NCLEX RN Review for Reduction of Risk Potential

1. A client’s laboratory results have been returned and the creatinine level is 7 mg/dL. This finding would lead the nurse to place the highest priority on assessing

a. Pupillary reflex.

b. Intake and output.

c. Capillary refill.

d. Temperature.

2. A client requires that a bronchoscopy procedure be done. Due to his physical condition, he will be awake during the procedure. As part of the pretest teaching, the nurse will instruct him that before the scope insertion, his neck will be positioned so that it is

a. In an extended position.

b. In a neutral position.

c. In a flexed position.

d. Hyperextended.

3. To evaluate a client’s condition following cardiac catheterization, the nurse will palpate the pulse

a. At the insertion site.

b. Distal to the catheter insertion.

c. Above the catheter insertion.

d. In all extremities.

4. A 76-year-old woman who has been in good health develops urinary incontinence over a period of several days and is admitted to the hospital for a diagnostic workup. The nurse would assess the client for other indicators of

a. Urinary tract infection.

b. Dementia.

c. Renal failure.

d. Fluid volume excess.

5. The nurse is assigned to care for a 20 year old who has just had chest tubes inserted. An important nursing action is to

a. Check the chest tubes every 2 hours for air leaks.

b. Keep the client flat to avoid leaks in the tubing.

c. Coil the tubes carefully to prevent kinking, which could result in an air leak.

d. Place a hemostat nearby in case of an air leak.

6. A client is on dialysis treatments three times per week. The nurse explains that the main advantage of using an internal arteriovenous fistula rather than an external arteriovenous cannula for dialysis is

a. It is easier to access the blood flow with the internal fistula than through the external cannula.

b. The internal fistula can be utilized immediately after insertion.

c. There is less risk of hemorrhage from the internal fistula.

d. Accessing the internal fistula is less uncomfortable for the client.

7. When evaluating all forms of traction, the nurse knows that the direction of pull is controlled by the

a. Rope/pulley system.

b. Amount of weight.

c. Client’s position.

d. Point of friction.

8. Russell’s traction is easily recognized because it incorporates a

a. Sling under the knee.

b. Pearson attachment.

c. Pelvic girdle.

d. Cervical halter.

9. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?

a. Hypotension and hypothermia.

b. Serosanguineous drainage from the puncture site.

c. Increased temperature and blood pressure.

d. Increased pulse and pallor.

10. A 60-year-old male client’s physician schedules a prostatectomy and orders a straight urinary drainage system to be inserted preoperatively. For the system to be effective, the nurse would

a. Coil the tubing above the level of the bladder.

b. Check that the collection bag is vented and distensible.

c. Position the collection bag above the level of the bladder.

d. Determine that the tubing is less than 3 feet in length.

11. Which of the following statements is true of skeletal traction?

a. Neurovascular complications are less apt to occur than with skin traction.

b. Fractures can be reduced because more weight can be used than with skin traction.

c. The client has less mobility than he does with skin traction.

d. It is preferred for children because fracture fragment alignment is so important.

12. Following brain surgery, the client suddenly exhibits polyuria and begins voiding 15 to 20 L/day. Specific gravity for the urine is 1.006. The nurse will recognize these symptoms as the possible development of

a. Diabetes, type I.

b. Addison’s disease.

c. Diabetes, insipidus.

d. Diabetes, type II.

13. The nurse enters the room of a client who is in the clonic phase of a tonic-clonic seizure. The initial nursing action should be to

a. Insert a padded mouth gag.

b. Gently restrain the limbs.

c. Obtain equipment for orotracheal suctioning.

d. Place some padding under the head.

14. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to

a. Check that the balloon is deflated on a regular basis.

b. Monitor IV fluids for the shift.

c. Check that a hemostat is at the bedside.

d. Regularly assess respiratory status.

15. Hemorrhage is a major complication following oral surgery and radical neck dissection. If this condition occurs, the most immediate nursing intervention would be to

a. Put pressure over the common carotid and jugular vessels in the neck.

b. Notify the surgeon immediately.

c. Treat the client for shock.

d. Immediately put the client in high-Fowler’s position.

ANSWER AND RATIONAL

1. B. The elevated creatinine level suggests impaired renal function. Assessing intake and output will provide data related to renal function. The other assessments are not indicative of renal function.

2. D. Hyperextension brings the pharynx into alignment with the trachea and allows the scope to be inserted without trauma.

3. B. Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong.

4. A. Urinary tract infections in the elderly often present as urinary incontinence that develops suddenly. Renal failure (1) and fluid volume excess (3) typically are characterized by oliguria. Dementia (4) develops slowly and is manifested by disordered thinking and behavior.

5. D. The most important safety measure is to tape a hemostat nearby to use in case of an air leak. Chest tubes should be checked periodically, but not necessarily every 2 hours (2). The client should be in semi-Fowler’s position to increase lung expansion.

6. C. There is an increased incidence of hemorrhaging with the external cannula. Hemorrhage results from the cannula becoming disconnected. One advantage of the external cannula is that it is painless to use. Surgery is required to establish the internal fistula and it should be allowed to heal for several weeks before being utilized.

7. A. The rope/pulley and weight system is arranged so that fracture fragments are in the desired approximate position for healing. The client’s position should always rest in line with the traction pull. The line of pull must never be interfered with by changing the position of a pulley and extension bar.

8. A. Russell’s traction is a type of skin traction that incorporates a sling under the knee that is connected by a rope to an overhead bar pulley. It is frequently used to treat femoral shaft fractures in the adolescent.

9. D. Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually no more than 1 L of fluid is removed at one time to prevent this from occurring.

10. B. The collection bag must be able to fill easily; therefore, it needs to be distended. The bag must be vented with a filter so that urine can be drained from the chamber. The tube must not be allowed to coil or become kinked above the level of the bladder. The collection bag is positioned below the level of the

bladder to allow for continuous urine drainage and prevent urine backflow into the bladder. In order to prevent reflux of urine, the tubing must be of sufficient length, usually 5 feet.

11. B. Because more weight can be applied with skeletal traction, it can be used to reduce fractures and maintain alignment. It is not used commonly in the elderly because of prolonged immobilization. It is not preferred for children because some displacement of fracture fragments is desirable to prevent growth disturbance. Frequently, clients have more mobility than they do with skin traction, because balanced suspension is often incorporated with skeletal traction.

12. C. Diabetes insipidus is an antidiuretic deficiency and may occur following brain surgery or head injury. It also occurs in young adults resulting from damage to the posterior lobe of the pituitary gland. Severe polyuria occurs when there is an inability to concentrate urine. These are not symptoms of types 1 and 2 diabetes (2, 3) or Addison’s disease (4) (which is adrenocorticol hypofunction).

13. D. Preventing cerebral trauma during the convulsion is a priority activity. Placing some form of padding under the head will protect the skull and brain from injury. Inserting a mouth gag (1) and restraining the limbs (3) are unsafe interventions. The nurse would not leave a seizing person to go and obtain equipment (4).

14. D. The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.

15. A. Putting pressure over the vessels in the neck may be lifesaving because a severe blood loss can occur rapidly, leading to shock and death. The surgeon would be notified as soon as possible.