NCLEX Practice Exam for Reduction of Risk Potential

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Published on February 25, 2017 by NCLEX Exams

NCLEX Practice Exam for Reduction of Risk Potential In Text Mode: All questions and answers are given for reading and answering at your own pace.

Question 1. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
A). “The tube controls the amount of air that enters your chest.”.
B). “The tube will remove excess air from your chest.”.
C). “The tube will seal the hole in your lung.”.
D). “The tube will drain fluid from your chest.”.

Question 1 Answer: B). “The tube will remove excess air from your chest.”.
Question 1 Explanation: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

Question 2. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a PRIORITY?
A). Auscultate for pulmonary congestion.
B). Monitor equality of peripheral pulses.
C). Assess for post operative arrhythmias.
D). Blanch nail beds for color and refill.

Question 2 Answer: C). Assess for post operative arrhythmias.
Question 2 Explanation: The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

Question 3. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
A). Relaxation and sleep.
B). Incisional healing.
C). Range of motion exercises.
D). Coughing and deep breathing.

Question 3 Answer: D). Coughing and deep breathing.
Question 3 Explanation: The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

Question 4. The nurse is assessing a client two hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s FIRST action should be to:
A). Apply pressure at the bleeding site.
B). Wrap the leg with elastic bandages.
C). Reinforce the dressing and elevate the leg.
D). Remove the dressings and re-dress the incision.

Question 4 Answer: C). Reinforce the dressing and elevate the leg.
Question 4 Explanation: Reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the physician immediately. This is an emergency post surgical situation.

Question 5. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the BEST explanation for the nurse to provide this client?
A). “The tube controls the amount of air that enters your chest.”.
B). “The tube will drain fluid from your chest.”.
C). “The tube will seal the hole in your lung.”.
D). “The tube will remove excess air from your chest.”.

Question 5 Answer: D). “The tube will remove excess air from your chest.”.
Question 5 Explanation: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.

Question 6. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for IMMEDIATE action by the nurse?
A). Pulse oximetery of 88.
B). Breath sounds can be heard bilaterally.
C). Client is unable to speak.
D). Mist is visible in the T-Piece.

Question 6 Answer: A). Pulse oximetery of 88.
Question 6 Explanation: Pulse oximetry should not be lower than 90.

Question 7. A client has a chest tube in place following a left lower lobectomy done after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the MOST appropriate nursing action?
A). Clamp the chest tube.
B). Prepare for blood transfusion.
C). Call the surgeon immediately.
D). Continue to monitor the rate of drainage.

Question 7 Answer: D). Continue to monitor the rate of drainage.
Question 7 Explanation: Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.

Question 8. The MOST effective nursing intervention to prevent atelectasis from developing in a post operative client is to:
A). Splint incision.
B). Maintain adequate hydration.
C). Assist client to turn, cough and deep breathe.
D). Ambulate client within 12 hours.

Question 8 Answer: C). Assist client to turn, cough and deep breathe.
Question 8 Explanation: Deep air excursion by turning, coughing, and deep breathing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.

Question 9. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take PRIORITY in planning care?
A). Fatigue.
B). Skin irritation.
C). Esophagitis.
D). Leukopenia.

Question 9 Answer: D). Leukopenia.
Question 9 Explanation: Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.

Question 10. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
A). Serum potassium 6 mEq/L.
B). Hemoglobin of 10.3 mg/dl.
C). Blood urea nitrogen 50 mg/dl.
D). Venous blood pH 7.30.

Question 10 Answer: A). Serum potassium 6 mEq/L.
Question 10 Explanation: Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

Question 11. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 L/min, his color is flushed and his respirations are 8/min. What should the nurse do FIRST?
A). Take baseline vital signs.
B). Obtain a 12-lead EKG.
C). Lower the oxygen rate.
D). Place client in high Fowler’s position.

Question 11 Answer: C). Lower the oxygen rate.
Question 11 Explanation: A low oxygen level acts as a stimulus for respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe, leading to increased hypoventilation, respiratory decompensation, and the development of or worsening of respiratory acidosis. Unless corrected, it can lead to the client’s death.

Question 12. A four year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do FIRST?
A). Notify the physician.
B). Reassess the foot in fifteen minutes.
C). Readjust the traction.
D). Administer the ordered prn medication.

Question 12 Answer: A). Notify the physician.
Question 12 Explanation: The findings are indicative of circulatory impairment. The physician (or practitioner) must be notified immediately.

Question 13. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote:
A). Incisional healing.
B). Incisional healing.
C). Relaxation and sleep.
D). Deep breathing and coughing.

Question 13 Answer: D). Deep breathing and coughing.
Question 13 Explanation: The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.

Question 14. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
A). Clamp the chest tube.
B). Prepare for blood transfusion.
C). Continue to monitor the rate of drainage.
D). Call the surgeon immediately.

Question 14 Answer: C). Continue to monitor the rate of drainage.
Question 14 Explanation: Blood that comes in contact with the pleural space becomes defibrinogenated and usually will not clot. It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest

Question 15. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
A). Blanch nail beds for color and refill.
B). Assess for post operative arrhythmias.
C). Auscultate for pulmonary congestion.
D). Monitor equality of peripheral pulses.

Question 15 Answer: B). Assess for post operative arrhythmias.
Question 15 Explanation: The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.

Question 16. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported IMMEDIATELY?
A). Venous blood pH 7.30.
B). Blood urea nitrogen 50 mg/dl.
C). Hemoglobin of 10.3 mg/dl.
D). Serum potassium 6 mEq/L.

Question 16 Answer: D). Serum potassium 6 mEq/L.
Question 16 Explanation: Although all of these findings are abnormal, the elevated potassium is a life threatening finding and must be reported immediately.

Question 17. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
A). “I can’t lie in one position for more than thirty minutes.”.
B). “I suffer from claustrophobia.”.
C). “I am allergic to shrimp.”.
D). “I developed a severe headache after a spinal tap.”.

Question 17 Answer: C). “I am allergic to shrimp.”.
Question 17 Explanation: A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could be as serious as seizures.

Question 18. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
A). Increased heart rate.
B). Loss of pulse in the extremity.
C). Decreased urine output.
D). Increased blood pressure.

Question 18 Answer: B). Loss of pulse in the extremity.
Question 18 Explanation: Loss of the pulse in the extremity would indicate impaired circulation.

Question 19. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the FIRST action the nurse should perform?
A). Disconnect the client from the ventilator and use a manual resuscitation bag.
B). Press the alarm re-set button on the ventilator.
C). Perform a quick assessment of the client’s condition.
D). Call the respiratory therapist for help.

Question 19 Answer: C). Perform a quick assessment of the client’s condition.
Question 19 Explanation: A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.

Question 20. The priority is postoperative respiratory toilet. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. This will only be achieved with the appropriate pain management.
A). Increased temperature.
B). Involuntary muscle spasms.
C). Dyspnea.
D). Pallor.

Question 20 Answer: C). Dyspnea.
Question 20 Explanation: Client’s having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.

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