NCLEX NCLEX-PN
Kaplan NCLEX Question of The Day
1. While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse’s next action?
- A. Leave the scabbed area alone and apply extra ointment
- B. Notify the physician
- C. Gently remove the debris and re-dress the wound
- D. Apply skin softening lotion for 3 hours and then re-dress
Correct answer: Gently remove the debris and re-dress the wound
Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.
2. An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
- A. “I think I was a lonely child because I could not tell anyone about my abuse.”
- B. “I am now aware of how deep-seated my anger is. Before, I did not realize I was angry.”
- C. “The program has given me the courage to tell my mother how I felt about her role in my hurt.”
- D. “There are so many people just like me, who are just normal people that had bad things happen to them.”
Correct answer: “I am now aware of how deep-seated my anger is. Before, I did not realize I was angry.”
Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.
3. The physician's role in case management includes all of the following except:
- A. participating in interdisciplinary planning for clients.
- B. serving as the expert for resource utilization.
- C. consulting with the case management team to facilitate timely orders as needed.
- D. contributing to the documentation of a client's needs for services.
Correct answer: serving as the expert for resource utilization.
Rationale: The correct answer is 'serving as the expert for resource utilization.' While physicians play a crucial role in case management, their primary focus is on medical diagnosis and treatment rather than resource utilization. Choices A, C, and D are all roles that physicians typically fulfill in case management. A physician participating in interdisciplinary planning for clients ensures comprehensive care, consulting with the case management team helps in coordinating timely orders, and contributing to the documentation of a client's needs for services aids in providing appropriate care. Therefore, serving as the expert for resource utilization does not align with the primary responsibilities of a physician in case management.
4. A patient's nurse taking a history notes complaints of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia and hypertension. Which of the following may be occurring?
- A. The patient may be developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct answer: The patient may be having a MI
Rationale: In this scenario, the patient's symptoms of shortness of breath (SOB) and weakness in the lower extremities, along with a history of hyperlipidemia and hypertension, are suggestive of a myocardial infarction (MI). It is important to note that MI can present with a variety of symptoms, including those affecting the respiratory system and muscle weakness. Choices A, C, and D are incorrect because the patient's symptoms are more indicative of a myocardial infarction rather than congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or peripheral vascular disease (PVD).
5. What classification of drug is Diltiazem?
- A. Calcium-Channel Blocker
- B. NSAID
- C. ACE Inhibitor
- D. Beta-Blocker
Correct answer: Calcium-Channel Blocker
Rationale: Diltiazem belongs to the class of calcium-channel blockers, not NSAIDs, ACE Inhibitors, or Beta-Blockers. Calcium-channel blockers like Diltiazem are used to treat conditions such as hypertension by relaxing blood vessels and increasing the supply of blood and oxygen to the heart. Therefore, the correct classification for Diltiazem is a Calcium-Channel Blocker. NSAIDs, ACE Inhibitors, and Beta-Blockers belong to different classes of drugs with distinct mechanisms of action and therapeutic uses, making them incorrect choices for Diltiazem.
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