NURSING NCLEX modle 9 questions with correct answers and rationale*graded A*

1. Questions 1. 1.ID: 8 A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? 1. 1.ID: 8 A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9 A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright­red blood. The nurse should take which immediate action? Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 5 A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 8 A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). Awarded 2.0 points out of 2.0 possible points. 5. 5.ID: 9 A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? warded 1.0 points. 6. 6.ID: 7 A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9 A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. Which action should the nurse take first? Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9 A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 6 A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9 A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: 1 A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client’s room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first? Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 7 A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 1 A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 7 A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client’s room before allowing the client to drink? Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 7 A client in the postanesthesia care unit has an as­needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 3 A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 8 A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time? Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 4 A nurse receives a telephone call from a nurse on the post­anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 1 A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? % Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 6 A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply. creatinine 0.8 mg/dL (70 μmol/L) ...............................................continued...............................................