Kaplan NCLEX Question of The Day

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A client complaining of chest pain is prescribed an intravenous infusion of nitroglycerin (Nitro-Bid). After the infusion is initiated, the occurrence of which symptom warrants the nurse discontinuing an intravenous infusion of nitroglycerin?

  • A. Frontal headache
  • B. Orthostatic hypotension
  • C. Decrease in intensity of chest pain
  • D. Cool clammy skin
Correct Answer: D

Rationale: The correct answer is 'Cool clammy skin.' This assessment finding indicates decreased cardiac output that could result from excessive vasodilation. Cool clammy skin is a sign of poor perfusion, suggesting that the blood pressure might be dropping too low. Discontinuing the nitroglycerin infusion is crucial to prevent further complications.

Choice A, 'Frontal headache,' is a common side effect of nitroglycerin but not a reason to discontinue the infusion unless severe or persistent. Choice B, 'Orthostatic hypotension,' may occur as a side effect of nitroglycerin but does not necessarily warrant discontinuation unless severe. Choice C, 'Decrease in intensity of chest pain,' is actually an expected therapeutic response to nitroglycerin and indicates improved myocardial perfusion, so it is not a reason to stop the infusion.

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The nurse is caring for a client complaining of intense headaches with increasing pain for the past one month. An MRI is ordered. In reviewing the client's information, which piece of information is of concern?

  • A. Allergy to shellfish
  • B. Has a cardiac pacemaker
  • C. A diabetic
  • D. No IV access
Correct Answer: B

Rationale: The correct answer is 'Has a cardiac pacemaker.' If a client with a cardiac pacemaker undergoes an MRI, the magnetic field can interfere with the pacemaker's function, leading to serious complications or even death. It is crucial to ensure that the pacemaker is compatible with MRI imaging or to consider alternative imaging modalities. The other choices, such as 'Allergy to shellfish,' 'A diabetic,' and 'No IV access,' are not direct contraindications for an MRI scan and do not pose the same level of risk as having a cardiac pacemaker.

Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?

  • A. The hematocrit is adversely affected due to increased vascular volume.
  • B. AEDs can lead to blood dyscrasia as a side effect.
  • C. AEDs may cause aplastic anemia and megaloblastic anemia.
  • D. Some AEDs induce white blood cell reduction.
Correct Answer: B

Rationale: When a client is being treated with antiepileptic drugs (AEDs), it is essential to monitor for potential side effects on blood parameters. Some AEDs can lead to blood dyscrasia, which includes conditions like aplastic anemia and megaloblastic anemia. Therefore, drawing a complete blood count and differential helps in identifying these adverse effects early. Choices A, C, and D are incorrect because the primary concern when monitoring blood parameters in clients on AEDs is the risk of blood dyscrasia, not changes in hematocrit due to vascular volume, white blood cell reduction, or immune modulation.

A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?

  • A. Respiratory acidosis
  • B. Respiratory alkalosis
  • C. Metabolic acidosis
  • D. Metabolic alkalosis
Correct Answer: C

Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DKA). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones. Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis. Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction. Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis. Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.

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 most common cause of acute renal failure is shock. In cases of shock, such as hypovolemic shock where there is low blood volume, the kidneys receive inadequate blood flow leading to acute renal failure. This can result in the kidneys starting to die within 20 minutes of low pressure. While nephrotoxic drugs can also cause acute renal failure, shock is more commonly associated with this condition. An enlarged prostate can lead to urinary retention but is not the most common cause of acute renal failure. Diabetes, on the other hand, can cause chronic kidney disease over time but is not typically the primary cause of acute renal failure.

A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?

  • A. "I became dizzy when I stood up."?
  • B. "I was nauseated and began vomiting."?
  • C. "The pain started in my chest and stopped after I sat down."?
  • D. "The pain began with a migraine and progressed to numbness in my left arm."?
Correct Answer: B

Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.

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