NCLEX-PN
Kaplan NCLEX Question of The Day
1. What is the most common cause of acute renal failure?
- A. Shock
- B. Nephrotoxic drugs
- C. Enlarged prostate
- D. Diabetes
Correct answer: A
Rationale: The correct answer is 'Shock.' Acute renal failure is commonly caused by inadequate blood flow to the kidneys, which can occur in cases of shock. This leads to decreased kidney function and potential kidney damage. While nephrotoxic drugs can also cause acute renal failure, shock is the primary and most common cause. An enlarged prostate may lead to obstructive uropathy but is not the most prevalent cause of acute renal failure. Diabetes is typically associated with chronic kidney disease rather than acute renal failure.
2. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
- A. Stay with the client, remove the dressing, and elevate the head of bed.
- B. Call a code, open the trach set, and position the client supine.
- C. Have the client say "EEE"? to check for laryngeal integrity.
- D. Immediately go to the nurse's station and call the physician
Correct answer: A
Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.
3. A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?
- A. Request a private room on the GYN floor
- B. Assign her to a private room on the postpartum unit
- C. Discharge her home as soon as her condition is stable
- D. Room her with another client who experienced a pregnancy loss
Correct answer: A
Rationale: In this situation, the most appropriate room assignment for the client who delivered a stillborn infant would be to request a private room on the GYN floor. This client needs privacy to grieve, and having a private space allows for family members to offer support. Placing her in a GYN unit ensures that she is away from the maternity unit's sights and sounds, which could be painful reminders for her. Assigning her to a postpartum unit may cause distress due to the presence of other mothers and newborns. Discharging her home too early may not allow her sufficient time for emotional and physical recovery. Rooming her with another client who experienced a pregnancy loss may not provide the necessary privacy and space she needs for her emotional well-being.
4. A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- A. Secure the restraints to the bed rails on all extremities.
- B. Notify the physician that restraints have been placed properly.
- C. Communicate with the patient and family the need for restraints.
- D. Position the head of the bed at a 45-degree angle.
Correct answer: C
Rationale: In cases where restraints are considered necessary for a patient, it is crucial to communicate effectively with both the patient and their family about the reasons for this decision. This helps ensure that all parties involved understand the necessity of restraints and are informed about the potential risks and benefits. Option A, securing restraints to the bed rails on all extremities, is not appropriate as it does not involve proper communication or ethical considerations. Option B, notifying the physician that restraints have been placed properly, overlooks the importance of patient and family involvement in decision-making. Option D, positioning the head of the bed at a 45-degree angle, is unrelated to the use of restraints and does not address the situation at hand.
5. A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?
- A. With a physical therapist treating the patient
- B. With a social worker planning for discharge
- C. With another nurse on duty to plan for break time
- D. In the hallway outside the patient's room
Correct answer: D
Rationale: The correct answer is 'In the hallway outside the patient's room.' Discussing client information in a public area like a hallway can potentially breach patient confidentiality as it increases the risk of unauthorized individuals overhearing sensitive information. Choices A, B, and C involve discussing client information with other healthcare professionals in appropriate settings, which are more likely to maintain patient confidentiality compared to discussing in a public space like a hallway. Option D is the correct choice because it highlights a scenario where patient information is at higher risk of exposure to unauthorized individuals, hence violating patient confidentiality.
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