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nclex

  1. 1. 1. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote: a. Relaxation and sleep b. Deep breathing and coughing c. Incisional healing d. Range of motion exercises 2. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? a. Clamp the chest tube b. Call the surgeon immediately c. Prepare for blood transfusion d. Continue to monitor the rate of drainage 3. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? a. Blood urea nitrogen 50 mg/dl b. Hemoglobin of 10.3 mg/dl c. Venous blood pH 7.30 d. Serum potassium 6 mEq/L 4. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? a. Blanch nail beds for color and refill b. Assess for post operative arrhythmias c. Auscultate for pulmonary congestion d. Monitor equality of peripheral pulses
  2. 2. 5. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? a. “The tube will drain fluid from your chest.” b. “The tube will remove excess air from your chest.” c. “The tube controls the amount of air that enters your chest.” d. “The tube will seal the hole in your lung.” 6. A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST? a. Notify the physician b. Readjust the traction c. Administer the ordered prn medication d. Reassess the foot in fifteen minutes 7. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST? a. Obtain a 12-lead EKG b. Place client in high Fowler’s position c. Lower the oxygen rate d. Take baseline vital signs 8. The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to: a. Wrap the leg with elastic bandages b. Apply pressure at the bleeding site
  3. 3. c. Reinforce the dressing and elevate the leg d. Remove the dressings and re-dress the incision 9. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform? a. Disconnect the client from the ventilator and use a manual resuscitation bag b. Perform a quick assessment of the client’s condition c. Call the respiratory therapist for help d. Press the alarm re-set button on the ventilator 10. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY? a. Blood urea nitrogen 50 mg/dl b. Hemoglobin of 10.3 mg/dl c. Venous blood pH 7.30 d. Serum potassium 6 mEq/L 11. A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action? a. Clamp the chest tube b. Call the surgeon immediately c. Prepare for blood transfusion d. Continue to monitor the rate of drainage 12. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain
  4. 4. management to promote: a. Relaxation and sleep b. Coughing and deep breathing c. Incisional healing d. Range of motion exercises 13. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management. a. Pallor b. Increased temperature c. Dyspnea d. Involuntary muscle spasms 14. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse? a. Breath sounds can be heard bilaterally b. Mist is visible in the T-Piece c. Pulse oximetery of 88 d. Client is unable to speak 15. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care? a. Esophagitis b. Leukopenia c. Fatigue d. Skin irritation 16. A client is diagnosed with a spontaneous pneumothorax
  5. 5. necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client? a. “The tube will drain fluid from your chest.” b. “The tube will remove excess air from your chest.” c. “The tube controls the amount of air that enters your chest.” d. “The tube will seal the hole in your lung.” 17. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY? a. Blanch nail beds for color and refill b. Assess for post operative arrhythmias c. Auscultate for pulmonary congestion d. Monitor equality of peripheral pulses 18. The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to: a. Maintain adequate hydration b. Assist client to turn, cough and deep breathe c. Ambulate client within 12 hours d. Splint incision 19. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? a. “I can’t lie in one position for more than thirty minutes.” b. “I am allergic to shrimp.” c. “I suffer from claustrophobia.” d. “I developed a severe headache after a spinal tap.” 20. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a
  6. 6. complication from the procedure? a. Increased blood pressure b. Increased heart rate c. Loss of pulse in the extremity d. Decreased urine output Answer and Rationale- Reduction of Risk Potential NCLEX Practice Test << Back to Questions 1. Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management. 2. Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest 3. Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately. 4. Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. 5. Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space. 6. Answer A. The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately. 7. Answer C. A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of
  7. 7. respiratory acidosis. Unless corrected, it can lead to the client’s death. 8. Answer C. Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation. 9. Answer B. A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist. 10. Answer D. Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately. 11. Answer D. Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest. 12. Answer B. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management. 13. Answer C. Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication. 14. Answer C. Pulse oximetry should not be lower than 90. 15. Answer B. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer. 16. Answer B. The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space. 17. Answer B. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. 18. Answer B. Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in
  8. 8. preventing atelectasis following surgery. 19. Answer B. A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures. 20. Answer C. Loss of the pulse in the extremity would indicate impaired circulation.

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