NCLEX Questions

A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. The nurse determines that further teaching is required if the client performs which action?

1. Holds the walker using the hand grips 2. Advances the walker with reciprocal motion 3. Leans forward slightly when advancing the walker 4. Supports body weight on the hands while advancing the weaker leg Answer: 2. Advances the walker with reciprocal motion Rationale: A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward 1 side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation.

A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period?

1.In 24 hours 2.In 48 hours 3.In about 8 hours 4.Within 20 to 30 minutes of application Answer: 4. Within 20 to 30 minutes of application Rationale: A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes.

Which nursing actions would indicate a need for further teaching as it applies to fire safety? Select all that apply.

1. Activates a fire alarm upon discovery of a fire 2. Aims the fire extinguisher at the top of the fire 3. Evacuates any clients that may be in immediate danger 4. Uses the mnemonic PASS to help extinguish the fire 5. Sweeps the fire extinguisher in an upward and downward motion Answer: 1, 2, 3, & 5 Rationale: Use the mnemonic RACE to prioritize in the event of a fire. R is rescue clients in immediate danger, A is alarm (sound the alarm), C is confine the fire by closing all doors, and E is extinguish.

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2º F (36.2º C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

1. Document the findings. 2.Attempt to arouse the client. 3.Contact the primary health care provider (PHCP) immediately. 4.Check the medication administration history on the PCA pump. Answer: 2. Attempt to arouse the client Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine if further action is needed. The nurse should contact the PHCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client.

The nurse should provide which home care instructions to a client who had a laryngectomy and has a stoma? Select all that apply.

1. Increase the humidity in the home. 2.Obtain and wear a MedicAlert bracelet. 3.Wear clothing that does not cover the stoma. 4.Stay away from people who have a respiratory infection. 5.Be careful with showering to avoid water entering the stoma. 6.Decrease fluid intake to prevent excessive secretions from the stoma. Answer: 1, 2, 4, 5 Rationale: The nurse should teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include obtaining a MedicAlert bracelet, avoiding exposure to people with infections, avoiding swimming, using care when showering, and preventing debris from entering the stoma. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.

No pain 2.Groin pain 3.Sciatic pain 4.Pain referred to the lower leg 5.Pain referred to the lower back 6.Pain referred to the back of the knee

1. No pain 2. Groin pain 3. Sciatic pain 4. Pain referred to the lower leg 5.Pain referred to the lower back 6.Pain referred to the back of the knee Answer: 1, 2, 5, & 6 Rationale: Clients with a fractured hip may have no pain, groin pain, pain referred to the lower back, or pain referred to the back of the knee. Sciatic pain and pain referred to the lower leg are not examples of complaints of pain related to hip fracture.

The nurse is assessing the status of pain in an alert older client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain? Select all that apply.

1. Pain is something that must be lived with. 2.Nurses are too busy to listen to reports of pain. 3.Pain signifies a serious illness or impending death. 4.Reporting pain will result in being labeled as a "bad" client. 5.Expressing pain is only done by people who want attention. 6.Nurses and other caregivers often give too much medication to older clients. Answer: 1, 2, 3, 4 Rationale: Some beliefs and concerns of older adults about pain include the following: pain is something that must be lived with, nurses are too busy to listen to reports of pain, pain signifies a serious illness or impending death, and reporting pain will result in being labeled as a "bad" client.

A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse should implement which action while using this solution?

1. Rinse off immediately following irrigation. 2.Pour onto sterile sponges, and pack in wound. 3.Let the solution run freely over normal skin tissue. 4.Use each bottle of solution for 2 weeks before replacing. Answer: 1. Rinse off immediately following irrigation Rationale: Sodium hypochlorite is a solution that is used for irrigating and cleaning necrotic or purulent wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. (It can be used to pack necrotic wounds, however.) It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. The solution is unstable, and it is best to prepare a fresh solution for use during each dressing change.

A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard?

1. Void into a bedpan and then empty the urine into the toilet. 2. Disinfect the toilet with bleach after voiding for 6 hours after a treatment. 3. Purchase extra bottles of scented disinfectant for daily bathroom cleansing. 4. Have 1 bathroom strictly set aside for the client's use for the next 2 months. Answer: 2. Disinfect the toilet with bleach after voiding for 6 hours after treatment Rationale: After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours after the treatment.

Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions?

1.Apply once a day and leave it open to the air. 2.Apply twice a day and leave it open to the air. 3.Apply twice a day and cover it with a sterile dressing. 4.Apply once a day and cover it with a sterile dressing. Answer: 4. Apply once a day and cover it with a sterile dressing. Rationale: Collagenase is used in the treatment of dermal lesions and severe burns. Its action is to debride the affected area. It is applied once daily and covered with a sterile dressing. Options 1, 2, and 3 are incorrect application procedures.

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client?

1.Ensure that a sterile safety pin is through the drain. 2.Measure the amount of drainage in a measuring container. 3.Establish that the drain is at the prescribed amount of suction. 4.Squeeze the suction device and close the port after emptying the drain. Answer: 1. Ensure tht a sterile safety pin is through the drain. Rationale: A Penrose drain is a soft, flat, flexible drain in which 1 end is placed in the wound or incision and the other end is outside the wound. It is an open drainage system that drains onto the skin surface or onto a dressing. It is not sutured in place and thus should have a sterile safety pin (or other device per agency procedure) inserted through it to prevent the drain from going all the way into the wound.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

1.Notify the surgeon. 2.Clamp the surgical drain. 3.Change the dressing as prescribed. 4.Remove and replace the perineal packing. Answer: 3. Change the dressing as prescribed Rationale: Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse should change the dressing as prescribed. A surgical drain should not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

1.Retest the pH using another strip. 2.Document that the nasogastric tube is in the correct place. 3.Check for placement by auscultating for air injected into the tube. 4.Call the primary health care provider to request a prescription for a chest radiograph. Answer: 4. Call the primary health care provider to request a prescription for a chest radiograph Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the stomach.

The nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse should assess for which characteristic of wound drainage expected in the immediate postoperative period?

1.Serous 2.Grossly bloody 3.Serosanguineous 4.Serous with sputum Answer: 3. Serosanguineous Rationale: Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction that drains serosanguineous fluid.

The primary health care provider writes a prescription to apply a heating pad to a client's back. Which intervention is contraindicated and is unsafe?

1.Setting the heating pad on a low setting 2.Assessing the skin frequently for burns 3.Placing the heating pad under the client 4.Using tape to hold heating pad in place Answer: 3. Placing the heating pad under the client Rationale: The heating pad should never be placed under the client, but it should be placed lightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad. Options 1, 2, and 4 are appropriate measures for the use of a heating pad.

A primary health care provider (PHCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the PHCP's use?

1.Telfa dressing and Neosporin ointment 2.Petrolatum gauze and sterile 4 × 4 gauze 3.Benzoin spray and a hydrocolloid dressing 4. .Sterile 4 × 4 gauze, Neosporin ointment, and tape Answer: 2. Petrolatum gauze and sterile 4 x 4 gauze Rationale: On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site.