NCLEX

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a t-tube. To evaluate the effectiveness of the t-tube, the nurse should: a) monitor the multiple incision sites for bile drainage. b) unclamp the t-tube and empty the contents every day. c) assess the color and amount of drainage every shift. d) irrigate the tube with 20 mL of normal saline every 4 hours.

C A t-tube is inserted in the common bile duct to maintain patency when there is a likelihood of edema. The tube remains in place until edema from the duct exploration subsides. The bile color should be gold to dark green, and the amount of drainage should be closely monitored to ensure tube patency. Irrigation is not routinely done, unless prescribed using a smaller volume of fluid. The t-tube is not clamped in the early postop period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions.

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? a) Baked beans, hamburger, and milk b) Spaghetti with cream sauce, broccoli, and tea c) Bouillon, spinach, and soda d) Chicken cutlet, spinach, and soda

A Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection.

Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? a) preservation of muscle mass b) maintenance of joint mobility c) increase in muscle tone d) prevention of bone demineralization

B The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind? a) The current reimbursement system recognizes the family's nontechnical value priorities. b) Nurses should avoid asking the family caregivers to conduct the skilled task. c) Family caregivers are always perceived to be supportive of good care. d) The nurse needs to be creative in integrating the technical and relational aspects of care.

D The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical value priorities. Nurses are expected to educate the family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be nonsupportive of good care if the families do not follow through.

A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract? a) Lavage. b) Compression. c) Decompression. d) Gavage.

C After abdominal surgery, the reason for inserting a NG tube is to decompress the gastrointestinal tract until peristaltic action returns. Compression may be used to control bleeding esophageal varices. Lavage is used to remove substances from the stomach or control bleeding. Gavage is used to provide enteral feedings.

A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? a) Instilling eye drops b) I.V. catheter insertion c) Nasogastric tube irrigation d) Colostomy irrigation

B Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority? a) Keeping the perineal area clean and dry b) Maintaining a fluid intake of 1 L/day c) Offering the client the urinal every 3 hours d) Applying moist, warm compresses to the client's groin

A Because the skin, the body's first line of defense, is broken and excoriated, keeping the area clean and dry is a priority and promotes healing. Offering the urinal every 3 hours would help set a voiding schedule; however, to avoid incontinence, the urinal should be offered more often. Fluid intake of 1 L/day is insufficient for a client who has been diagnosed as dehydrated, and the fluids wouldn't aid healing. Continued incontinence as well as moist compresses would contribute to additional skin excoriation and breakdown.

A nurse should question an order for a heating pad for a client who has: a) active bleeding. b) a reddened abscess. c) an edematous lower leg. d) purulent wound drainage.

A Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? a) "I will administer the enema while lying on my left side with my right knee flexed." b) "I will administer the enema while lying on my back with both knees flexed." c) "I will administer the enema while lying on my right side with my left knee flexed." d) "I will administer the enema while sitting on the toilet."

A Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

Which option is an example of a primary preventive measure? a) Avoiding overexposure to the sun b) Practicing monthly breast self-examination c) Having an annual physical examination d) Participating in a cardiac rehabilitation program

A Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; these measures typically include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client? a) The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions. b) Surgical wound infection is most likely to occur during the first postoperative day. c) The client's skin should be assessed hourly. d) The client should be encouraged to take food and fluids to prevent dehydration and malnutrition.

A The nurse should encourage the client to cough and breathe deeply as soon as possible after surgery to help prevent atelectasis and pneumonia. She shouldn't encourage the client to take food or fluids until bowel sounds are present (usually 24 hours postoperatively). Wound infection is a concern, but usually not during the first postoperative day. The nurse should assess the client's skin every 2 hours when he is made to either change position or get out of bed.

A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing? a) With two people, one at each side using a drawsheet, one person at the head, and one person at the feet. b) With two people, one at each side using a drawsheet, and one person at the head. c) With two people using a roller and a drawsheet. d) With two people at each side using a drawsheet.

A The nurse should plan for two people, one at each side using a drawsheet, one person at the head, and one person at the feet to transfer an elderly, drowsy client with fragile skin to avoid shearing of the integumentary system. Using only two or three people allows for dragging of some part of the client, which leads to shearing of the dependent part.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? a) The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. b) The alveoli expand and increase the lung surface available for ventilation. c) The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. d) There is increased blood flow to the lungs to allow them to recover from the trauma of surgery.

B Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon.

Which indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client: a) breathes in through the mouth and out through the nose. b) takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. c) breathes in through the nose and out through the mouth. d) uses diaphragmatic breathing in the lying, sitting, and standing positions.

B The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene.

A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff? a) A staff nurse fills a client prescription at the hospital pharmacy because the pharmacist on duty is busy. b) A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. c) A nursing assistant administers medications to a client in ICU. d) A nursing assistant attempts to initiate I.V. therapy.

B The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. A nurse-manager can't be held legally responsible for the nurse's refusal in this situation. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants, and a staff nurse isn't licensed to fill prescriptions.The nurse-manager can be held legally responsible for these actions.

The nurse is planning care for a client on complete bed rest. The plan of care should include all except: a) use of thromboembolic disease support (TED) hose. b) maintaining the client in the supine position. c) turning every 2 hours. d) passive and active range-of-motion exercises.

B Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? a) After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing. b) The client rinses around the clean incision site, using gauze squares moistened with normal saline. c) The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. d) The client rinses around the clean incision site, using gauze squares moistened with tap water.

B To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline — not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares.

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response? a) "Why don't you decide about activity after you return from recovery?" b) "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." c) "It is always a good idea to rest quietly after surgery, which will help minimize further pain." d) "The physician will probably order you to lie flat for 24 hours."

B To prevent venous stasis and improve muscle tone, circulation, and respiratory function, the client should be encouraged to move around after surgery. Pain medication will be administered to permit movement. Early ambulation with associated pain management reduces postoperative risk, and all other answers do not reflect this.

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize? a) Legumes and cheese b) Fruits and vegetables c) Lean meats and low-fat milk d) Whole grain products

C Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

As a nurse-manager of a medical-surgical unit reviews the month's risk-management data, she notices that a number of incident reports were completed because 6 p.m.(1800) medications were administered late. Dinner is served between 5:30 p.m. (1730) and 6 p.m. (1800). Staff take their dinner breaks between 5 p.m. (1700) and 6:30 p.m.(1830). Based on this information, which is the most appropriate action for the nurse-manager to take? a) Decide that the staff must postpone dinner breaks until at least 7 p.m. (1900). b) Terminate the nurses responsible for failing to administer medications on time. c) Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m. (1800), and staff availability between 5 p.m. (1700) and 6 p.m. (1800). d) Decide that the kitchen staff must change the time they deliver supper trays.

C An effective nurse-manager knows that to accurately evaluate risk-management findings, she must look at the entire process and the circumstances surrounding each incident. Terminating staff without such evaluation doesn't resolve all the problem's contributing factors. She shouldn't change dinner breaks or kitchen delivery times unless she has evaluated how these factors influence medication administration.

A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort? a) Negligence b) Right to refuse care c) Assault d) Battery

C Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

Which of the following nursing interventions is appropriate for preventing pressure ulcers in an older adult? a) Clean the skin daily using mild soap and hot water. b) Encourage the client to sit in a chair as much as possible. c) Perform a systematic skin assessment at least once a day. d) Massage bony prominences gently every shift.

C Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should be avoided. Massaging bony prominences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sitting should be avoided; the client's position should be adjusted at least every hour.

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions? a) The urine is a deep yellow. b) There is no odor present. c) The seal around the stoma is intact. d) The skin around the stoma is red.

C If the appliance becomes too full, it is likely to pull away from the skin completely or to leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly. The skin around the seal should not be red or irritated, which could indicate a leak. There will likely be an odor from the urine. Deep yellow urine indicates that the client should be increasing fluid intake.

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? a) Holding sterile objects above the waist b) Opening the outermost flap of a sterile package away from the body c) Pouring solution onto a sterile field cloth d) Leaving a 1″ (2.5-cm) edge around the sterile field

C Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.

A nurse is assessing a client 2 days after surgery for infection. Which sign or symptom is most indicative of infection? a) Rectal temperature of 100° F (37.8° C) b) The presence of pain at the incision site c) Red, warm, swollen, tender incision with foul drainage d) White blood cell (WBC) count of 8,000/μl

C Redness, warmth, swelling, tenderness, and foul drainage in the incision area indicate a postoperative infection. Pain at the incision site would be expected on postoperative day 2. A rectal temperature of 100° F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/μl. This client's WBC count falls within this normal range.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. Which of the following should happen in this case? a) The wishes of his family should be followed. b) The client should be resuscitated if he experiences respiratory arrest. c) The client should be treated with antibiotics for pneumonia. d) Pharmacologic interventions should not be initiated.

C The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? a) Tympanic b) Axillary c) Rectal d) Oral

C When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

Which intervention can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) working on a medical-surgical unit? a) Transfuse 1 unit packed red blood cells (RBCs) b) Teach a client with newly diagnosed diabetes how to perform blood glucose testing c) Administer morphine 4 mg IV bolus d) Administer zolpidem 5 mg as needed for sleep

D The nurse practice act regulates nursing licensure and practice. When delegating activities, the nurse should assess the experience of LPN/LVNs and be familiar with both the nurse practice acts and hospital policies. LPN/LVN can administer oral medications, but cannot administer IV medications, transfuse blood, or perform client teaching. In addition, registered nurses should provide most of the care for unstable clients so client acuity needs to be a consideration.

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to: a) apply a weakened alcohol solution to clean the area. b) wash the area with soap and water to disinfect it. c) remove the raised skin because the blister has already broken. d) clean the area with normal saline solution and cover it with a protective dressing.

D The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.

The nurse has just received change-of-shift report on four clients. Based on the following, the nurse should assess which of the following clients first? a) 38-year-old who is 2 days post-mastectomy due to breast cancer, having difficulty coping with the diagnosis. b) 84-year-old with resolving left-side weakness who is slightly confused and has been awake most of the night. c) 52-year-old with pneumonia and chronic back pain who is requesting pain medication. d) 35-year-old admitted after a motor vehicle accident whose urine output has totaled 30 mls over the last 2 hours.

D Urine output should be at least 500 ml in 24 hours (20 ml/hr); this client's output has been just 15 ml/hr for the past 2 hours, requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping to listen and further determine her needs.