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NCLEX Practice Tests & Sample Questions 105th Edition
1. A nurse assigned to care for a client with cirrhosis reviews the nursing care plan and notes a nursing diagnosis of ineffective breathing pattern related to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing?
A. Supine
B. Sims
C. Semi-Fowler’s
D. Prone
Answer: C. Semi-Fowler’s
Rationale: The client with an ineffective breathing pattern related to pressure on the diaphragm should be placed in a semi-Fowler’s or Fowler’s position. The nurse should support the client’s arms and chest with pillows to facilitate breathing by relieving pressure on the diaphragm. The supine, Sims, and prone positions all are flat positions and would further affect the breathing pattern in the client.
Test-Taking Strategy: Use the process of elimination and note the similarities between options 1, 2, and D. All of these positions are flat positions. Option 3 is the option that is different. Review care to the client with cirrhosis if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Gastrointestinal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 730.
2. A nurse is assisting in checking for Tinel’s sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique would the nurse expect to be used to elicit this sign?
A. Ask the client to flex the wrist at a 90-degree angle for 1 minute and assess for numbness
B. Percuss the medial nerve at the wrist as it enters the carpal tunnel and assess for tingling sensations
C. Dorsiflex the client’s hand and assess for pain in the forearm
D. Place pressure on the client’s radial nerve and assess for circulation
Answer: B. Percuss the medial nerve at the wrist as it enters the carpal tunnel and assess for tingling sensations
Rationale: Tinel’s sign is assessed by percussing the medial nerve at the wrist as it enters the carpal tunnel. A tingling sensation over the distribution of the nerve occurs in CTS. Phalen’s maneuver is performed by asking the client to flex the wrist at a 90-degree angle for 1 minute. Numbness and tingling over the distribution of the median nerve, the palmar surface of the thumb, and the index and middle fingers suggest CTS. Phalen’s maneuver is also an indication of CTS. Options 3 and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the assessment techniques related to CTS. Note that the words “carpal tunnel” appear both in the question and in the correct option. Review the procedure for checking Tinel’s sign if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1461.
3. A nurse is caring for a client following an abdominal hysterectomy performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse would appropriately:
A. Notify the registered nurse immediately
B. Remove the NG tube
C. Feed the client
D. Document the finding and continue to check for bowel sounds
Answer: D. Document the finding and continue to check for bowel sounds
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days owing to bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube is not removed and the client should receive nothing by mouth (NPO) until after the onset of bowel sounds. There is no need to notify the registered nurse immediately.
Test-Taking Strategy: Use the process of elimination and note the key words 1 day ago. Recalling that bowel sounds may not return for 3 to 4 postoperative days will direct you to option D. If you had difficulty with this question, review normal postoperative findings.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Fundamental Skills
References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 47-48.
deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 749.
4. A nurse is assisting in preparing a teaching plan of care for a client being discharged from the hospital following surgery for testicular cancer. Which instruction will the nurse suggest to include in the plan?
A. An elevation in temperature should be reported to the physician
B. You can lift heavy objects (those weighing 20 pounds or more) after 1 week following surgery
C. You can be fitted for a prosthesis in 6 months
D. You can climb stairs after 1 week
Answer: A. An elevation in temperature should be reported to the physician
Rationale: For the client who had testicular surgery, the nurse should emphasize the importance of notifying the physician if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. Often a prosthesis is inserted during surgery, so the client does not have to wait 6 months. The nurse instructs the client that he will be able to resume most of his usual activities within 1 week after discharge, except for lifting heavy objects (those weighing 20 pounds or more) and stair-climbing.
Test-Taking Strategy: Use the process of elimination. Remember, after any surgical procedure, elevation of temperature could signal an infection and should be reported. Review post-testicular surgery teaching points if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Adult Health/Oncology
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 991.
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