the nurse is caring for an infant after repair of an inguinal hernia which of these assessment findings indicates that the surgical repair was effecti
Logo

Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. After repair of an inguinal hernia, the infant is being cared for. Which assessment finding indicates that the surgical repair was effective?

Correct answer: D

Rationale: The absence of inguinal swelling when the infant cries or strains indicates that the surgical repair of the inguinal hernia was effective. Inguinal swelling typically occurs with crying or straining in cases of this condition. A clean, dry incision signifies the absence of wound infection post-surgery but does not directly indicate the effectiveness of the hernia repair. Abdominal distension suggests a gastrointestinal issue unrelated to the hernia repair. An adequate flow of urine is not specific to evaluating the success of inguinal hernia repair.

2. 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.

3. What drives respiration in a patient with advanced chronic respiratory failure?

Correct answer: A

Rationale: In patients with advanced chronic respiratory failure, such as those with chronic obstructive pulmonary disease (COPD), the respiratory drive shifts from being primarily stimulated by high levels of carbon dioxide (hypercapnia) to being driven by low oxygen levels (hypoxemia). This shift is due to the body's adaptation to chronic respiratory acidosis and hypoxemia. As a result, hypoxemia becomes the primary stimulus for respiration in these patients. Hypocapnia, a low level of carbon dioxide, is not a common driver of respiration in patients with advanced chronic respiratory failure. Therefore, the correct answer is hypoxemia.

4. The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?

Correct answer: C

Rationale: Administering analgesic therapy as ordered is the most appropriate action during the acute phase of a sickle cell vasoocclusive crisis. In this phase, the primary focus is on managing the severe pain experienced by the individual. Analgesic therapy helps alleviate the pain and discomfort associated with the crisis. The other options are not the priority during this phase. Fluid restriction is not recommended as hydration is crucial in managing a vasoocclusive crisis. Ambulation may worsen the pain and should be minimized during this phase. Encouraging increased caloric intake is not directly related to managing the acute phase of a vasoocclusive crisis.

5. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

Correct answer: C

Rationale: After surgical repair of a cleft lip on the right side, the nurse should position the infant carefully to ensure comfort and prevent complications. Placing the infant in the prone position or on the stomach is not recommended as it may cause rubbing of the surgical site against the mattress. The optimal position for the infant is the left lateral position, away from the surgical repair site, to minimize the risk of trauma. Placing the infant on the right lateral position would be contraindicated as it is on the side of the repair. Additionally, positioning the infant upright on the back can help prevent airway obstruction by secretions, blood, or the tongue. Therefore, the correct choice is to place the infant in the left lateral position to promote safety and comfort post cleft lip surgery.

Similar Questions

A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?
A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
A nurse is caring for an infant who has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?
The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care?

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