NCLEX RN Review for Reduction of Risk Potential

1. A clients laboratory results have been returned and the creatinine level is 7
mg/dL. This finding would lead the nurse to place the highest priority on assessing

a. Pupillary reflex.
b. Intake and output.
c. Capillary refill.
d. Temperature.

2. A client requires that a bronchoscopy procedure be done. Due to his physical

condition, he will be awake during the procedure. As part of the pretest teaching,
the nurse will instruct him that before the scope insertion, his neck will be
positioned so that it is

a. In an extended position.
b. In a neutral position.
c. In a flexed position.
d. Hyperextended.

3. To evaluate a clients condition following cardiac catheterization, the nurse will

palpate the pulse

a. At the insertion site.

b. Distal to the catheter insertion.

c. Above the catheter insertion.

d. In all extremities.

4. A 76-year-old woman who has been in good health develops urinary incontinence
over a period of several days and is admitted to the hospital for a diagnostic
workup. The nurse would assess the client for other indicators of

a. Urinary tract infection.

b. Dementia.
c. Renal failure.
d. Fluid volume excess.

5. The nurse is assigned to care for a 20 year old who has just had chest tubes
inserted. An important nursing action is to

a. Check the chest tubes every 2 hours for air leaks.

b. Keep the client flat to avoid leaks in the tubing.
c. Coil the tubes carefully to prevent kinking, which could result in an air leak.
d. Place a hemostat nearby in case of an air leak.

6. A client is on dialysis treatments three times per week. The nurse explains that
the main advantage of using an internal arteriovenous fistula rather than an
external arteriovenous cannula for dialysis is

a. It is easier to access the blood flow with the internal fistula than through the
external cannula.
b. The internal fistula can be utilized immediately after insertion.
c. There is less risk of hemorrhage from the internal fistula.
d. Accessing the internal fistula is less uncomfortable for the client.

7. When evaluating all forms of traction, the nurse knows that the direction of pull is
controlled by the

a. Rope/pulley system.
b. Amount of weight.
c. Clients position.
d. Point of friction.

8. Russells traction is easily recognized because it incorporates a

a. Sling under the knee.

b. Pearson attachment.
c. Pelvic girdle.
d. Cervical halter.

9. Immediately following a thoracentesis, which clinical manifestations indicate that

a complication has occurred and the physician should be notified?

a. Hypotension and hypothermia.

b. Serosanguineous drainage from the puncture site.
c. Increased temperature and blood pressure.
d. Increased pulse and pallor.

10. A 60-year-old male clients physician schedules a prostatectomy and orders a

straight urinary drainage system to be inserted preoperatively. For the system to be
effective, the nurse would

a. Coil the tubing above the level of the bladder.

b. Check that the collection bag is vented and distensible.
c. Position the collection bag above the level of the bladder.
d. Determine that the tubing is less than 3 feet in length.

11. Which of the following statements is true of skeletal traction?

a. Neurovascular complications are less apt to occur than with skin traction.
b. Fractures can be reduced because more weight can be used than with skin
traction.
c. The client has less mobility than he does with skin traction.
d. It is preferred for children because fracture fragment alignment is so important.

12. Following brain surgery, the client suddenly exhibits polyuria and begins voiding
15 to 20 L/day. Specific gravity for the urine is 1.006. The nurse will recognize these
symptoms as the possible development of

a. Diabetes, type I.
b. Addisons disease.
c. Diabetes, insipidus.
d. Diabetes, type II.

13. The nurse enters the room of a client who is in the clonic phase of a tonic-clonic
seizure. The initial nursing action should be to

a. Insert a padded mouth gag.

b. Gently restrain the limbs.
c. Obtain equipment for orotracheal suctioning.

d. Place some padding under the head.

14. A client being treated for esophageal varices has a Sengstaken-Blakemore tube
inserted to control the bleeding. The most important assessment is for the nurse to

a. Check that the balloon is deflated on a regular basis.

b. Monitor IV fluids for the shift.
c. Check that a hemostat is at the bedside.
d. Regularly assess respiratory status.

