a client is having a tubal ligation in the outpatient surgical clinic postoperatively it is priority for the nurse to determine
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Nursing Elites

NCLEX-PN

NCLEX Question of The Day

1. After a client has a tubal ligation in the outpatient surgical clinic, what is the priority for the nurse to determine?

Correct answer: C

Rationale: The priority for the nurse is to ensure the client has a safe way to get home and adequate care after discharge. It is crucial to determine the client's transportation arrangements and availability of care at home to ensure a smooth transition postoperatively. Options A and B, though important, are not immediate priorities compared to the client's safety and well-being after the procedure. Option D is incorrect as spending the night at the surgical center is not typically part of the plan for outpatient surgery.

2. In conducting a community health fair for a group of middle-aged citizens, which statement should the nurse emphasize in reducing the risk of coronary heart disease?

Correct answer: B

Rationale: Engaging in an aerobic exercise class every day is crucial in reducing the risk of coronary heart disease. Aerobic exercises help keep the heart in shape, lower blood pressure, and improve cholesterol levels. It is recommended to participate in at least 150 minutes of moderate-intensity aerobic exercise per week, which can be achieved by engaging in aerobic exercise daily. Choice A has been corrected to emphasize the frequency required to significantly reduce the risk of coronary heart disease. Choice C has been modified to suggest moderation in alcohol intake, as excessive alcohol consumption is harmful. Choice D is also incorrect as a balanced diet, not specifically high-protein, high-fat, is recommended to reduce the risk of coronary heart disease and maintain a healthy weight.

3. A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?

Correct answer: D

Rationale: A dark red color is an abnormal finding when assessing the stoma as it indicates inadequate blood supply, possibly due to ischemia. Mild edema, minimal bleeding, and a rose color are expected findings one day post colostomy surgery. Mild edema can be present due to tissue trauma and inflammation, minimal bleeding can occur initially, and a healthy stoma typically appears pink to red, known as a rose color, indicating good blood supply and tissue perfusion. Therefore, the dark red color is the abnormal finding in this scenario.

4. A patient has fallen off a bicycle and fractured the head of the proximal fibula. A cast was placed on the patient's lower extremity. Which of the following is the most probable result of the fall?

Correct answer: A

Rationale: The correct answer is peroneal nerve injury. The head of the proximal fibula is in close proximity to the peroneal nerve, making it susceptible to injury when there is a fracture. The peroneal nerve runs along the fibula and can be affected by trauma to this area. Choice B, tibial nerve injury, is incorrect as the fracture site is closer to the peroneal nerve, not the tibial nerve. Choice C, sciatic nerve injury, is incorrect as the injury is more localized to the fibular head area where the peroneal nerve is affected. Choice D, femoral nerve injury, is incorrect as the femoral nerve is not immediately adjacent to the proximal fibula and is not typically affected by this type of injury.

5. After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?

Correct answer: A

Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.

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