral blood flow are not typically associated with an overdose of Premarin.
2. The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse’s best response?
- A. Bring the swaddled fetus to the mother
- B. Explain that the cause of death must be determined before she can see the baby
- C. Ask her if she is sure she wants to see the baby
- D. Tell her it would be better to wait until she is in her room before she sees the baby
Correct answer: Bring the swaddled fetus to the mother
Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.
3. Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)
- A. Greater than 1000 cells per deciliter
- B. Less than 500 cells per deciliter
- C. Greater than 2000 cells per deciliter
- D. Less than 200 cells per deciliter
Correct answer: Less than 200 cells per deciliter
Rationale: A T4 cell count of less than 200 cells per deciliter indicates symptomatic AIDS. This severe depletion of T4 cells signifies advanced HIV infection and a significantly compromised immune system. Choices A, B, and C are incorrect because T4 cell counts above 2000, above 1000, or below 500 cells per deciliter, respectively, are not indicative of symptomatic AIDS.
4. When teaching bleeding precautions to a client with leukemia, the PN should include which of the following instructions?
- A. Use a soft toothbrush.
- B. Use dental floss daily.
- C. Hold pressure on any scrapes for 1–2 minutes.
- D. Use a triple-edged razor.
Correct answer: Use a soft toothbrush.
Rationale: The correct answer is to 'Use a soft toothbrush.' A soft toothbrush is recommended because it is less likely to cause the gums to bleed in clients with leukemia, who are at risk of bleeding due to overcrowding of white cells at the expense of other cell types like platelets. Choice B, 'Use dental floss daily,' is incorrect because dental floss is contraindicated and can make the gums bleed in clients with leukemia. Choice C, 'Hold pressure on any scrapes for 1–2 minutes,' is incorrect because when clotting is impaired, pressure should be held for 5–10 minutes or longer until the bleeding stops. Choice D, 'Use a triple-edged razor,' is incorrect because an electric razor should be used instead of a triple-edged razor to prevent small cuts and bleeding in clients with leukemia.
5. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask a client providing subjective data?
- A. Do you normally experience menstrual cramps with your periods?
- B. Do you smoke cigarettes?
- C. Are you currently dieting?
- D. Do you engage in strenuous exercise, such as jogging?
Correct answer: B: 'Do you smoke cigarettes?'
Rationale: The correct question the nurse should ask to identify risk factors associated with the use of an oral contraceptive is whether the client smokes cigarettes. Oral contraceptives are associated with an increased risk of thromboembolic phenomena, particularly when combined with other risk factors like smoking and a history of thrombosis. Other risk factors include hypertension, cerebrovascular disease, coronary artery disease, and postoperative thrombosis risk. Choices A, C, and D are not directly related to the increased risks associated with oral contraceptive use. Menstrual cramps, dieting, and strenuous exercise are not significant risk factors for thromboembolic events.
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