NCLEX Practical Nursing 102th Edition

NCLEX Practical Nursing 102th Edition

1. What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

A. Oxygen via nasal cannula
B. Suction equipment
C. Cardiac monitor
D. A straw

Answer: B. Suction equipment

Rationale: General anesthesia depresses the gag reflex, which in turn increases the risk for aspiration. Suction equipment must be available in the event that the client aspirates. Oxygen may be administered postoperatively and a cardiac monitor may be present, but they have nothing to do with initiation of postoperative diet intake. A straw may help the client sip fluids, but is not necessary.

Test-Taking Strategy: Focus on the issue of the question, which is the risk for aspiration and airway clearance. This will direct you to option B. Option 2 maintains airway clearance. Review care to the postoperative client if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Fundamental Skills
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 41.

2. A nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse tells the client about the importance of returning to the health care clinic as scheduled for which priority assessment?

A. Vitamin B12 and folic acid studies
B. Renal function studies
C. Vital sign measurements
D. Gastric analysis studies

Answer: A. Vitamin B12 and folic acid studies

Rationale: Common nutritional problems following stomach removal include vitamin B12 and folic acid deficiency. This may result from a deficiency of an intrinsic factor and/or inadequate absorption because food enters the bowel too quickly. Option 3 may be a component of the assessment at a follow-up health care visit but is not a priority assessment. Options 2 and 4 are not necessary studies following a total gastrectomy.

Test-Taking Strategy: Focus on the issue—the complications associated with gastrectomy. Recalling that vitamin B12 deficiency occurs with this type of surgery will direct you to option A. Review the complications following gastrectomy if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Gastrointestinal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 690.

3. A client is seen in the health care clinic, and acute pyelonephritis is suspected. The nurse reviews the client’s record and would expect to note which associated signs and symptoms documented?

A. Nausea and vomiting
B. Flank pain on the unaffected side
C. Low-grade fever
D. Pale, dilute urine

Answer: A. Nausea and vomiting

Rationale: Typical manifestations of acute pyelonephritis include high fever, chills, nausea, vomiting, and flank pain on the affected side with costovertebral angle tenderness, general weakness, and headache. The client often exhibits the typical signs and symptoms of cystitis, with production of urine that is foul-smelling and cloudy or bloody and that has an increased white blood cell (WBC) count.

Test-Taking Strategy: Use the process of elimination. The least likely option is flank pain on the unaffected side, so option 2 is eliminated first. Pale, dilute urine is the next unlikely option, since infection usually causes the urine to become bloody or at least turbid. To select between the remaining options, you need to know that pyelonephritis causes high fever, chills, nausea, and vomiting, which would direct you to option 1. Review the manifestations of acute pyelonephritis if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Renal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 769.

4. A nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further instruction?

A. “I should elevate my arm to reduce the swelling.”
B. “I should use a sling to limit movement and keep my arm elevated.”
C. “I should return to the physician in about 10 days to have the sutures removed.”
D. “I should perform pronation and supination exercises of my wrist starting 24 hours after surgery.”

Answer: D. “I should perform pronation and supination exercises of my wrist starting 24 hours after surgery.”

Rationale: Postoperatively, the client will have a bulky dressing in place for 4 to 7 days. The affected arm is elevated to reduce swelling. A sling is useful to limit movements and to keep the arm elevated. The sutures are removed in about 10 days after surgery. Within 2 to 3 weeks postoperatively, the client will begin physical therapy, with exercises done to promote full range of motion of the wrist and prevent adhesion formation in the carpal tunnel.

Test-Taking Strategy: Note the key words need for further instruction. These words indicate a false response question and that you need to select the incorrect client statement. Eliminate options 1 and 2 first because they are similar. Noting the anatomical location of the surgery will assist you in eliminating option 3 and direct you to option 4 as the correct answer to this question. Review postoperative teaching points for the client with carpal tunnel syndrome if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Adult Health/Musculoskeletal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 818.

Read also:

• NCLEX Practical Nursing with Answers 101th Edition
• Study NCLEX Practical Nursing with Answers 100th Edition
• Study NCLEX PN Answers 99th Edition

Thank you for your attention with reading our article NCLEX Practical Nursing 102th Edition (Adult Health/Renal/Musculoskeletal/Gastrointestinal/Fundamental Skills). Thanks for your participation, like and share if this is usefull.

Share this post