Exam 1 NCLEX Practice

a) Ask the client to rate the dyspnea on a scale of 0 to 10. All answers are correct but A is best because dyspnea is subjective & we can re evaluate to see if interventions are working

A nurse is providing care to a terminally ill client who admits to experiencing dyspnea. Which of the following would be the best to do to assess the severity of the client's symptom? a) Ask the client to rate the dyspnea on a scale of 0 to 10. b) Have the client state if the dyspnea is mild, moderate, or severe. c) Question the client about when the dyspnea eases or worsens. d) Auscultate the client's lung sounds for changes.

a. Arteriography b. Open reduction of a fracture d. Cystoscopy f. Paracentesis

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply. a. Arteriography b. Open reduction of a fracture c. Insertion of a urethral catheter d. Cystoscopy e. Insertion of a peripheral intravenous line f. Paracentesis

isotonic hypotonic

A patient is dehydrated. First administer a ________ IV solution, then a ___________ IV solution if necessary.

D. Manage oxygenation status ABCs!

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? A. Manage patient pain B. Control the bleeding C. Maintain fluid balance D. Manage oxygenation status

d. History of cardiac and pulmonary disease.

All clients having surgery have a degree of risk associated with the surgery. The nurse would evaluate which of the following client-related factors as contributing to a high degree of risk associated with surgery? a. Institution reputation. b. Average nutritional status. c. Little likelihood of complications. d. History of cardiac and pulmonary disease.

a. Patient complaint of pain and visible swelling in calf

In monitoring a client for post-operative complications, which of the following is an indication of a potential complication that warrants notifying the MD? a. Patient complaint of pain and visible swelling in calf b. Clear yellow urine output of 30cc/h c. Heart rate of 92 and BP of 100/64. d. A rectal temp of 99.6F.

d. Assessment of breath sounds and encouraging deep breathing. ABCs!

In the first 24 hours postop following bowel surgery, the nurse gives priority to: a. Assessment of urine output and encouraging oral intake. b. Assessment for infection and changing wound dressing. c. Assessment of bowel function and controlling nausea. d. Assessment of breath sounds and encouraging deep breathing.

b) Normalizing adaptation to a continuation of the old life

Many people find the referral to a grief support group both comforting and beneficial after the death of a loved one. What is the most important accomplishment available by attending a grief support group? a) Providing a framework for incorporating the old life into the new life b) Normalizing adaptation to a continuation of the old life c) Aiding in adjusting to using old, familiar social skills d) The normalization of feelings and experiences

d. Pain unrelieved by medication.

The effectiveness of preoperative teaching will be most negatively influenced by: a. The presence of a significant other during the teaching session. b. Concern regarding the amount of insurance reimbursement. c. Prior experience with surgery in family members. d. Pain unrelieved by medication.

B. Assess the patient's vital signs

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? A. Assess the patient's pain B. Assess the patient's vital signs C. Check the rate of the IV infusion D. Check the physician's postoperative orders

B. Restoring circulating volume Hang normal saline!

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? A. Blood administration B. Restoring circulating volume C. An EKG to check circulatory status D. Return to surgery to check for internal bleeding

c. Verifies that the operative consent is signed.

The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function? a. Completes the preoperative assessment. b. Develops a plan of care. c. Verifies that the operative consent is signed. d. Provides psychological support.

b. Stage II: Excitement

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. a. Stage I: Beginning anesthesia b. Stage II: Excitement c. Stage III: Surgical anesthesia d. Stage IV: Medullary depression

a. Identify potential or actual health problems.

Which of the following activities would the nurse carry out in the preoperative period for a client scheduled for surgery? a. Identify potential or actual health problems. b. Perform specialized procedures to assure safety. c. Assess client's responses to interventions. d. Intervene to prevent complications.

a. Maintain patient safety (airway & circulation)

Which of the following is the most important initial nursing activity in the postoperative recovery area? a. Maintain patient safety (airway & circulation) b. Administer medications and fluids c. Assess level of pain d. Inspect the surgical site

c) Oral Acetaminophen Start with Tylenol, unless pt is vomiting or cannot swallow. Can give Tylenol on an empty stomach.

Which of the following should the RN recommend the patient try from his "hospice E-kit" when he states his pain is 8/10? a) Oral Haldol liquid b) Oral Morphine liquid c) Oral Acetaminophen d) Oral Atropine sulfate drops