NCLEX NCLEX-PN
Kaplan NCLEX Question of The Day
1. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client’s spouse asks the nurse about the reason for having two chest tubes. The nurse’s response is based on the knowledge that the upper chest tube is placed to:
- A. Remove air from the pleural space
- B. Create access for irrigating the chest cavity
- C. Evacuate secretions from the bronchioles and alveoli
- D. Drain blood and fluid from the pleural space
Correct answer: Remove air from the pleural space
Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.
2. A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team should the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?
- A. Physical therapist
- B. Occupational therapist
- C. Clergy
- D. Social worker
Correct answer: Social worker
Rationale: In this scenario, the appropriate member of the healthcare team to plan the discharge and transition from the hospital to the rehabilitation facility is the social worker. Social workers are trained to provide counseling services, emotional support, arrange placements in care facilities, and locate financial resources for clients. While clergy provide spiritual support and guidance, physical therapists assist in physical treatments, and occupational therapists help with activities of daily living, the social worker is best suited to address the client's needs related to discharge planning and transition. Therefore, the correct answer is the social worker.
3. A teenage client is admitted to the hospital because of an acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
- A. lungs
- B. liver
- C. kidneys
- D. adrenal glands
Correct answer: liver
Rationale: Acetaminophen is extensively metabolized in the liver. An acetaminophen overdose can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect. Acetaminophen overdose does not typically cause life-threatening problems in the lungs, kidneys, or adrenal glands. While prolonged acetaminophen use may increase the risk of renal dysfunction, a single overdose primarily affects the liver.
4. The nurse who was not promoted then went to the utility room and slammed several cupboard doors while looking for Kleenex. This behavior exemplifies:
- A. displacement.
- B. sublimation
- C. conversion.
- D. reaction formation.
Correct answer: displacement.
Rationale: Displacement unconsciously transfers emotions associated with a person, object, or situation to another less threatening person, object, or situation. In this scenario, the nurse slammed doors instead of expressing anger towards the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. Since slamming cupboard doors is not a constructive activity, this choice is incorrect. Conversion involves transforming anxiety into physical symptoms, which is not demonstrated in the given behavior. Reaction formation keeps unacceptable feelings or behaviors out of awareness by displaying the opposite feeling or behavior, which is not the case here.
5. When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct answer: developing interventions for grief and loss
Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.
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