15. Hemorrhage is a major complication following oral surgery and radical neck
dissection. If this condition occurs, the most immediate nursing intervention would
be to

a. Put pressure over the common carotid and jugular vessels in the neck.
b. Notify the surgeon immediately.
c. Treat the client for shock.
d. Immediately put the client in high-Fowlers position.

ANSWER AND RATIONAL

1. B. The elevated creatinine level suggests impaired renal function. Assessing
intake and output will provide data related to renal function. The other assessments
are not indicative of renal function.

2. D. Hyperextension brings the pharynx into alignment with the trachea and allows
the scope to be inserted without trauma.

3. B. Palpating pulses distal to the insertion site is important to evaluate for

thrombophlebitis and vessel occlusion. They should be bilateral and strong.

4. A. Urinary tract infections in the elderly often present as urinary incontinence that
develops suddenly. Renal failure (1) and fluid volume excess (3) typically are
characterized by oliguria. Dementia (4) develops slowly and is manifested by
disordered thinking and behavior.

5. D. The most important safety measure is to tape a hemostat nearby to use in

case of an air leak. Chest tubes should be checked periodically, but not necessarily
every 2 hours (2). The client should be in semi-Fowlers position to increase lung
expansion.

6. C. There is an increased incidence of hemorrhaging with the external cannula.

Hemorrhage results from the cannula becoming disconnected. One advantage of
the external cannula is that it is painless to use. Surgery is required to establish the
internal fistula and it should be allowed to heal for several weeks before being
utilized.

7. A. The rope/pulley and weight system is arranged so that fracture fragments are
in the desired approximate position for healing. The clients position should always
rest in line with the traction pull. The line of pull must never be interfered with by
changing the position of a pulley and extension bar.

8. A. Russells traction is a type of skin traction that incorporates a sling under the
knee that is connected by a rope to an overhead bar pulley. It is frequently used to
treat femoral shaft fractures in the adolescent.

9. D. Increased pulse and pallor are symptoms associated with shock. A

compromised venous return may occur if there is a mediastinal shift as a result of
excessive fluid removal. Usually no more than 1 L of fluid is removed at one time to
prevent this from occurring.

10. B. The collection bag must be able to fill easily; therefore, it needs to be
distended. The bag must be vented with a filter so that urine can be drained from
the chamber. The tube must not be allowed to coil or become kinked above the
level of the bladder. The collection bag is positioned below the level of the bladder
to allow for continuous urine drainage and prevent urine backflow into the bladder.
In order to prevent reflux of urine, the tubing must be of sufficient length, usually 5
feet.

11. B. Because more weight can be applied with skeletal traction, it can be used to
reduce fractures and maintain alignment. It is not used commonly in the elderly
because of prolonged immobilization. It is not preferred for children because some
displacement of fracture fragments is desirable to prevent growth disturbance.
Frequently, clients have more mobility than they do with skin traction, because
balanced suspension is often incorporated with skeletal traction.

12. C. Diabetes insipidus is an antidiuretic deficiency and may occur following brain
surgery or head injury. It also occurs in young adults resulting from damage to the
posterior lobe of the pituitary gland. Severe polyuria occurs when there is an
inability to concentrate urine. These are not symptoms of types 1 and 2 diabetes (2,
3) or Addisons disease (4) (which is adrenocorticol hypofunction).

13. D. Preventing cerebral trauma during the convulsion is a priority activity. Placing
some form of padding under the head will protect the skull and brain from injury.
Inserting a mouth gag (1) and restraining the limbs (3) are unsafe interventions. The
nurse would not leave a seizing person to go and obtain equipment (4).

14. D. The respiratory system can become occluded if the balloon slips and moves
up the esophagus, putting pressure on the trachea. This would result in respiratory
distress and should be assessed frequently. Scissors should be kept at the bedside
to cut the tube if distress occurs. This is a safety intervention.

15. A. Putting pressure over the vessels in the neck may be lifesaving because a
severe blood loss can occur rapidly, leading to shock and death. The surgeon would
be notified as soon as possible.