NCLEX NCLEX-PN
Kaplan NCLEX Question of The Day
1. The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?
- A. Pain management
- B. Airway assessment
- C. Fluid volume status monitoring
- D. Risk for infection prevention
Correct answer: C: Fluid volume status monitoring
Rationale: Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option A) is essential but not the priority in this situation. While airway assessment (Option B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.
2. Which of the following is the drug of choice to decrease uric acid levels?
- A. prednisone (Colisone)
- B. allopurinol (Zyloprim)
- C. indomethacin (Indocin)
- D. hydrochlorothiazide (HydroDiuril)
Correct answer: allopurinol (Zyloprim)
Rationale: Allopurinol is the correct drug to decrease uric acid levels as it is used to treat gout by reducing uric acid formation. Prednisone is a corticosteroid that decreases inflammation, not uric acid levels. Indomethacin is an analgesic, anti-inflammatory, and antipyretic agent, not specifically used to reduce uric acid levels. Hydrochlorothiazide is a thiazide diuretic primarily used for treating hypertension and edema, not for reducing uric acid levels.
3. A client complains that her skin is redder than normal. The nurse notes the client’s skin, documents hyperemia, and explains to the client that this condition is caused by which factor?
- A. Constriction of the underlying blood vessels
- B. An increased amount of bilirubin in the blood
- C. Increased perfusion of the surrounding tissues
- D. Excess blood in the dilated superficial capillaries
Correct answer: Excess blood in the dilated superficial capillaries
Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.
4. When a client has a chest drainage system in place, where should the system be placed?
- A. above the level of the client's chest
- B. at the level of the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct answer: below the level of the chest
Rationale: A chest drainage system should be placed below the level of the client’s chest to ensure proper drainage of fluid from the chest. Placing the system above the level of the chest or at the shoulders would not allow gravity to assist in the drainage process, potentially leading to complications such as fluid accumulation. Similarly, placing it at the level of the chest would not create the necessary gravity-dependent flow for effective drainage, which is crucial for the proper functioning of the chest drainage system.
5. If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?
- A. retrograde ejaculation
- B. decreased plasma testosterone
- C. hypertrophy of testicles
- D. state of euphoria
Correct answer: decreased plasma testosterone
Rationale: In chronic renal failure, untreated, the client is at risk of developing decreased plasma testosterone. This condition leads to atrophy of the testicles and decreased spermatogenesis. Retrograde ejaculation is not a complication of chronic renal failure but can occur after transurethral resection of the prostate. The testicles atrophy in chronic renal failure; they do not hypertrophy. Additionally, chronic renal failure often leads to a state of depression, not euphoria.
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