on morning rounds the nurse finds a somnolent client with a blood glucose of 89 mgdl a sulfonurea and a proton pump inhibitor are scheduled to be admi
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

Correct answer: A

Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.

2. Which of the following diseases or conditions is least likely to be associated with an increased potential for bleeding?

Correct answer: C

Rationale: Pernicious anemia is least likely to be associated with an increased potential for bleeding. Pernicious anemia results from vitamin B12 deficiency due to a lack of intrinsic factor, leading to faulty absorption from the gastrointestinal tract. While pernicious anemia can lead to other health issues, bleeding tendencies are not a primary concern. Metastatic liver cancer (choice A) can cause liver dysfunction leading to decreased synthesis of clotting factors, increasing the risk of bleeding. Gram-negative septicemia (choice B) can lead to disseminated intravascular coagulation (DIC) causing excessive bleeding. Iron-deficiency anemia (choice D) can result in microcytic hypochromic red blood cells, which can impair oxygen transport and lead to tissue hypoxia, but it is not directly associated with a significant potential for bleeding.

3. A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?

Correct answer: A

Rationale: The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.

4. 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?

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.

5. The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?

Correct answer: A.

Rationale: The correct answer is Hypocalcemia. In hypoparathyroidism, where the parathyroid glands are not producing sufficient parathyroid hormone, calcium levels become inadequate. This leads to hypocalcemia, characterized by symptoms such as muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia are not typically associated with hypoparathyroidism. While hyperphosphatemia can be seen in hypoparathyroidism due to decreasing calcium levels, the question specifically asks about the primary electrolyte imbalance closely related to hypoparathyroidism, which is hypocalcemia.

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