nclex questions 4100 exam 1 With Complete Solutions
A client admitted to the hospital with a suspected diagnosis of
acute pancreatitis is being assessed by the nurse. Which
assessment findings would be consistent with acute pancreatitis?
Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
5.Abdominal guarding and tenderness 6.Left upper quadrant
pain with radiation to the back Correct Answer 4, 5, 6
Rationale:Grayish-blue discoloration at the flank is known as
Grey-Turner's sign and occurs as a result of pancreatic enzyme
leakage to cutaneous tissue from the peritoneal cavity. The client
may demonstrate abdominal guarding and may complain of
tenderness with palpation. The pain associated with acute
pancreatitis is often sudden in onset and is located in the
epigastric region or left upper quadrant with radiation to the
back. The other options are incorrect.
A client being discharged home after renal transplantation has a
risk for infection related to immunosuppressive medication
therapy. The nurse determines that the client needs further
teaching on measures to prevent and control infection if the
client states that it is necessary to take which action?
1.Take an oral temperature daily.
2.Use good hand-washing technique.
3.Take all scheduled medications exactly as prescribed.
,4.Monitor urine character and output at least 1 day each week.
Correct Answer 4
Rationale:The client receiving immunosuppressive medication
therapy must learn and use infection control methods for use at
home. The client self-monitors urine output and its
characteristics on a daily basis. The client must learn proper
hand-washing technique and should take the temperature daily
to detect early infection. This is especially important because the
client also takes corticosteroids, which mask signs and
symptoms of infection. All medications should be taken exactly
as prescribed.
A client experiencing end-stage kidney disease has an
arteriovenous (AV) fistula placed surgically for hemodialysis.
Which action is most appropriate for the nurse to document in
the plan for care of the AV fistula?
1.Palpate the bruit of the AV fistula weekly to assess for
thrombosis.
2.Use the AV fistula site for blood draws to prevent increased
pain of multiple blood draws.
3.Take the blood pressure readings in the extremity with the AV
fistula to get a more accurate reading.
4.Teach the client to avoid carrying heavy objects that would
compress the AV fistula and cause thrombosis. Correct Answer
4
Rationale:An AV fistula is a vascular access system that is
required for hemodialysis. It is a device established for clients
who need long-term hemodialysis. It is created by connecting an
artery to a vein inside the body to create a vessel that can handle
the amount of blood flow necessary for effective dialysis.
,Bleeding, clotting, and infection are risks with all vascular
devices. It also is very important to avoid any activity that would
promote the status of blood or increase the risk for infection.
Taking the blood pressure in the affected arm, carrying heavy
objects in the arm, and lying on the arm at night could increase
the risk for clotting in the fistula. To check circulation of the
fistula, the nurse should palpate or feel for the thrill or auscultate
(listen with a stethoscope) for the bruit. It is important to do this
at least daily to ascertain the patency of the fistula. To avoid
infection, that extremity is never used for peripheral intravenous
access (placement of an intravenous line) or for blood draws.
Strict aseptic technique is used in accessing the fistula for
dialysis.
A client is admitted to the hospital with a diagnosis of acute
pancreatitis. Which would the nurse expect the client to report
about the pain?
1.Eating helps to decrease the pain.
2.The pain usually increases after vomiting.
3.The pain is mostly around the umbilicus and comes and goes.
4.The pain increases when the client sits up and bends forward.
Correct Answer 2
Rationale:Pain with acute pancreatitis usually increases after
vomiting because of an increase in intraductal pressure caused
by retching, which leads to further obstruction of the outflow of
pancreatic secretions. The pain is a steady and intense epigastric
pain that radiates to the client's back and flank. The pain may
lessen when the client sits up or bends forward. Eating
exacerbates the pain by stimulating the secretion of enzymes.
, A client is admitted to the hospital with suspected bladder
cancer. The nurse assesses the client for which early signs and
symptoms of the disease?
1.Proteinuria and dysuria
2.Hematuria and absence of pain
3.Painful urination and hematuria
4.Pyuria and palpable abdominal mass Correct Answer 2
Rationale:The most common earliest manifestation of bladder
cancer is hematuria that is not accompanied by pain. The
hematuria is intermittent at first. Later signs and symptoms
include hematuria with dysuria and frequency because of
bladder irritation. Pyuria and proteinuria are not part of the
clinical picture. A mass usually is not palpable.
A client is being evaluated as a potential kidney donor for a
family member. The client asks the nurse why separate teams
are evaluating donor and recipient. What is the most appropriate
response by the nurse?
1.Helps reduce the cost of the preoperative workup
2.Saves the client and the recipient valuable preoperative time
3.Avoids a conflict of interest between the team evaluating the
recipient and the team evaluating the donor
4.Provides for a sufficient number of persons reviewing the case
so that no information is overlooked Correct Answer 3
Rationale:Both the kidney donor and the kidney recipient need
thorough medical and psychological evaluation before transplant
surgery. Separate teams evaluate the donor and the recipient to
avoid a conflict of interest in providing care for the 2 clients.
