Chap 11,13, & 14 NCLEX questions

(PDA Chap 12 page 106 #7) The nurse is taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to attention of the surgeon? 1. Obesity for approximately 5 years 2. history of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal age, gender and height

#2 Body dysmorphic disorder is preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment. Focus: Prioritization

(pg. 275 #205) A client is to have gastric savage. In which position should the nurse place the client when the nasogastric tube is being inserted? 1. Supine 2. Mid-Fowler 3. High-Fowler 4. Trendelenburg

Correct #3 The High-fowlers position promotes optimal entry into the esophagus aided by gravity. Reasons why the other answers are incorrect: 1, 2 This position does not take full advantage of the effect of gravity. 4 This position will contribute to aspiration. The head of the bed should be raised, not lowered.

(Pg 57 # 72) A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1. Orient the client to the unit environment. 2. Have a copy of hospital regulations available. 3. Explain that there is no reason to be concerned. 4. Reassure the client that the staff is available to answer questions.

Correct 1. Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment Reasons why the other answers are incorrect: 2. This is part of orienting the client to the unit. This alone is not enough when orienting a client to the hospital. 3. This may be false reassurance, because no one can guarantee that there is no reason to be concerned. 4. This implies that staff members are available only if the client has specific questions.

(Pg 59 #103) What principle must a nurse consider when caring for a client with a closed wound drainage system? 1. Gravity causes fluids to flow down a pressure gradient. 2. Fluid flow rate is determined by the diameter of the lumen. 3. Siphoning causes fluids to flow from one level to a lower level 4.Fluids flow from an area of higher pressure to one of lower pressure.

Correct: 4. A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device. Reasons why the other answers are incorrect: 1. This is Newton's law of gravity, which is not the physical principle underlying the functioning of a portable wound drainage system. 2 & 3 Although true, this is not what causes the fluid to drain in a portable wound drainage system

(Pg 59 #104) A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely? 1. Sodium 2. Calcium 3. Chloride 4. Potassium

Correct: 4. Release of adrenocortical steroids (cortisol) by the stress of surgery causes renal retention of sodium and excretion of potassium. Reasons why the other answers are incorrect: 1. Although sodium may be depleted by nasogastric suction, retention by the kidneys generally balances this loss 2 & 3 This is not depleted by surgery or urinary excretion.

(pg. 278 #235) A client is admitted to the surgical unit from the post anesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? 1. Use normal saline to irrigate the tube. 2. Employ sterile technique when irrigating the tube. 3. Withdraw the tube quickly when decompression is terminated. 4. Allow the client to have small sips of ice water unless nauseated.

Correct: 1. Patency of the tube should be maintained to ensure continued suction. Use of normal saline minimizes build and electrolyte disturbances during irrigation. Reasons why the other answers are incorrect: 2. The stomach is not considered a sterile body cavity, so medical asepsis is indicated. 3. Care must be taken to avoid traumatizing the mucosa 4. Ice chips and water represent fluid intake, which must be approved by the health care provider; being hypotonic in nature, such intake may lower the level of serum electrolytes.

(pg. 278 #236) After a partial gastrectomy is performed, a client is returned from the post anesthesia care unit to the surgical unit with an IV solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is an order for instillation of the nasogastric tube pen. The nurse should instill: 1. 30 mL of normal saline and continue the suction. 2. 20 mL of air and clamp off the suction for 1 hour. 3. 50 mL of saline and increase the pressure of the suction 4. 15 mL of distilled water and disconnect the suction for 30 minutes.

Correct: 1. Physiologic normal saline is used in gastric instillations to prevent electrolyte imbalance. Because of fresh gastric sutures, slow and gentle instillation of saline should be performed to reestablish patency of the tube, and then the tube should be reconnected to suction to ensure stomach decompression. Reasons why the other answers are incorrect: 2, 4 The purpose of the instillation is to maintain the patency of the tube for gastric decompression; with disconnection from suction, a buildup of secretions and air can occur, or the tube can become blocked by viscous drainage. 3. Increasing the pressure may cause damage to the suture line.

(Pg 59 #101) A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? 1. Attempt to identify the client's concerns. 2. Reassure the client that the surgery is routine. 3. Report the client's anxiety to the health care provider. 4. Provide privacy by pulling the curtain around the client.

Correct: 1. The nurse should assess the situation before planning an intervention. Reasons why the other answers are incorrect: 2. This minimizes concerns and cuts off communication 3. This is premature; more information is needed. 4. The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.

(Pg 780 #105) A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? 1. "Don't worry; these tests are routine." 2. "They are done to identify other health risks." 3. "They determine whether surgery will be safe." 4. "I don't know; your health care provider ordered them."

Correct: 2. Certain diagnostic test (e.g. CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery Reasons why the other answers are incorrect: 1. Feelings will not be dispelled by this response; it also blocks further communication 3. Surgery poses a risk despite test results. 4. Lack of knowledge without a statement of plans to obtain the information suggests incompetence on the part of the nurse.

(Pg 59 #99) While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1. "I don't mind it." 2. "You seem upset." 3. "This is part of my job." 4. "Nurses get used to this"

Correct: 2. The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Reasons why the other answers are incorrect: 1. & 4. This response negates the client's feelings and presents a negative connotation 3. This response focuses on the task rather than on the client's feelings

(pg. 278 #234) Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's nasogastric tube is bright red. What should the nurse do first? 1. Notify the health care provider. 2. Clamp the nasogastric tube for one hour 3. Determine that this is an expected finding 4. Irrigate the nasogastric tube with iced saline

Correct: 3. Nasogastric drainage is expected to be bright red during the first 12 hours after surgery in response to hemostasis in the surgical area. Reasons why the other answers are incorrect: 1. This is unnecessary; bloody drainage is expected this soon after surgery 2. Nasogastric suction must be working, and the tube must remain patent to prevent stress on the suture line. 4. The nasogastric tube is only irrigated if the health care provider orders it because of the danger of injury to the suture line; generally saline at room temperature is ordered.

(Pg 53 #24) What should the nurse do initially when obtaining consent for surgery? 1. Describe the risks involved in the surgery. 2. Explain that obtaining the signature is routine for any surgery. 3. Witness the client's signature, which the nurse's signature will document. 4. Determine whether the client's knowledge level is sufficient to give consent.

Correct: 4. Informed consent means the client must comprehend the surgery, the alternatives, and the consequences. Reasons why the other answers are incorrect: 1. This description is not within nursing's domain. 2. Although this is true, it does not determine the client's ability to give informed consent. 3. Although this is true, the nurse should first assess the client's knowledge of the surgery