Online Practice Test 37

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 37 > NCLEX® Review Date/Time Submitted: July 25, 2012 at 2:32 PM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		While witnessing a preoperative consent, the nurse learns that the client does not understand the risks of the surgery. The nurse's best action is to: Your Answer: Notify the surgeon
		Objective: Describe the phases of the perioperative period. Rationale: The primary responsibility for informed consent lies with the attending surgeon, not the interdisciplinary team. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Strategy: Understand contemporary nursing practice
2.		A nurse assesses the functioning of a client's nasogastric suction following abdominal surgery. Which one of the following indicates that a problem exists with the suction?  Your Answer: The air vent tube is open at the level of the waist.
		Objective: Demonstrate ongoing nursing assessments and interventions for the postoperative client. Rationale: All answers, except "The air vent tube is open at the level of the waist," are expected when nasogastric suction is properly functioning. The air vent tube should be higher than the level of the waist. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Understand contemporary nursing practice.
3.		Prior to surgery, a client receives a preoperative anticholinergic medication. This medication is used to: Your Answer: Reduce oral and pulmonary secretions
		Objective: Identify nursing responsibilities in planning perioperative nursing care. Rationale: The medication is used to reduce oral and pulmonary secretions. Anxiety-reducing medications are sedatives and tranquilizers. Sedation medications are narcotic analgesics. Histamine-receptor medications reduce gastric acidity and fluid volume. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Decide what is the best action for client and situation.
4.		Which complication is a client with obesity at greater risk of suffering than a client without the disease? Your Answer: Delayed healing
		Objective: Identify potential postoperative complications and describe nursing interventions to prevent them. Rationale: Obese clients have a greater risk of delayed healing. Electrolyte imbalance, seizures, and constipation are complications found after surgery, but clients with obesity are not at a significantly greater risk than others. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		An operating room nurse prepares a client for surgery. Which practice reflects current standards? Your Answer: Shaving the surgical site and 2 inches around the perimeter Correct Answer: Positioning the client after anesthesia and before surgical draping
		Objective: Evaluate the effectiveness of perioperative nursing interventions. Rationale: Maintenance of skin integrity is important, so hair removal is done only when necessary, at the surgical site only. Positioning is done after anesthesia but before draping. Position the client in anatomic position. If a depilitory is used, the antimicrobial is used afterward. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		A client has an appendectomy. This is an example of what kind of surgery? Your Answer: Ablative
		Objective: Discuss various types of surgery according to degree of urgency, degree of risk, and purpose. Rationale: Appendectomy is an example of ablative surgery. Diagnostic confirms or establishes a diagnosis, palliative relieves or reduces pain, and constructive restores function or appearance. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		A client who is having a mastectomy expresses sadness about losing her breast. The most appropriate nursing diagnosis is: Your Answer: Ineffective Individual Coping Correct Answer: Anticipatory Grieving
		Objective: Give examples of pertinent nursing diagnoses for surgical clients. Rationale: The appropriate nursing diagnosis is anticipatory grieving. Ineffective individual coping is incorrect because the client is not expressing conflicting values. Knowledge deficit is wrong because the client is not expressing lack of knowledge. Fear is wrong because the client is not expressing fear of surgery or outcome. Nursing Process: Planning Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		The nurse is aware that the client requires clarification of preoperative instructions when the client says: Your Answer: "It is OK to drink some juice in the morning."
		Objective: Describe essential preoperative teaching, including pain control, moving, leg exercises, and coughing and deep-breathing exercises. Rationale: The client repeats correct information, except that juice is not allowed the morning of surgery. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Decide what is the best action for client and situation
9.		A nurse assesses a postoperative client who has a rapid, weak pulse; urine output less than 30 ml/hr; and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect? Your Answer: Hypovolemic shock
		Objective: Identify potential postoperative complications and describe nursing interventions to prevent them. Rationale: The nurse should expect hypovolemic shock. Thrombophlebitis, aspiration pneumonia, and wound dehiscence could have similar symptoms with the addition of one more symptom. Thrombophlebitis is calf inflammation or pain. Aspiration pneumonia is shortness of breath and cough. Wound dehiscence pertains to opening of the wound stitches. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Read question and prioritize nursing actions.
10.		When would a postoperative client probably require the most pain medication? Your Answer: 4 hours after surgery Correct Answer: 12-36 hours after surgery
		Objective: Demonstrate ongoing nursing assessments and interventions for the postoperative client. Rationale: Pain medication is not usually required immediately or shortly after surgery, due to the effects of anesthesia. If pain continues to be intense 48-60 hours after surgery, a problem may exist. Bring the pain to the attention of the surgeon. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Read question and prioritize nursing actions.