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NCLEX-RN Exam Questions - Part 70
1. A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for:
A) Knowledge deficit
B) Urinary retention
C) Impaired physical mobility
D) Ineffective breathing pattern
2. A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
A) Monitoring the chest tubes
B) Positioning the client on the right side
C) Positioning the client in semi-Fowler position with a pillow under the shoulder and back
D) Monitoring the right lung for an increase in rales
3. A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
A) Reinforce the dressing.
B) Continue to monitor the dressing.
C) Notify the physician.
D) Note the time and amount of blood.
4. A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection?
A) Acute
B) Chronic
C) Hyperacute
D) Hyperchronic
5. A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
A) 'I know I will need special swallowing training after my surgery.'
B) 'The quality of my voice will be excellent after surgery.'
C) 'I will have very little difficulty swallowing after surgery.'
D) 'I may also have to have a radical neck dissection done.'
A) Knowledge deficit
B) Urinary retention
C) Impaired physical mobility
D) Ineffective breathing pattern
2. A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
A) Monitoring the chest tubes
B) Positioning the client on the right side
C) Positioning the client in semi-Fowler position with a pillow under the shoulder and back
D) Monitoring the right lung for an increase in rales
3. A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
A) Reinforce the dressing.
B) Continue to monitor the dressing.
C) Notify the physician.
D) Note the time and amount of blood.
4. A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection?
A) Acute
B) Chronic
C) Hyperacute
D) Hyperchronic
5. A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
A) 'I know I will need special swallowing training after my surgery.'
B) 'The quality of my voice will be excellent after surgery.'
C) 'I will have very little difficulty swallowing after surgery.'
D) 'I may also have to have a radical neck dissection done.'
1. Right Answer: D
Explanation: (A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have aFoley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.
2. Right Answer: D
Explanation: (A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to re-expand on the operative side. (B) The pneumonectomy client should be positioned on the back or operated side because the sutured bronchial stump may open, allowing fluid to drain into the unoperated side and drown the client. (C) The client should not have a pillow under the shoulder and back because of the subscapular incision. (D) Rales are commonly heard over the base of the remaining lung, but an increase could indicate circulatory overload and therefore should be closely monitored.
3. Right Answer: C
Explanation: (A) The dressing should not be reinforced without first notifying the physician. The decision may be made by the physician to reinforce the dressing after assessing the amount of bleeding. (B) Blood on the dressing is unusual and should make the nurse aware that something more than continuing to monitor the dressing should be done. (C) The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. (D)The time and amount of blood do need to be recorded after the physician is notified.
4. Right Answer: A
Explanation: (A) The sudden development of fever, graft tenderness, increased white blood count, and malaise are signs and symptoms of an acute rejection that commonly occurs at 3 months. (B) Chronic rejection occurs slowly over a period of months to years and mimics chronic renal failure. (C) Hyperacute rejection occurs immediately after surgery up to 48 hours postoperatively. (D) Hyperchronic rejection is not a type of rejection.
5. Right Answer: C
Explanation: (A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the clients voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.
Explanation: (A) The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a priority nursing diagnosis postoperatively. (B) The client will have aFoley catheter for a day or two after surgery. Urinary retention is usually not a problem once the Foley catheter is removed. (C) A client having a cholecystectomy should not be physically impaired. In fact, the client is encouraged to begin ambulating soon after surgery. (D) Because of the location of the incision, the client having a cholecystectomy is reluctant to breathe deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.
2. Right Answer: D
Explanation: (A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to re-expand on the operative side. (B) The pneumonectomy client should be positioned on the back or operated side because the sutured bronchial stump may open, allowing fluid to drain into the unoperated side and drown the client. (C) The client should not have a pillow under the shoulder and back because of the subscapular incision. (D) Rales are commonly heard over the base of the remaining lung, but an increase could indicate circulatory overload and therefore should be closely monitored.
3. Right Answer: C
Explanation: (A) The dressing should not be reinforced without first notifying the physician. The decision may be made by the physician to reinforce the dressing after assessing the amount of bleeding. (B) Blood on the dressing is unusual and should make the nurse aware that something more than continuing to monitor the dressing should be done. (C) The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. (D)The time and amount of blood do need to be recorded after the physician is notified.
4. Right Answer: A
Explanation: (A) The sudden development of fever, graft tenderness, increased white blood count, and malaise are signs and symptoms of an acute rejection that commonly occurs at 3 months. (B) Chronic rejection occurs slowly over a period of months to years and mimics chronic renal failure. (C) Hyperacute rejection occurs immediately after surgery up to 48 hours postoperatively. (D) Hyperchronic rejection is not a type of rejection.
5. Right Answer: C
Explanation: (A) A client with a supraglottic (horizontal partial) laryngectomy would require special swallowing training, not a vertical partial laryngectomy. (B) The quality of the clients voice will be altered but adequate for communication. (C) The client will have minimal difficulty swallowing. (D) A radical neck dissection may be done with a total laryngectomy, but not with a partial laryngectomy.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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