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NCLEX-RN Exam Questions - Part 67
1. The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
A) Palpate these pulses again in 15 minutes.
B) Use a Doppler to determine presence and strength of these pulses.
C) Document the finding that the pulses are not palpable.
D) Call the physician and notify the physician of this finding.
2. The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?
A) Increase in gastric secretions
B) Increase in peristalsis
C) Disorientation
D) Drowsiness
3. A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin. The sequence in which the next of kin would be asked for the consent would be:
A) Parent, spouse, adult child, sibling
B) Spouse, adult child, parent, sibling
C) Spouse, parent, sibling, adult child
D) Parent, spouse, sibling, adult child
4. A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
A) Serosanguinous
B) Purulent
C) Sanguinous
D) Catarrhal
5. A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
A) Excoriation
B) Dehiscence
C) Decortication
D) Evisceration
A) Palpate these pulses again in 15 minutes.
B) Use a Doppler to determine presence and strength of these pulses.
C) Document the finding that the pulses are not palpable.
D) Call the physician and notify the physician of this finding.
2. The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?
A) Increase in gastric secretions
B) Increase in peristalsis
C) Disorientation
D) Drowsiness
3. A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin. The sequence in which the next of kin would be asked for the consent would be:
A) Parent, spouse, adult child, sibling
B) Spouse, adult child, parent, sibling
C) Spouse, parent, sibling, adult child
D) Parent, spouse, sibling, adult child
4. A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
A) Serosanguinous
B) Purulent
C) Sanguinous
D) Catarrhal
5. A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
A) Excoriation
B) Dehiscence
C) Decortication
D) Evisceration
1. Right Answer: B
Explanation: (A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.
2. Right Answer: B
Explanation: (A) Metoclopramide does not stimulate gastric secretions. (B) This response is expected with metoclopramide, in addition to increasing gastric emptying. (C)Disorientation is a symptom of metoclopramide overdose. The drug should be discontinued. (D) Drowsiness is a symptom of metoclopramide overdose and the drug should be discontinued.
3. Right Answer: B
Explanation: (A) Spouse and adult child would be asked before a parent. (B) The order of kin relationship for an adult, as determined from legal intestate succession, is usually spouse, adult child, parent, sibling. (C) Parent and sibling would be asked after adult child. (D) Spouse and adult child would be asked before parent. Sibling would be asked last.
4. Right Answer: C
Explanation: (A) Drainage from a surgical incision usually proceeds from sanguinous to serosanguinous. (B) Purulent drainage usually indicates infection and should not be seen initially from a surgical incision. (C) Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous. (D) Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
5. Right Answer: D
Explanation: (A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
Explanation: (A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.
2. Right Answer: B
Explanation: (A) Metoclopramide does not stimulate gastric secretions. (B) This response is expected with metoclopramide, in addition to increasing gastric emptying. (C)Disorientation is a symptom of metoclopramide overdose. The drug should be discontinued. (D) Drowsiness is a symptom of metoclopramide overdose and the drug should be discontinued.
3. Right Answer: B
Explanation: (A) Spouse and adult child would be asked before a parent. (B) The order of kin relationship for an adult, as determined from legal intestate succession, is usually spouse, adult child, parent, sibling. (C) Parent and sibling would be asked after adult child. (D) Spouse and adult child would be asked before parent. Sibling would be asked last.
4. Right Answer: C
Explanation: (A) Drainage from a surgical incision usually proceeds from sanguinous to serosanguinous. (B) Purulent drainage usually indicates infection and should not be seen initially from a surgical incision. (C) Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous. (D) Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
5. Right Answer: D
Explanation: (A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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