NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 441:

  A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:

  A. Knowledge deficit

  B. Urinary retention

  C. Impaired physical mobility

  D. Ineffective breathing pattern

  Correct Answer: D

  (A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have a Foley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.

• Question 442:

  A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the client that to regulate the bowel, colostomy irrigation should be performed at

  the same time each day.

  The best time is:

  A. After meals

  B. Before meals

  C. Every 2 hours

  D. At bedtime

  Correct Answer: A

  (A) Bowel movements should be regulated at a specific time each day to prevent "accidents." Irrigating after meals takes advantage of the gastrocolic reflex and time of increased peristalsis, so better results may be produced. After meals is the normal time that peristalsis begins in most persons and evacuation of feces occurs. (B) Irrigating before meals may cause poor results because of decreased gastrocolic reflex and decreased peristalsis. (C) Irrigating a colostomy every 2 hours may produce hyperactivity of the bowel, leading to irritation and diarrhea. This would not aid in regulation of the bowel. (D) If irrigation of a colostomy were done at bedtime, there is greater chance of having an "accident" during sleep. This would not be an advantageous practice of bowel regulation.

• Question 443:

  Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:

  A. The nurse may lift only the weights that are applying traction in order to reposition him in bed

  B. The client will need special skin care at the pin site according to hospital policy or the physician's preference

  C. The traction pull should result in an immediate increase in comfort and reduce the need for pain medication

  D. The client should be discouraged from participating in self-care activities to avoid the risk of disrupting the traction

  Correct Answer: B

  (A) Skeletal traction, including the weights that are applying the traction, is never released by the nurse. (B) It is necessary to keep the pin site clean and free from infection. (C) When first placed in traction, the client may experience increased discomfort as a result of the traction pull fatiguing the muscle. (D) When the child in traction is allowed to participate in his care, it gives him a measure of control and helps him to cope with the situation.

• Question 444:

  A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as:

  A. 500 mL

  B. 540 mL

  C. 600 mL

  D. 655 mL

  Correct Answer: B

  (A, C, D) This answer is a miscalculation. (B) 1 oz = 30 mL; therefore, 18 oz x.

• Question 445:

  A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication's effectiveness, the nurse should monitor the:

  A. prothrombin time (PT)

  B. partial thromboplastin time (PTT)

  C. PTT-C

  D. Fibrin split products

  Correct Answer: A

  (A) PT evaluates adequacy of extrinsic clotting pathway. Adequacy of warfarin therapy is monitored by PT. (B) PTT evaluates adequacy of intrinsic clotting pathway. Adequacy of heparin therapy is monitored by PTT. (C) There is no such laboratory test. (D) Fibrin split products indicate fibrinolysis. This is a screening test for disseminated intravascular coagulation. Heparin therapy may increase fibrin split products.

• Question 446:

  A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?

  A. "I will not drive but ride in the front seat of the car with a seat belt on for my first doctor's appointment."

  B. "When I bathe tomorrow morning, I will be very careful not to get soap on my incision."

  C. "I am allowed to exercise by walking for short periods."

  D. "Teach my husband about the diet. He'll be doing all the cooking now."

  Correct Answer: C

  (A)

  Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt.

  (B)

  Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.

• Question 447:

  A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

  A. Loss of ability to speak and communicate effectively

  B. Aspiration and weight loss

  C. Secondary infection resulting from poor oral hygiene

  D. Drooling

  Correct Answer: B

  (A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.

• Question 448:

  A 47-year-old client comes to the emergency department complaining of moderate flank, abdominal, and testicular pain with nausea of 4 hours' duration. After physical examination and obtaining the client's history, the physician suspects urethral obstruction by calculi. The nurse realizes that the physician will order which one of the following diagnostic studies to best confirm the diagnosis?

  A. Cystoscopy

  B. Kidneys, ureter, bladder, x-ray of abdomen

  C. Intravenous pyelogram with excretory urogram

  D. Ureterolithotomy

  Correct Answer: C

  (A) Cystoscopy is an endoscopic procedure that uses an instrument (a cystoscope) to visualize the internal bladder and ureter structures and to capture and remove an obstructing stone. (B) Kidney, ureter, bladder x-ray is used to outline gross structural changes in the kidneys, ureter, and bladder and will determine the general location of a stone. (C) An intravenous pyelogram with excretory urogram is used to visualize the kidneys, kidney pelvis, ureters, and bladder. This procedure is used specifically to determine whether urethral obstruction is partial or complete; it shows the exact location of the stone and dilation of the ureter above the stone. (D) Ureterolithotomy is a surgical procedure in which the ureter is incised and the stone is manually removed because the stone is unable to pass through the ureter independently.

• Question 449:

  A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?

  A. High calcium, low phosphorus

  B. Low calcium, high phosphorus

  C. Two-gram sodium diet

  D. Low calcium and phosphorus, acid ash

  Correct Answer: D

  (A) The stones consist of calcium and phosphorus; therefore, these minerals should be avoided. A high-calcium diet is contraindicated. (B) A high-phosphorus diet is contraindicated. (C) A 2-g sodium diet is a cardiac diet. (D) A low-calcium and phosphorus diet will reduce further calculi formation.

• Question 450:

  A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:

  A. Two to 4 hours after the last drink

  B. Six to 8 hours after the last drink

  C. Immediately on admission D. Twenty-four hours after the last drink

  Correct Answer: B

  (A) This answer is incorrect. Alcohol withdrawal usually begins approximately 6? hours after the last drink. (B) This answer is correct. It takes approximately 6? hours for metabolism of alcohol. (C) This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. (D) This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6? hours of the last drink.