the nurse is assigned to care for a child following surgery to correct cryptorchidism which priority action should the nurse include in the plan of ca the nurse is assigned to care for a child following surgery to correct cryptorchidism which priority action should the nurse include in the plan of ca
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NCLEX RN Exam Review Answers

1. Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?

Correct answer: Prevent tension on the suture.

Rationale: The correct answer is to prevent tension on the suture. After surgery for cryptorchidism, the testicle is held in position by an internal suture that should not be dislodged. Immobilization of the area for a week is crucial to prevent complications like bleeding and infection. Monitoring urine for glucose and acetone is unrelated to this surgery. While maintaining hydration is important, forcing fluids is not necessary. Encouraging coughing and deep breathing every hour may be a postoperative consideration, but it is not the priority for this specific surgery.

2. Which of the following screening tools have been found to have high diagnostic accuracy for screening for intimate partner violence?

Correct answer: D

Rationale: All of the above screening tools, including HITS, HARK, and STaT, have been found to have high diagnostic accuracy for screening intimate partner violence, as per the National Preventive Services Task Force. These tools are effective in identifying current or recent intimate partner violence. While the Partner Violence screen may have some predictive value for future intimate partner violence, the question specifically focuses on screening tools with high diagnostic accuracy, making 'All of the above' the correct choice. Choices A, B, and C are specific validated screening tools for intimate partner violence, each with its own set of questions that have been shown to be effective in identifying individuals experiencing intimate partner violence. Therefore, 'All of the above' is the most comprehensive and accurate choice for this question.

3. A daughter of a Chinese-speaking client approaches the nurse and asks multiple questions while maintaining direct eye contact. Which culturally related concept would the daughter’s behavior reflect?

Correct answer: Assimilation

Rationale: The correct answer is assimilation. Assimilation involves incorporating the behaviors of a dominant culture. In this scenario, maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike, which is not demonstrated by the daughter's behavior. Ethnocentrism is the perception that one’s beliefs are superior to those of others, which is not evident in this situation.

4. What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016

Correct answer: 7/7/2017

Rationale: The expected date of delivery is calculated using Nagle’s rule which is: The first day of last menstrual period – 3 months + 7 days = the estimated date of delivery

5. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

Correct answer: Encourage range of motion and ambulation

Rationale: Encouraging range of motion and ambulation is an effective preventive measure for deep vein thrombosis in post-surgical clients. Mobility helps improve blood circulation, reducing the risk of clot formation. Elastic stockings help prevent blood pooling and clotting in the legs by providing external pressure to support venous return. Massaging the legs twice daily may help with circulation but is not as effective as promoting movement and ambulation. Placing pillows under the knees is a comfort measure and does not directly address the prevention of deep vein thrombosis.

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