NCLEX Quiz: Reduction Of Risk Potential In Medicine

1. The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to:

Maintain adequate hydration

Assist client to turn, cough and deep breathe

Ambulate client within 12 hours

Splint incision

Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.

Explanation

Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.

2. A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST?

Notify the physician

Readjust the traction

Administer the ordered prn medication

Reassess the foot in fifteen minutes

The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.

Explanation

The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.

3. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?

“I can’t lie in one position for more than thirty minutes.”

“I am allergic to shrimp.”

“I suffer from claustrophobia.”

“I developed a severe headache after a spinal tap.”

A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.

Explanation

A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.

4. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:

Relaxation and sleep

Coughing and deep breathing

Incisional healing

Range of motion exercises

The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

Explanation

The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

5. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse?

Breath sounds can be heard bilaterally

Mist is visible in the T-Piece

Pulse oximetery of 88

Client is unable to speak

Pulse oximetry should not be lower than 90.

Explanation

Pulse oximetry should not be lower than 90.

6. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:

Relaxation and sleep

Deep breathing and coughing

Incisional healing

The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

Explanation

The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

7. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

Blood urea nitrogen 50 mg/dl

Hemoglobin of 10.3 mg/dl

Venous blood pH 7.30

Serum potassium 6 mEq/L

Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

Explanation

Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

8. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

Pallor

Increased temperature

Dyspnea

Involuntary muscle spasms

Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.

Explanation

Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.

9. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

Increased blood pressure

Increased heart rate

Loss of pulse in the extremity

Decreased urine output

Loss of the pulse in the extremity would indicate impaired circulation.

Explanation

Loss of the pulse in the extremity would indicate impaired circulation.

10. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform?

Disconnect the client from the ventilator and use a manual resuscitation bag

Perform a quick assessment of the client’s condition

Call the respiratory therapist for help

Press the alarm re-set button on the ventilator

A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.

Explanation

A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.

11. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY?

Blood urea nitrogen 50 mg/dl

Hemoglobin of 10.3 mg/dl

Venous blood pH 7.30

Serum potassium 6 mEq/L

Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

Explanation

Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

12. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?

“The tube will drain fluid from your chest.”

“The tube will remove excess air from your chest.”

“The tube controls the amount of air that enters your chest.”

“The tube will seal the hole in your lung.”

The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

Explanation

The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

13. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

“The tube will drain fluid from your chest.”

“The tube will remove excess air from your chest.”

“The tube controls the amount of air that enters your chest.”

“The tube will seal the hole in your lung.”

The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

Explanation

The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

14. A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action?

Clamp the chest tube

Call the surgeon immediately

Prepare for blood transfusion

Continue to monitor the rate of drainage

Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.

Explanation

Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.

15. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

Clamp the chest tube

Call the surgeon immediately

Prepare for blood transfusion

Continue to monitor the rate of drainage

Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest

Explanation

Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest

16. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY?

Blanch nail beds for color and refill

Assess for post operative arrhythmias

Auscultate for pulmonary congestion

Monitor equality of peripheral pulses

The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

Explanation

The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

17. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

Blanch nail beds for color and refill

Assess for post operative arrhythmias

Auscultate for pulmonary congestion

Monitor equality of peripheral pulses

The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

Explanation

The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

18. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST?

Obtain a 12-lead EKG

Place client in high Fowler’s position

Lower the oxygen rate

Take baseline vital signs

A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.

Explanation

A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.

19. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?

Esophagitis

Leukopenia

Fatigue

Skin irritation

Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.

Explanation

Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.

20. The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to:

Wrap the leg with elastic bandages

Apply pressure at the bleeding site

Reinforce the dressing and elevate the leg

Remove the dressings and re-dress the incision

Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.

Explanation

Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.