Comprehensive NCLEX-RN| Exam #8: (75 Questions and Correct Answers/ Rationale (2022 update) Grade A

Comprehensive NCLEX-RN| Exam #8: (75 Questions and Correct Answers/ Rationale (2022 update) Grade A 70. Question Category: Safe and Effective Care Environment The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the: A. Serum collection (Davol) drain B. Client’s pain C. Nutritional status D. Immobilizer Correct Answer: A. Serum collection (Davol) drain Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Maintain patency of drainage devices when present. Note characteristics of wound drainage. Reduces the risk of infection by preventing the accumulation of blood and secretions in the joint space (medium for bacterial growth). Purulent, non serous, odorous drainage is indicative of infection, and continuous drainage from incision may reflect developing skin tract, which can potentiate the infectious process. 71. Question Category: Health Promotion and Maintenance Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates an understanding of the nurse’s teaching? A. "I must flush the tube with water after feedings and clamp the tube." B. "I must check placement four times per day." C. "I will report to the doctor any signs of indigestion." D. "If my father is unable to swallow, I will discontinue the feeding and call the clinic." Correct Answer: A. “I must flush the tube with water after feedings and clamp the tube.” The client’s family member should be taught to flush the tube after each feeding and clamp the tube. PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. 72. Question Category: Physiological Integrity The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor? A. Bleeding on the dressing is 3cm in diameter. B. The client has a temperature of 100.6°F (38.1°C). C. The client’s hematocrit is 26%. D. The urinary output has been 60 during the last 2 hours. Correct Answer: C. The client’s hematocrit is 26%. The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Results from a hematocrit test are reported as the percentage of blood cells that are red blood cells. Normal ranges vary substantially with race, age, and sex. The definition of normal red-blood-cell percentage also varies from one medical practice to another. 73. Question Category: Health Promotion and Maintenance The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism? A. The client has traveled out of the country in the last 6 months. B. The client’s parents are skilled stained-glass artists. C. The client lives in a house built in one. D. The client has several brothers and sisters. Correct Answer: B. The client’s parents are skilled stained-glass artists. Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. 74. Question Category: Safe and Effective Care Environment A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living? A. High-seat commode B. Recliner C. TENS unit D. Abduction pillow Correct Answer: A. High-seat commode The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. There is also equipment available for patients to help them follow their newly prescribed hip precautions. Some patients purchase raised toilet seats and chairs to prevent them from bending at the hip more than 90 degrees. 75. Question Category: Physiological Integrity An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should: A. Administer oxygen via nasal cannula B. Have narcan (naloxone) available C. Prepare to administer blood products D. Prepare to do cardio resuscitation Correct Answer: B. Have narcan (naloxone) available Narcan is the antidote for narcotic overdose. Naloxone is indicated for the treatment of opioid toxicity, specifically to reverse respiratory depression from opioid use. It is useful in accidental or intentional overdose and acute or chronic toxicity. Common opioid overdoses treated with naloxone include heroin, fentanyl, carfentanil, hydrocodone, oxycodone, methadone, and others. 1. Question Category: Physiological Integrity A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? A. Sexual dysfunction related to radiation therapy B. Anticipatory grieving related to terminal illness C. Tissue integrity related to prolonged bed rest D. Fatigue related to chemotherapy Correct Answer: A. Sexual dysfunction related to radiation therapy Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Know the importance of sex to individual, partner, and patient’s motivation for change. Because lymphomas often affect the relatively young who are in their productive years, these people may be affected more by these problems and may be less knowledgeable about the possibilities of change. 2. Question Category: Physiological Integrity A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor: A. Platelet count B. White blood cell count C. Potassium levels D. Partial prothrombin time (PTT) Correct Answer: A. Platelet count Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. The laboratory tests will show low platelet count, usually 40×10^9/L for over three months. Blood film shows large platelets and tiny platelet fragments. Bone marrow examination shows an increased number of megakaryocytes. 3. Question Category: Physiological Integrity The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, it will be most important to teach the client and family about: A. Bleeding precautions B. Prevention of falls C. Oxygen therapy D. Conservation of energy Correct Answer: A. Bleeding precautions The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Review laboratory results for coagulation status as appropriate: platelet count, prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen, bleeding time, fibrin degradation products, vitamin K, activated coagulation time (ACT); and educate the at-risk patient and caregivers about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. 4. Question Category: Physiological Integrity A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? A. Place the client in Trendelenburg position for postural drainage B. Encourage coughing and deep breathing every 2 hours C. Elevate the head of the bed 30° D. Encourage the Valsalva maneuver for bowel movements Correct Answer: C. Elevate the head of the bed 30° Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. A, B, and D are incorrect. In the immediate postoperative period, patients are monitored in an intensive care unit with monitoring for neurological deterioration, epistaxis, visual dysfunction, diabetes insipidus (DI), and hypotension secondary to acute hypocortisolism. 5. Question Category: Physiological Integrity The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: A. Measure the urinary output B. Check the vital signs C. Encourage increased fluid intake D. Weigh the client Correct Answer: B. Check the vital signs A large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension). Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume. 6. Question A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding? A. Place the client in a sitting position with the head hyperextended B. Pack the nares tightly with gauze to apply pressure to the source of bleeding C. Pinch the soft lower part of the nose for a minimum of 5 minutes D. Apply ice packs to the forehead and back of the neck Correct Answer: C. Pinch the soft lower part of the nose for a minimum of 5 minutes The client should be positioned upright and leaning forward, to prevent aspiration of blood. Usual sites of external bleeding may include the bleeding in the mouth from a cut, bite, or from cutting or losing a tooth; nosebleeds for no obvious reasons; heavy bleeding from a minor cut, or bleeding from a cut that resumes after stopping for a short time. Hemophiliacs do not bleed faster or more frequently. Instead, they bleed longer due to a deficiency of clotting factor. Clients are often aware of bleeding before clinical manifestation. Bleeding can be life-threatening to these clients. 7. Question Category: Physiological Integrity A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is: A. Blood pressure B. Temperature C. Output D. Specific gravity Correct Answer: A. Blood pressure Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Primary adrenal insufficiency occurs after bilateral adrenalectomy. Signs and symptoms are volume depletion, hypotension, hyponatremia, hyperkalemia, fever, abdominal pain. Patients are managed by replacement therapy based on glucocorticoids (hydrocortisone or cortisone), mineralocorticoids (fludrocortisone) in cases of confirmed corticoids or aldosterone deficiency, respectively.