Question 1

A client receives an autograft of skin from his abdomen to his right arm after suffering a third-degree burn from a campfire. Select the instructions by the nurse that best insure that the newly grafted skin is not rejected.

Accepted Answer

Keeping the right arm in a sling with minimal range of motion helps protect the graft site, allowing it to heal properly and reducing the risk of graft rejection.

Question 2

Identify the action by the public health nurse that best reduces the risk for infection of a man who now has a positive purified protein derivative (PPD) skin test and whose wife was recently diagnosed with active pulmonary tuberculosis.

Accepted Answer

The best action is to begin a 6- to 12-month course of treatment with rifampin, as this is the standard treatment for latent tuberculosis infection. Obtaining a list of names of other persons his wife has come into contact with may be necessary for contact tracing, but it does not directly reduce the man's risk of infection. Instructing the man to remain in isolation for 1 week is not a sufficient response, as the risk of transmission can persist beyond 1 week. Readministering the PPD is not necessary, as a positive result is indicative of latent tuberculosis infection and further testing is not required.

Question 3

Identify the action by the nurse that would promote the optimal effectiveness of Bryant's traction for a 3-year-old child in the pediatric unit who sustained a fractured femur in a fall from his front porch.

Accepted Answer

Maintaining the hips at a 90-degree angle to the body ensures proper alignment and effectiveness of Bryant's traction, which is crucial for healing a fractured femur.

Question 4

Identify the activity instructions given by the nurse at the time of discharge to a client with acute hepatitis A that best promote the client's recovery.

Accepted Answer

The answer of Identify the activity instructions given by the...

Question 5

Identify the instructions by the nurse that best help prevent complications from renal disease in a client who is being prepared for hemodialysis due to end-stage renal disease secondary to polycystic kidney disease.

Accepted Answer

Limiting sodium intake and avoiding salt substitutes can help prevent complications such as fluid overload, hypertension, and electrolyte imbalances in clients with renal disease. Additionally, instructions to drink 2 to 3 liters per day and increase intake of fresh fruits are not necessarily specific to preventing complications related to hemodialysis, and the recommendation to eat 3 to 5 ounces of meat at each meal may not be appropriate for clients with renal disease who require hemodialysis due to increased protein metabolism.

Question 6

Choose the position that the nurse should place a client in to best relieve the midsternal chest pain caused by pericarditis secondary to a viral infection.

Accepted Answer

Sitting up 90 degrees and leaning forward is the best position for a client with pericarditis as it decreases pressure on the pericardium and can relieve chest pain. This position also helps to expand the lungs and improve breathing.

Question 7

Select the action by the nurse that best helps promote the adaptation of a client in Addisonian crisis.

Accepted Answer

Addisonian crisis is a medical emergency that occurs when the body does not have enough vitamin B12. Vitamin B12 is essential for the production of red blood cells, and without it, the body cannot produce enough healthy red blood cells. This can lead to a number of serious health problems, including anemia, fatigue, and weight loss. In Addisonian crisis, the body's adrenal glands also stop working properly, which can lead to low blood pressure, shock, and even death.The nurse can help promote the adaptation of a client in Addisonian crisis by assigning the client to a private room. This will help to reduce the risk of infection and provide the client with a quiet and restful environment.

Question 8

Select the most effective action a nurse can take to protect a client who has been recently diagnosed with thrombocytopenia.

Accepted Answer

Thrombocytopenia is a condition characterized by decreased platelet count, which can increase the risk of bleeding. By using the smallest needle possible to administer medications, the nurse can minimize the risk of bleeding from injection sites. Using a wheelchair, increasing fluid intake, or limiting family visits do not directly address the risk of bleeding associated with thrombocytopenia.

Question 9

Identify the nursing intervention that has the highest priority for a client who is experiencing hemiparesis secondary to an intercerebral blood clot (stroke).

Accepted Answer

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Question 10

A client is admitted to the medical/surgical unit with acute pancreatitis secondary to a viral infection. Select the action by the nurse that is most important in promoting healing of the pancreas.

Accepted Answer

The most important action in promoting healing of the pancreas in acute pancreatitis is maintaining the client in a strict NPO status. This allows the pancreas to rest and decreases stimulation of enzyme secretion, which can worsen inflammation and damage to the pancreas. Adequate hydration and pain control are also important interventions, but these are not listed as options. Placing the client in the prone position is not a recommended intervention for pancreatitis as it can increase pressure in the abdomen and worsen pain. Decreasing IV intake is not appropriate as clients with acute pancreatitis often require IV fluids to maintain hydration and prevent complications such as renal failure. Administering IV antibiotics may be necessary if there is evidence of infection, but it is not the most important intervention for promoting healing of the pancreas in acute pancreatitis.

Question 11

Identify the nursing action that is most appropriate when the nurse assesses a small amount of clear, watery fluid oozing from the nose of a client who received a blow to the head in a barroom fight.

