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NCLEX Exam in Multiple Choice with Answer 126th Edition
1. A nurse caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. What intervention would best facilitate the client’s participation in infant care?
A. Encouraging the client to take pain medication as ordered
B. Maintaining the client in supine position whenever possible
C. Limiting fluid intake to keep the bladder empty
D. Promoting family members to care for the infant
Answer: A. Encouraging the client to take pain medication as ordered
Rationale: Nursing responsibilities for the care of a client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler’s position to facilitate drainage and lessen congestion, and providing appropriate analgesia. Option 1 is the only nursing intervention that demonstrates the nurse’s understanding of both the physiological and psychosocial needs of the postpartum client experiencing endometritis. Keeping the client comfortable will facilitate interest in caring for the infant. Options 2, 3, and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology associated with endometritis. Option 4 can be eliminated first because the client is the mother. Knowing that options 2 and 3 identify inappropriate nursing interventions for the client with endometritis will assist in directing you to option A. Review the pathophysiology associated with endometritis if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 292.
2. A nurse is collecting data on a client admitted to the hospital with hepatitis. Which objective data would indicate that the client might have suffered liver damage?
A. Brown stools
B. Blood-tinged urine
C. Pruritus
D. Amber urine
Answer: C. Pruritus
Rationale: Significant damage to liver cells renders them unable to metabolize bilirubin. When a red blood cell is broken down, hemoglobin is released. The heme portion is catabolized into unconjugated bilirubin. The liver then takes that unconjugated bilirubin and transforms it into conjugated bilirubin that passes into the hepatic ducts and eventually into the bowel, providing the normal brown color to stool. When bilirubin is not metabolized by the liver, it accumulates in the circulation, and is minimally excreted by the skin, causing jaundice and pruritus. It is also eliminated unchanged by the kidneys, causing urine to become dark brown.
Test-Taking Strategy: Use the process of elimination. Recalling the pathophysiology associated with hepatitis and the manifestations associated with liver damage will direct you to the correct option. Review these clinical manifestations if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Gastrointestinal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 721.
3. A nurse is reviewing the physician’s orders of a client admitted to the hospital with a diagnosis of liver disease. Which medication order would the nurse question?
A. Lorazepam (Ativan)
B. Acetaminophen (Tylenol)
C. Furosemide (Lasix)
D. Omeprazole (Prilosec)
Answer: B. Acetaminophen (Tylenol)
Rationale: Acetaminophen can cause hepatotoxicity, and its use is avoided in the client with liver disease. Furosemide and omeprazole do not adversely affect liver function. Lorazepam can cause liver damage in high doses or with long-term therapy, but can still be used (with caution) in the client with liver disease.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the medications that are hepatotoxic to answer this question. Remember that acetaminophen is hepatotoxic. Review the contraindications associated with acetaminophen if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 8.
4. A nurse planning care for a client with hepatitis plans to meet the client’s safety needs by:
A. Monitoring prothrombin time and partial thromboplastin time
B. Bathing with tepid water
C. Assisting with meals
D. Weighing and recording a weight daily
Answer: A. Monitoring prothrombin time and partial thromboplastin time
Rationale: When liver function is impaired, as in the client with hepatitis, some important body functions do not occur. The liver synthesizes fibrinogen, prothrombin, and factors needed for normal blood clotting. Without those clotting ingredients, bleeding may occur either internally or externally. Monitoring coagulation studies provides the nurse with information needed to plan ways to reduce the risk of hemorrhage when providing care. Assisting with meals would not be an issue unless dysphagia was present. Daily weight is often part of a nursing care plan, but is more related to fluid balance than safety. Tepid baths may decrease the pruritus associated with jaundice, but this is not a safety issue.
Test-Taking Strategy: Use the process of elimination. Focus on the issue of the question, safety. Recalling the pathophysiology associated with hepatitis and that the risk of bleeding is a concern will direct you to option A. Review care to the client with hepatitis if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Gastrointestinal
References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 232.
Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 721.
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