A client admitted to the hospital with a suspected diagnosis of
acute pancreatitis is being assessed by the nurse. Which
assessment findings would be consistent with acute pancreatitis?
Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
5.Abdominal guarding and tenderness 6.Left upper quadrant
pain with radiation to the back Correct Answer 4, 5, 6
Rationale:Grayish-blue discoloration at the flank is known as
Grey-Turner's sign and occurs as a result of pancreatic enzyme
leakage to cutaneous tissue from the peritoneal cavity. The client
may demonstrate abdominal guarding and may complain of
tenderness with palpation. The pain associated with acute
pancreatitis is often sudden in onset and is located in the
epigastric region or left upper quadrant with radiation to the
back. The other options are incorrect.
A client being discharged home after renal transplantation has a
risk for infection related to immunosuppressive medication
therapy. The nurse determines that the client needs further
teaching on measures to prevent and control infection if the
client states that it is necessary to take which action?
1.Take an oral temperature daily.
2.Use good hand-washing technique.
3.Take all scheduled medications exactly as prescribed.
,4.Monitor urine character and output at least 1 day each week.
Correct Answer 4
Rationale:The client receiving immunosuppressive medication
therapy must learn and use infection control methods for use at
home. The client self-monitors urine output and its
characteristics on a daily basis. The client must learn proper
hand-washing technique and should take the temperature daily
to detect early infection. This is especially important because the
client also takes corticosteroids, which mask signs and
symptoms of infection. All medications should be taken exactly
as prescribed.
A client experiencing end-stage kidney disease has an
arteriovenous (AV) fistula placed surgically for hemodialysis.
Which action is most appropriate for the nurse to document in
the plan for care of the AV fistula?
1.Palpate the bruit of the AV fistula weekly to assess for
thrombosis.
2.Use the AV fistula site for blood draws to prevent increased
pain of multiple blood draws.
3.Take the blood pressure readings in the extremity with the AV
fistula to get a more accurate reading.
4.Teach the client to avoid carrying heavy objects that would
compress the AV fistula and cause thrombosis. Correct Answer
4
Rationale:An AV fistula is a vascular access system that is
required for hemodialysis. It is a device established for clients
who need long-term hemodialysis. It is created by connecting an
artery to a vein inside the body to create a vessel that can handle
the amount of blood flow necessary for effective dialysis.
,Bleeding, clotting, and infection are risks with all vascular
devices. It also is very important to avoid any activity that would
promote the status of blood or increase the risk for infection.
Taking the blood pressure in the affected arm, carrying heavy
objects in the arm, and lying on the arm at night could increase
the risk for clotting in the fistula. To check circulation of the
fistula, the nurse should palpate or feel for the thrill or auscultate
(listen with a stethoscope) for the bruit. It is important to do this
at least daily to ascertain the patency of the fistula. To avoid
infection, that extremity is never used for peripheral intravenous
access (placement of an intravenous line) or for blood draws.
Strict aseptic technique is used in accessing the fistula for
dialysis.
A client is admitted to the hospital with a diagnosis of acute
pancreatitis. Which would the nurse expect the client to report
about the pain?
1.Eating helps to decrease the pain.
2.The pain usually increases after vomiting.
3.The pain is mostly around the umbilicus and comes and goes.
4.The pain increases when the client sits up and bends forward.
Correct Answer 2
Rationale:Pain with acute pancreatitis usually increases after
vomiting because of an increase in intraductal pressure caused
by retching, which leads to further obstruction of the outflow of
pancreatic secretions. The pain is a steady and intense epigastric
pain that radiates to the client's back and flank. The pain may
lessen when the client sits up or bends forward. Eating
exacerbates the pain by stimulating the secretion of enzymes.
, A client is admitted to the hospital with suspected bladder
cancer. The nurse assesses the client for which early signs and
symptoms of the disease?
1.Proteinuria and dysuria
2.Hematuria and absence of pain
3.Painful urination and hematuria
4.Pyuria and palpable abdominal mass Correct Answer 2
Rationale:The most common earliest manifestation of bladder
cancer is hematuria that is not accompanied by pain. The
hematuria is intermittent at first. Later signs and symptoms
include hematuria with dysuria and frequency because of
bladder irritation. Pyuria and proteinuria are not part of the
clinical picture. A mass usually is not palpable.
A client is being evaluated as a potential kidney donor for a
family member. The client asks the nurse why separate teams
are evaluating donor and recipient. What is the most appropriate
response by the nurse?
1.Helps reduce the cost of the preoperative workup
2.Saves the client and the recipient valuable preoperative time
3.Avoids a conflict of interest between the team evaluating the
recipient and the team evaluating the donor
4.Provides for a sufficient number of persons reviewing the case
so that no information is overlooked Correct Answer 3
Rationale:Both the kidney donor and the kidney recipient need
thorough medical and psychological evaluation before transplant
surgery. Separate teams evaluate the donor and the recipient to
avoid a conflict of interest in providing care for the 2 clients.