Accepted Answer

Testing the drainage for glucose can help determine if the fluid is cerebrospinal fluid (CSF), which can leak from the nose or ears after a skull fracture. This is a critical step in assessing for a potential basilar skull fracture. Encouraging the client to blow his nose, keeping the head flat, or asking about the object used in the assault does not directly address the potential severity of a CSF leak.

Question 12

After a third episode of cystitis, a client asks the nurse what she can do to prevent another infection. The nurse recommends that the client follow an acid-ash diet and avoid which of the following foods?

Accepted Answer

Milk and apples are alkaline-ash foods, which should be avoided in an acid-ash diet to help prevent urinary tract infections.

Question 13

The pulse oximeter connected to a client with viral pneumonia, but who has no other underlying respiratory disease, has had readings between 79% and 88% for the past half hour. Identify the type of oxygen delivery system that is most effective for the nurse to initiate when the client complains of shortness of breath.

Accepted Answer

The nonrebreather mask is the most effective choice in this scenario because it can deliver high concentrations of oxygen (up to 90%) and has a one-way valve that prevents the patient from inhaling their exhaled air. This is particularly important in patients with viral pneumonia, as they are at risk of developing acute respiratory distress syndrome (ARDS) due to the infection causing inflammation and fluid buildup in the lungs. The other options, nasal cannula, rebreather mask, and high-humidity face tent, would not be as effective in quickly increasing the patient's oxygen saturation.

Question 14

After a stab wound to the chest, a client develops a pneumothorax and has a chest tube inserted in the emergency room (ER) that is connected to a self-contained underwater-seal drainage system (pleur-evac). Select the action the ER nurse should take first when she notices that the second chamber has stopped bubbling.

Accepted Answer

When the second chamber stops bubbling, it indicates that the drainage system may be blocked, either by a clot or other material. The nurse should first check for any blockages in the drainage tube and remove them to allow the fluid to continue to drain properly. This will avoid complications such as tension pneumothorax or hemothorax, which can be life-threatening. The other options are not appropriate or necessary at this point, as the system may not be defective and suction should not be increased without first addressing the potential blockage.

Question 15

Identify the statement made by the nurse during the discharge instructions to a client with a hiatal hernia that best aids in the prevention of gastrointestinal discomfort.

Accepted Answer

Eating smaller, more frequent meals can help prevent discomfort and reflux associated with a hiatal hernia. Choosing bland, high-fiber foods may also be helpful in reducing symptoms. Lying down after eating or drinking excessive amounts of water during meals may exacerbate symptoms. Limiting carbohydrate intake is not specific to preventing gastrointestinal discomfort related to a hiatal hernia.

Question 16

A 32-year-old woman who has a fractured T-7 following an automobile accident develops urinary retention. The physician orders intermittent catheterizations every 6 hours, and the nurse obtains between 600 and 830 mL of urine each time. Select the most appropriate nursing action for this client.

Accepted Answer

Obtaining an order to catheterize the client more frequently (every 3 to 4 hours) is appropriate because the volumes of urine obtained indicate that the bladder is being allowed to fill too much, which can lead to bladder distension and further complications. The current schedule of every 6 hours is not sufficient to prevent these risks.

Question 17

Select the action that the nurse should take after finding a firm nodule during a scrotal examination of a 32-year-old man.

Accepted Answer

The answer of Select the action that the nurse should...

Question 18

Select the position that is best for the nurse to keep a client in who received a head injury in a sports accident and has his neck stabilized in a neck collar.

Accepted Answer

Low Fowler's position with the head elevated 30 degrees is recommended for a patient with a head injury and neck stabilization. This position helps reduce intracranial pressure and facilitates breathing while maintaining neck stabilization.

Question 19

Identify the initial action that the nurse should take to treat an acute episode of diabetic ketoacidosis (DKA) in a client with type I, insulin-dependent diabetes mellitus.

Accepted Answer

The initial action in treating an acute episode of DKA is to start an IV line of 0.45% normal saline at 150 mL per hour. This will help to rehydrate the client and correct any electrolyte imbalances that have occurred as a result of the DKA. Administration of insulin should follow, but it is important to rehydrate the client first to avoid worsening electrolyte imbalances. Sodium bicarbonate may be administered if the client's pH remains low despite correction of dehydration and electrolyte imbalances. Asking if the client has taken his insulin is important information to gather, but it is not the initial action to take in treating DKA.

Question 20

Identify the action by the nurse caring for a client who has just returned from extracorporeal shock wave lithotripsy that best promotes the client's physiological adaptation.

Accepted Answer

Increasing fluid intake to 2 to 3 liters per day promotes the physiological adaptation of flushing out any remaining stones or fragments in the urinary tract, preventing the formation of new stones, and promoting healing after the procedure. This action helps prevent urinary tract infections and promotes urinary flow, which helps to prevent the build-up of stone-forming substances. The other options are also important for the client's care but do not directly promote physiological adaptation after the procedure.

Quiz 11: Nclex: What You Need to Know