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NECLEX PN REAL EXAM 150 QUESTIONS AND VERIFIED ANSWERS LATEST UPDATE//GRADED A+ A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the priority nursing action in the immediate postoperative perio$34.49
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NECLEX PN REAL EXAM 150 QUESTIONS AND VERIFIED ANSWERS LATEST UPDATE//GRADED A+ A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the priority nursing action in the immediate postoperative perio
NECLEX PN REAL EXAM 150 QUESTIONS AND VERIFIED ANSWERS LATEST UPDATE//GRADED A+
A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the priority nursing action in the immediate postoperative period?
NECLEX PN REAL EXAM 150 QUESTIONS AND VERIFIED A...
NECL EX PN REAL EXAM 150 QUESTIONS AND VERIFIED ANSWERS 2024 -2025 LATEST UPDATE//GRADED A+ A client is shifted to the recovery unit after amputation of the left leg. Which of the following is the priority nursing action in the immediate postoperative period? A. Monitor Vital Signs B. Assess the proximal pulse at the amputated p art C. Keep a surgical tourniquet t the bedside D. Administer IV fluids - answer -C. Keep a surgical tourniquet t the bedside Rationale : Hemorrhage is the most concerning primary immediate complication of amputation. Therefore, a surgical tourniquet is kept at the bedside in case of acute bleeding. The practical nurse knows that human papillomavirus infection (HPV) can lead to: A. Cervical cancer B. Infertility C. Pelvic inflammatory disease (PID) D. Rectal cancer - answer -A. Cervical cancer Rationale: HPV can lead to cervical cancer due to changes of the cervix from the genital warts. There is no known connection between HPV and infertility, PID, or rectal cancer. The nurse is to apply an Ace wrap to the client's right lower leg. Which actio n should the nurse take to ensure that the dressing is not too tight: A. Remove it every hour and reapply B. Check the pedal pulses C. Obtain a Doppler study to determine circulation D. Allow the wrap to remain in place for a minimum of 24 hours - answer -B. Check the pedal pulses Rationale: To ensure that the Ace wrap is not too tight, the nurse should check the pulse, color, and temperature of the extremity . A doctor is preparing to remove a chest tube from a client. Before removing the tube, the nurse sh ould instruct the client to: A. Breathe normally B. Hold breathe and bear down C. Take a deep breath D. Cough on demand - answer -B. Hold breathe and bear down Rationale: The client should be asked to hold breathe and bear down which prevents changes in pressure until an occlusive dressing is applied. A client admitted to the floor 3 days ago after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's fi rst action should be to: A. Apply 02 at 2L/minute via mask B. Begin CPR C. Place the client in high Flower's position D. Administer a prescribed sedative - answer -C. Place the client in high Flower's position Rationale: The client during the post -operative period with a widening pulse pressure, SOB, and rales may have a pulmonary emboli. To facilitate breathing, he should be placed in high Flowler's position. Oxygen would the be applied. The nurse is caring for a pt. with a urinary catheter. The nurse shou ld do which of the following to prevent a urinary tract infection? (select all that apply) A. Provide perineal care each day and after each bowel movement B. Change the catheter every day C. Encourage the pt. to drink fluids D. Ask the physician to prescribe prophylactic antibiotics E. Assess the pt. every shift for signs of infection - answer -A. Provide perineal care each day and after each bowel movement C. Encourage the pt. to drink fluids E. Assess the pt. every shift for signs of infection The nurse is caring for a pt. with Raynaud's phenomenon. The nurse should emphasize that the pt. can reduce symptoms of this disease by: A. Increase coffee to three cups each day B. Keeping the house at 68 degrees F. C. Wearing gloves w hen handling frozen foods D. Running cold water over her hands during an episode - answer -C. Wearing gloves when handling frozen foods Rationale: Raynaud's phenomenon is characterized by vasospasm caused by extreme changes in temperature. Wearing gloves wh en handing cold caused by extreme changes in temperature. Wearing gloves when handing cold foods can help prevent the problem. This phenomenon is exacerbated by caffeine so the pt. should not increase caffeine intake. A house temperature of 68 degrees F is likely to increase vasospasm. During a vasospastic incident, the pt. can run warm water over her hands. A woman in labor has been pushing for one hour and is not making progress. Which of the following conditions could be hindering the descent of the fet us in the second stage of labor? A. A full bladder B. A paracervical block administered during the first stage of labor C. Mother lying in a side -lying position D. Fetus in left occiput anterior position - answer -A. A full bladder During a one -to-one conv ersation with a nurse, a client says, "I'm worried about my medication.'' The nurse replies, "Tell me more about that." The nurse's response is an example of: A. Focusing B. Clarifying C. Reflecting D. Refocusing - answer -A. Focusing You are caring for a child with cerebral palsy. You notice that the child's movements are very stiff, and it is very difficult for him to move his joints. What types of cerebral palsy does this child exhibit? A. Spastic cerebral palsy B. Ataxic cerebral palsy C. Athetoid cerebral palsy D. Coritcate cerebral palsy - answer -A. Spastic cerebral palsy Rationale: Spastic cerebral palsy causes stiffness and movement difficulties. Athetoid cerebral palsy leads to involuntary and uncontrolled movements. Ataxic cerebral palsy causes a disturbed sense of balance and depth perception. The nurse is caring for a patient with multiple sclerosis. Which of the following symptoms is NOT indicative of the disease? A. Muscle weakness B. Trouble with coordination and balance C. Th inking and memory problems D. Hearing Loss - answer -D. Hearing Loss Rationale : Hearing Loss. Common symptoms of MS include fatigue, weakness, spasticity, balance problems, bladder and bowel problems, numbness, thinking/memoray problems, vision loss, tremor s and depression. A patient is diagnosed with acute pancreatitis. Which of the following is the best choice for pain control? A. Morphine B. Ibuprofen C. Fentanyl D. Demerol - answer -D. Demerol Rationale : Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic . A patient has recently b een diagnosed with a peptic ulcer. Upon reviewing lab data, the nurse notices that the patient's Helicobacter pylori titer is elevated. Which of the following would indicate the best understanding of the data? A. Treatment will be to continue to assess and monitor Helicobacter pylori titers B. Treatment involves educating the patient to avoid solid foods C. Treatment will consist of Ranitidine and Antibiotics D. Treatment will involve surgical intervention - answer -C. Treatment will consist of Ranitidine an d Antibiotics Rationale: One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium's resistance to acid digestion. Giving antibiotics will control the in fection and Ranitidine, which is a histamine -2 blocker, will reduce acid secretion that can lead to an ulcer.
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