Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 85

1. A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing interventions is most important?

A) Place the client in a supine position.
B) Draw a blood sample for arterial blood gases.
C) Start O2 at 4 L/min.
D) Establish a patent airway.

2. A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:

A) There are stones present in her gallbladder
B) There are stones present in her kidneys
C) There are stones present in her common bile duct
D) There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain

3. A 48-year-old client is being seen in her physicians office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

A) Cullen - s sign
B) Rebound tenderness
C) Murphy - s sign
D) Turner - s sign

4. When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:

A) 50 - 100 mL
B) 200 - 300 mL
C) 300 - 500 mL
D) 1000 - 1200 mL

5. The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are:

A) Clay or gray colored
B) Watery and loose
C) Bright-red streaked
D) Black

1. Right Answer: D
Explanation: (A) During impending respiratory failure or asthmatic complications, the client is placed in the high-Fowler position to facilitate comfort and promote optimal gas exchange. (B) Arterial blood gases are monitored in the treatment of respiratory failure during an asthma attack, but it is not an initial intervention. (C) O2 therapy is used during an asthma attack, but it is not the initial intervention. The usual prescribed amount is a cautiously low flow rate of 12 L/min. (D) Wheezing is a characteristic clinical finding during an asthma attack. If wheezing suddenlyceases, it usually indicates a complete airway obstruction and requires immediate treatment for respiratory failure or arrest.

2. Right Answer: C
Explanation: (A)Cholelithiasisis the correct term used to describe the presence of stones in the gallbladder. (B)Nephrolithiasis,orrenal calculi,is the correct term used to describe the presence of stones in the kidney. (C)Choledocholithiasisis the correct term used to describe the presence of stones in the common bile duct. (D)Cholecystitisis the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.

3. Right Answer: C
Explanation: (A) This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. (B) This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. (C) This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. (D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.

4. Right Answer: C
Explanation: (A) During the first 24 hours after surgery, the drainage is normally 300500 mL and then decreases to about 200 mL in 24 hours during the next 34 days. (B)This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. (C) During the first 24 hours after surgery, this range is the expected amount of drainage. (D) The expected amount of drainage during the first 24 hours is 300500 mL. An output of >500 mLshould be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.

5. Right Answer: A
Explanation: (A) Clients who have obstruction in the biliary tract so that bile is not released into the duodenum experience a change in stools from brown to gray or clay colored. (B) This type of stool can occur with other GI problems, such as bacterial or viral infections, and other disease problems, and is not a common finding with biliary obstructions such as cholecystitis and cholelithiasis. (C) This type of stool is usually associated with a GI or bowel problem, such as lower GI bleeding, rather than with biliary obstructions. (D) This type of stool is usually associated with a GI or bowel problem, such as upper GI bleeding, rather than with biliary obstructions.

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