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Ngn nclex pn actual exam test bank all questions and well answers top rated version for highly recommended by experts |new and revised$30.49
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Ngn nclex pn actual exam test bank all questions and well
answers top rated version for highly recommended by experts
|new and revised
The client is admitted to the unit after a cholescystectomy. Montgomery straps are
utilized with this client. The nurse is aware that Montgomery straps are utilized on this
client because:
A. The client is at risk for evisceration
B. The client will require frequent dressing changes
C. The straps provide support for drains that are inserted into the incision
D. No sutures or clips are used to secure the incision. - B. The client will require
frequent dressing changes
why?
Montgomery straps are used to secure dressing that require frequent dressing changes
because the client with a cholescystectomy usually has a large amount of drainage on
the dressing. Montgomery straps are also used for clients who are allergic to several
types of tape.
The physician has order that the client's medication be administered intrathecally. The
nurse is aware that the medications will be administered by which method?
A. Intravenously
B. Rectally
C. Intramuscularly
D. Into the cerebrospinal fluid - D. Into the cerebrospinal fluid
why?
Intrathecal medications are administered into the cerebrospinal fluid. This method of
administering medications is reserved for the client with metastases, the client with
chronic pain, or the client with cerebrospinal infections.
Which client can be best assigned to the newely licensed to the Practical Nurse?
A. The client receiving chemotherapy
,B. The client post-coronary bypass
C. The client with a TURP
D. The client with diverticulitis - D. The client with diverticulitis
why?
The best client to assign to the newly licensed nurse is the most stable client; in this
case, it's the client with diverticulitis.
The nurse notes the patient care assistant looking through the personal items of the
client with cancer. Which action should be taken by the RN?
A. Notify the police department as a robbery
B. Report this behavior to the charge nurse
C. Monitor the situation and note whether any items are missing
D. Ignore the situation until items are reported missing - B. Report the behavior to the
charge nurse
why?
The best action at this time is to report the incident to the charge nurse. Further action
might be needed, but it should be determined by the charge nurse.
The nurse overhears the patient care assistant speaking harshly to the client with
dementia. The charge nurse should:
A. Change the nursing assistant's assignment
B. Explore the interaction with the nursing assistant
C. Discuss the matter with the client's family
D. Initiate a group session with the nursing assistant. - B. Explore the interaction with
the nursing assistant
why?
The best action for the nurse to take is to explore the interaction with the nursing
assistant. This will allow for clarification of the situation.
A home health nurse is planning for her daily visits. Which client should the home health
nurse visit first?
A. A client with AIDS being treated with Foscarnet
B. A client with a fractured femur in a long leg cast
C. A client with a laryngeal cancer with a laryngetomy
D. A client with diabetic ulcers to the left foot - C. A client with a laryngeal cancer with a
laryngetomy
,why?
The client with laryngeal cancer has a potential airway alteration and should be seen
first.
The nurse is assigned to care from infant with physiologic jaundice. Which action by the
nurse would facilitate elimination of the bilirubin?
A. Increase the infant's fluid intake
B. Maintain the infant's body temp at 98.6 F
C. Minimize tactile stimulation
D. Decrease caloric intake - A. Increase the infant's fluid intake
why?
Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining
the body temp is important but will not assist in eliminating bilirubin.
The graduate licensed practical nurse is assigned to care for the client on ventilator
support, pending organ donation. Which goal should receive priority?
A.Maintain the client's systolic blood pressure at 70 mm/Hg or greater
B. Maintain the client's urinary output greater than 300 cc/hr
C. Maintain the client's body temp of greater than 33 F rectal
D. Maintain the client's hematocrit less than 30% - A. Maintain the client's systolic blood
pressure at 70 mm/Hg or greater
why?
When the cadaver client is being prepared to donate and organ, the systolic blood
pressure should be maintained at 70 mm/Hg or greater to ensure a blood supply to the
donor organ.
Which action by the novice nurse indicates need for further teaching?
A. A nurse fails to wear gloves to remove a dressing
B. The nurse applies the oxygen saturation monitor to the earlobe
C. The nurse elevates the head of the bed to check blood pressure
D. The nurse places the extremity to a dependent position to acquire a peripheral blood
sample - A. A nurse fails to wear gloves to remove a dressing
why?
The nurse who fails to wear gloves to remove a contaminated dressing needs further
instruction
, The nurse is preparing the client for a mammogram. To prepare the client for a
mammogram, the nurse should tell the client:
A. Restrict her fat intake for one week before the test
B. To omit creams, powders, or deodorants before the exam
C. The mammography replaces the need for self breast exams
D. That mammography requires higher does of radiation than an x-ray. - B. To omit
creams, powders, or deodorants before the exam.
why?
The client having the mammogram should be instructed to omit deodorants or powders
beforehand because powders and deodorants can be interpreted as abnormal.
Which of the following roommates would be best for the client with gastric resection?
A. A client with Chron's disease
B. A client with pneuomia
C. A client with gastritis
D. A client with phlebitis - D. A client with phlebitis
why?
The most suitable roommate for the client with gastric resection is the client with
phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious.
The licensed practical nurse is working with a RN and a patient care assistant. Which of
the following clients should be cared for by the RN?
A. A client two days post-appendectomy
B. A client one week post-thyroidectomy
C. A client 3 days post- splenectomy
D. A client 2 days post- thoracotomy - D. A client 2 days post-thoracotomy
why?
The most critical client should be assigned to the RN; in this case, that is the client 2
days post-thoracotomy.
]
the nurse is caring for a client scheduled for removal of a pituitary tumor using the
transsphenoidal approach. the nurse should be particularly alert to:
A. Nasal congestion
B. Abdominal Tenderness
C. Muscle Tetany
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