The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
A. Call the surgeon and ask him or her to see the client to clarify the information
B. Explain the procedure and complications to the client
C. Check in the physician’s progress notes to see if understanding has been documented
D. Check with the client’s family to see if they understand the procedure fully
A. Call the surgeon and ask him or her to see the client to clarify the information
B. Explain the procedure and complications to the client
C. Check in the physician’s progress notes to see if understanding has been documented
D. Check with the client’s family to see if they understand the procedure fully
NCLEX Test-Plan
The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is…
Answer A: It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse’s purview
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?
A. Hearing aid
B. Contact lenses
C. Wedding ring
D. Artificial eye
A. Hearing aid
B. Contact lenses
C. Wedding ring
D. Artificial eye
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NCLEX Test-Plan
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye
Answer B: It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.
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A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate?
A. Reinsert the protruding organ and cover with 4×4s
B. Cover the wound with a sterile 4×4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound
Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case.
A. Reinsert the protruding organ and cover with 4×4s
B. Cover the wound with a sterile 4×4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound
Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case.
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The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
A. That cannot be assessed
B. That is in situ
C. With increasing lymph node involvement
D. With distant metastasis
Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.
A. That cannot be assessed
B. That is in situ
C. With increasing lymph node involvement
D. With distant metastasis
Answer B: Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.
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Next Gen Revision Questions
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
A. Force fluids 24 hours before the procedure
B. Ask the client to void immediately before the study
C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
D. Cover the client’s reproductive organs with an x-ray shield
Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs.
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
A. Force fluids 24 hours before the procedure
B. Ask the client to void immediately before the study
C. Hold medication that affects the central nervous system for 12 hours pre- and post-test
D. Cover the client’s reproductive organs with an x-ray shield
Answer B: The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs.
Practical #medsurg Nclex revision question
A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
A. Trendelenburg position
B. Ice to the entire extremity
C. Buck’s traction
D. An abduction pillow
Answer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect.
A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
A. Trendelenburg position
B. Ice to the entire extremity
C. Buck’s traction
D. An abduction pillow
Answer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect.
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Medical administrative & #nursing care @Nclex Test-Plan Question.
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
A. A weight loss of 10 pounds in 2 weeks
B. Complaints of numbness and tingling in the extremities
C. A red, beefy tongue
D. A hemoglobin level of 12.0gm/dL
Answer C: A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal.
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
A. A weight loss of 10 pounds in 2 weeks
B. Complaints of numbness and tingling in the extremities
C. A red, beefy tongue
D. A hemoglobin level of 12.0gm/dL
Answer C: A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal.
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A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
A. You will be sitting for the examination procedure.
B. Portions of the procedure will cause pain or discomfort.
C. You will be given some medication to anesthetize the area.
D. You will not be able to drink fluids for 24 hours before the study.
Answer B: Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.
A. You will be sitting for the examination procedure.
B. Portions of the procedure will cause pain or discomfort.
C. You will be given some medication to anesthetize the area.
D. You will not be able to drink fluids for 24 hours before the study.
Answer B: Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.
#medsurg practical next gen Question.
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
A. Assessment of the client’s level of anxiety
B. Evaluation of the client’s exercise tolerance
C. Identification of peripheral pulses
D. Assessment of bowel sounds and activity
Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
A. Assessment of the client’s level of anxiety
B. Evaluation of the client’s exercise tolerance
C. Identification of peripheral pulses
D. Assessment of bowel sounds and activity
Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.
The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential?
A. You cannot eat food prepared in a microwave.
B. You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.
C. You should use your cellphone on your right side.
D. You will not be able to fly on a commercial airliner with the defibrillator in place.
Answer C: The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane.
A. You cannot eat food prepared in a microwave.
B. You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.
C. You should use your cellphone on your right side.
D. You will not be able to fly on a commercial airliner with the defibrillator in place.
Answer C: The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane.
When preparing a pre-school age for tonsillectomy, which information does the nurse provide?
A) "You'll need to be good and take your medication after surgery".
B) "You'll have a mask like this on your face when you go to sleep".
C) "You'll be allowed to eat ice cream when you wake up".
D) "Nurses will be taking your vital signs very often"
A) "You'll need to be good and take your medication after surgery".
B) "You'll have a mask like this on your face when you go to sleep".
C) "You'll be allowed to eat ice cream when you wake up".
D) "Nurses will be taking your vital signs very often"
NCLEX Test-Plan
When preparing a pre-school age for tonsillectomy, which information does the nurse provide? A) "You'll need to be good and take your medication after surgery". B) "You'll have a mask like this on your face when you go to sleep". C) "You'll be allowed…
Correct B. Pre-school client can be prepared for tonsillectomy by making them to handle equipment such as face mask or ice packs
There is a note in an adolescent age client stating that only one parent may receive medical information related to the client's condition. The excluded parent calls the nurse and ask about the client's staus
How does the nurse best respond?
A) Give the parent general information and updates
B) Instruct the parent to contact the other parent
C) Allow the client to explain the situation to the parent
D) Allow the parent to discuss the client's condition with the charge nurse
How does the nurse best respond?
A) Give the parent general information and updates
B) Instruct the parent to contact the other parent
C) Allow the client to explain the situation to the parent
D) Allow the parent to discuss the client's condition with the charge nurse
NCLEX Test-Plan
There is a note in an adolescent age client stating that only one parent may receive medical information related to the client's condition. The excluded parent calls the nurse and ask about the client's staus How does the nurse best respond? A) Give the…
B is Correct. Respect client choice to exclude a parent from client's information and direct the excluded to the other parent for information.
The nurse plan to improve quality of life for a client with AIDS. Which is priority for a client who experiences multiple infections.
A) Nutritional issues
B) Pain management
C) Learning needs
D) Development needs.
A) Nutritional issues
B) Pain management
C) Learning needs
D) Development needs.
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