Kaplan NCLEX Question of The Day

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When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?

  • A. Allergies to shellfish
  • B. Date of last platelet donation
  • C. Time of last oral intake
  • D. Blood type
Correct Answer: B

Rationale: The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.

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When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?

  • A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
  • B. Risk for injury related to active loss of blood from the vascular space
  • C. Deficient knowledge related to the client's lack of understanding of the disease process
  • D. Impaired skin integrity related to the development of bruises and/or hematoma
Correct Answer: B

Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.

Which hormone is responsible for amenorrhea in the pregnant woman?

  • A. Progesterone
  • B. Estrogen
  • C. Follicle-stimulating hormone (FSH)
  • D. Human chorionic gonadotropin (hCG)
Correct Answer: A

Rationale: Correct! Progesterone is the hormone responsible for amenorrhea in pregnant women. Progesterone plays a crucial role in maintaining the uterine lining for implantation and supporting early pregnancy. High levels of progesterone during pregnancy suppress the normal menstrual cycle, leading to amenorrhea. Estrogen, FSH, and hCG do not directly cause amenorrhea in pregnant women. Estrogen is involved in the development of female secondary sexual characteristics, FSH is involved in the growth and maturation of ovarian follicles, and hCG is produced by the placenta to support the production of progesterone during pregnancy.

A healthcare provider is screening patients for various vaccines. Which of the following vaccines is contraindicated during pregnancy?

  • A. Diphtheria
  • B. Hepatitis B
  • C. Mumps
  • D. Tetanus
Correct Answer: C

Rationale: The correct answer is Mumps. The Mumps vaccine, along with the Rubella vaccine, is contraindicated during pregnancy due to the theoretical risk of affecting the developing fetus. Diphtheria, Hepatitis B, and Tetanus vaccines are considered safe during pregnancy and are often recommended to protect both the pregnant individual and the developing fetus. Therefore, choices A, B, and D are incorrect.

The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?

  • A. Pink-tinged
  • B. Straw-colored
  • C. Clear
  • D. Dark amber
Correct Answer: D

Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color. Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.

Which electrolyte imbalance would be the nurse's priority concern in the burn client?

  • A. Hypernatremia
  • B. Hyperkalemia
  • C. Hypoalbuminemia
  • D. Hypermagnesemia
Correct Answer: B

Rationale: The correct answer is hyperkalemia. In a burn client, the nurse's priority concern is hyperkalemia due to cell lysis, which releases potassium into the bloodstream. This can lead to dangerous levels of potassium in the blood. Hypernatremia (Choice A) is less likely in burn clients. Hypoalbuminemia (Choice C) can occur but is not the priority in the immediate management of a burn client. Hypermagnesemia (Choice D) is not typically associated with burn injuries.

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