NCLEX-PN
Next Generation Nclex Questions Overview 3.0 ATI Quizlet
1. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder
Correct answer: C
Rationale: Serosanguinous drainage is expected after a classic cholecystectomy resection. The appropriate intervention is to reinforce the dressing to maintain pressure and promote clot formation. Changing the dressing prematurely increases the risk of infection as it disturbs the wound. Applying an abdominal binder is not indicated as it can interfere with visualizing the dressing and assessing for any signs of bleeding or infection. Notifying the physician is not necessary at this point unless there are signs of excessive bleeding or other concerning symptoms.
2. Ethical and moral issues concerning restraints include all of the following except:
- A. emotional impact on the client and family
- B. dignity of the client
- C. client's quality of life
- D. policies and procedures
Correct answer: D
Rationale: The correct answer is 'policies and procedures.' While policies and procedures are important for guidance and structure, they do not inherently involve ethical or moral considerations. The emotional impact on the client and family, the dignity of the client, and the client's quality of life are all directly related to ethical and moral concerns when it comes to the use of restraints. These factors are crucial in ensuring that the use of restraints is not only physically necessary but also ethically justifiable and respects the individual's rights and well-being. Therefore, options A, B, and C are all aspects that touch upon ethical and moral dimensions in the context of restraints.
3. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
- A. "I will assist you in arranging to have a medicine woman present."?
- B. "We do not allow medicine women in exam rooms."?
- C. "That does not make any difference in the outcome."?
- D. "It is old-fashioned to believe in that."?
Correct answer: A
Rationale: The correct response is to show cultural awareness and respect the client's request by offering assistance in arranging for the medicine woman to be present. This approach acknowledges the importance of cultural beliefs and practices in the client's care, fostering trust and cooperation. Choices B, C, and D are inappropriate as they dismiss or belittle the client's cultural beliefs, showing insensitivity and lack of respect, which can negatively impact the nurse-client relationship.
4. Ethical and moral issues concerning restraints include all of the following except:
- A. emotional impact on the client and family.
- B. dignity of the client.
- C. client's quality of life.
- D. policies and procedures.
Correct answer: D
Rationale: The correct answer is 'policies and procedures.' While policies and procedures are essential for managing restraints, they are not in themselves ethical or moral issues. The emotional impact on the client and family, the dignity of the client, and the client's quality of life are all ethical and moral concerns related to the use of restraints. These aspects focus on the well-being, respect, and rights of the individual, which are fundamental ethical considerations in healthcare practice. Choices A, B, and C are directly tied to ethical and moral considerations by highlighting the impact on individuals involved and their overall quality of life and dignity, making them key factors to address in ethical decision-making.
5. A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
- A. calcium
- B. magnesium
- C. potassium
- D. sodium chloride
Correct answer: D
Rationale: When a client with an ileus is placed on intestinal tube suction, the primary electrolyte lost is sodium chloride. Duodenal intestinal fluid contains potassium (K+), sodium (Na+), and bicarbonate. Suctioning is done to remove excess fluids, leading to a decrease in the client's sodium chloride levels. Therefore, options A, B, and C are incorrect as calcium, magnesium, and potassium are not the primary electrolytes lost during intestinal suction in a client with an ileus.
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