Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 117

1. A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:

A) Cries easily and says she is having abdominal pain
B) Develops a temperature of 102_F
C) Has no bowel sounds
D) Has a urine output of 200 mL for 4 hours

2. A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.Teaching related to skin care for the client would include which of the following?

A) Teach her to completely clean the skin to remove all ointments and markings after each treatment.
B) Teach her to cover broken skin in the treated area with a medicated ointment.
C) Encourage her to wear a tight-fitting vest to support her scapula.
D) Encourage her to avoid direct sunlight on the area being treated.

3. A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?

A) His weight increases from 165 to 175 lb.
B) His urine output is equal to his total fluid intake.
C) His urine output has been>35 mL/hr for the past 12 hours.
D) His blood pressure is 94/62.

4. A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:

A) He should monitor his sputum, stools, and urine for signs of bleeding.
B) His daily diet should include a large amount of fluid.
C) He should not be concerned about having to fly on a commuter airplane on a weekly basis.
D) He should not worry about having children because this disease is passed on only by female carriers.

5. A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?

A) Hemodialysis involves less time to filter the blood; but the client must consider travel time, distance, and inconvenience.
B) Hemodialysis involves more time to filter the blood than does peritoneal dialysis.
C) Peritoneal dialysis has almost no complications and is less time consuming than hemodialysis. Therefore it is preferred.
D) Peritoneal dialysis requires that a home health nurse prepare and administer the treatments.

1. Right Answer: B
Explanation: (A) The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. (B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. (C)The client is expected to have no bowel soundsfor 2448 hours after surgery because of the trauma to the bowel. (D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.

2. Right Answer: D
Explanation: (A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.

3. Right Answer: C
Explanation: (A) A weight gain of 10 lb represents a state of overhydration. (B) He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. (C) A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. (D) A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.

4. Right Answer: B
Explanation: (A) Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. (B) Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. (C) Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. (D) Male and female clients with sickle cell disease can pass the trait on to their offspring.Therefore, this client should receive genetic counseling prior to having children.

5. Right Answer: A
Explanation: (A) Hemodialysis is faster in clearing the blood of toxins than peritoneal dialysis. However, clients must consider the time that they spend traveling to the dialysis center and the disruption in their daily lives. (B) Peritoneal dialysis requires several exchanges with dwelling time for the dialysate and therefore takes longer than hemodialysis. (C) Several serious complications of peritoneal dialysis include peritonitis, catheter displacement and/or plugging, or pain during dialysis. (D) A client can be taught to self-administer peritoneal dialysis without the aid of a professional.

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