NCLEX-PN
Kaplan NCLEX Question of The Day
1. The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct answer: C
Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume. Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.
2. 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.
3. When dressing a severe burn to the right hand, it is important for the nurse to:
- A. Apply a wet-to-dry dressing for debridement
- B. Wrap each digit individually to prevent webbing
- C. Open blisters to allow drainage prior to dressing
- D. Allow the client to do as much of the dressing change as possible
Correct answer: B
Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.
4. When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?
- A. perineal shave
- B. enema
- C. urine specimen collection
- D. blood specimen collection
Correct answer: B
Rationale: The correct answer is 'enema.' Administering an enema to a client with placenta previa can dislodge the placenta, leading to an increased risk of bleeding and complications. It is crucial to avoid any interventions that may disrupt the placenta's positioning. Collecting urine and blood specimens are necessary for diagnostic purposes and monitoring, while a perineal shave is a routine procedure that does not pose a risk to the client with placenta previa.
5. A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:
- A. creamy, pink-tinged vaginal drainage.
- B. stomatitis.
- C. constipation.
- D. xerostomia.
Correct answer: A
Rationale: The correct answer is 'creamy, pink-tinged vaginal drainage.' This side effect persists for 1 to 2 months after the removal of a cervical implant. Diarrhea, not constipation, is usually a side effect of cervical implants. Stomatitis and xerostomia are local side effects of radiation to the mouth, not associated with cervical implants. Therefore, choices B, C, and D are incorrect.
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