NCLEX REVIEW Theory Exam 1

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take?

Stay with the patient and encourage him or her to remain still

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is MOST LIKELY to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery"

A client is being discharged to home after application of a plaster leg class. Which statement indicates that the client understands proper care of the cast?

"I need to avoid getting the cast wet"

The nurse has conducted preoperative reaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client NEEDS ADDITIONAL TEACHING if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery"

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

"I need to report a fever or swelling to my HCP"

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is MOST APPROPRIATE for the nurse to make to the client at this time as it relates to these techniques?

"Use of an incentive spirometer will help prevent pneumonia"

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor?

Bending or lifting

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which intervention should the nurse take? SATA

1. Contact the surgeon 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken

In monitoring a clients response to disease modifying antirheumatic drugs (DMARDS), which assessment findings would the nurse consider acceptable responses? SATA

1. Control of symptoms during periods of emotional stress 2. Normal WBC, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into surgery.

The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? SATA

1. I should not use someone elses crutches 2. I need to remove my scatter rugs at home 3. I need to have spare crutches and tips available

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? SATA

1. Keep the cast clean and dry 2. Allow the cast 24-72 hours to dry 3. Keep the cast and extremity elevated

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

A sedentary 65-year-old woman who smokes cigarettes

The nurse receives a telephone call form the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action FIRST on arrival to the client?

Assess the potency of the airway

The nurse is preparing discharge instructions for a client receiving baclofen. Which instruction should be included in the teaching plan?

Avoid the use of alcohol

The nurse is caring for a client being treated fir fat embolus after multiple fractures. Which data would the nurse evaluate as the MOST favorable indication of resolution of the fat embolus?

Clear mentation

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide?

Drink 3000 mL of fluid a day

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be BEST for the casted leg?

Elevated on pillows continuously for 24-48 hours

Cyclobenzaprine is prescribed for a client for muscle spasms and the nurse is reviewing the clients record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication?

Glaucoma

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before going into surgery

A client who has undergone readmission testing has had a blood drawn for serum laboratory studies including a complete blood count, coagulations studies, and electrolyte and creatinine levels. Which laboratory result should be reported to the surgeons office by the nurse, knowing that it could cause surgery to be postponed?

Hemoglobin, 8.0 g/dL

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

Impaired tissue perfusion

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become MOST concerned with which sign that could indicate an evolving complication?

Increasing restlessness

A client being measured for crutches asked the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would MOST LIKELY result from this improper crutch measurement?

Injury to the brachial plexus

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the clients record, knowing that this medication would be used with caution in which disorder?

Kidney disease

The nurse is analyzing the laboratory studies on a client recovering dantrolene. Which laboratory test would identify an adverse effect associated with the administration of this medication?

Liver function tests

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome?

Numbness and tingling in the fingers

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which MOST APPROPRIATE action in the care of this client?

Obtain a telephone consent from a family member, following agency policy

The nurse is reviewing a surgeons prescriptions sheet for a preoperative client that states that the client must be NPO after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?

Prednisone

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?

Presence of a "hot spot" on the cast

A client with a hip fracture asks the nurse about Buck's extension traction that is being applied before surgery and what is involved. The nurse should provide which information to the client?

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels.

The nurse is caring for a client who had an above the knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which IMMEDIATE action should the nurse take?

Rewrap the residual limb with an elastic compression bandage

A client who has diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at MOST risk for after surgery?

Separation of the wound edges

The nurse assess a clients surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Serous drainage

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide?

Take the medication with a full glass of water after rising in the morning

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be MOST concerned with which assessment finding?

Temperature of 101.6 orally

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is MOST IMPORTANT for the nurse to assess?

The white blood cell counts and platelet counts

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be MOST concerned with which finding?

Thick, yellow drainage from the pin sites

The nurse is caring for a client with a diagnosis of gout. Which lab value would the nurse expect to more in the client?

Uric Acid level of 9.0 mg/dL

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter MOST carefully during the next hour?

Urinary output of 20 mL/hour