the nurse in the day surgery center cares for a patient who has undergone an endoscopic procedure with general anesthesia the nurse understands that w
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?

Correct answer: B

Rationale: After an endoscopic procedure with general anesthesia, the priority nursing consideration is to not offer fluids, food, or any oral intake to the patient. Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. Raising the siderails of the patient's bed is important for safety but not the immediate priority. Checking the patient's temperature may be important but is not the priority immediately after the procedure. Teaching the patient to avoid aspirin or NSAIDS is important for post-procedure care but is not the priority immediately after the endoscopic procedure.

2. The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

Correct answer: D

Rationale: It is crucial for the nurse to inquire about whether the patient has received the bacille Calmette-Guerin (BCG) vaccine for TB before performing the skin test. Patients who have received the BCG vaccine can have a positive Mantoux test, leading to the need for alternative screening methods, such as a chest x-ray, to determine TB infection. While family history of TB and length of time in the United States are relevant factors, they do not directly impact the decision to perform the TB skin test. Asking about over-the-counter medications, unless relevant to TB treatment, is not as critical as assessing BCG vaccination status.

3. While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

Correct answer: B

Rationale: The correct answer is 'Separation from parents.' Separation anxiety is most evident from 6 months to 30 months of age and is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. The other choices, such as 'Strange bed and surroundings,' 'Presence of other toddlers,' and 'Unfamiliar toys and games,' may also have an impact on the child, but separation from parents is typically the most significant factor affecting behavior in a hospitalized 2-year-old.

4. A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?

Correct answer: B

Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.

5. A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

Correct answer: A

Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.

Similar Questions

Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals
The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
A healthcare professional is preparing to palpate and percuss a patient's abdomen as part of the assessment process. Which of these findings would cause the healthcare professional to immediately discontinue this part of the assessment?
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses