the nurse is preparing a client for surgery which item is most important to remove before sending the client to surgery
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Nursing Elites

NCLEX-PN

Nclex 2024 Questions

1. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?

Correct answer: B

Rationale: The correct answer is B: Contact lenses. It is crucial to remove contact lenses before surgery to prevent corneal drying, especially with non-extended wear lenses. Leaving the hearing aid or artificial eye in place does not pose harm to the client during surgery. While wedding rings are typically covered with tape, leaving them on is acceptable. Therefore, choices A, C, and D are incorrect in this scenario.

2. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?

Correct answer: C

Rationale: Carbamazepine (Tegretol) can suppress the bone marrow, leading to a decrease in the white blood cell count. A laboratory value of WBC 2,000 per cubic millimeter indicates a serious side effect of the drug. Choices A and D are within normal limits, while choice B is at the lower limit of normal. Therefore, choices A, B, and D are incorrect.

3. When questioning an elder about suspected abuse, how should the nurse keep the questions?

Correct answer: A

Rationale: When questioning an elder about suspected abuse, the nurse should keep the questions nonjudgmental. This approach helps the elder feel safe and more willing to share information. Probing questions might be perceived as invasive, confrontational questions can lead to defensiveness and denial, and indirect questions may not elicit the necessary information, resulting in confusion or misinterpretation.

4. An infant weighs 7 pounds at birth. What is the expected weight by 1 year of age?

Correct answer: D

Rationale: A birth weight of 7 pounds typically triples by the age of 1 year, resulting in an expected weight of 21 pounds. This significant weight gain is a normal growth pattern for infants as they usually experience rapid growth in the first year of life. Choices A, B, and C are incorrect because they do not account for the usual growth rate of an infant in the first year. Infants commonly triple their birth weight by the age of 1, making 21 pounds the expected weight.

5. A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?

Correct answer: D

Rationale: The correct answer is a fresh peach. It is the most suitable snack for a client with sodium restriction as it is naturally low in sodium. Peanut butter cookies (choice A), grilled cheese sandwich (choice B), and cottage cheese and fruit (choice C) contain higher amounts of sodium, making them unsuitable choices for someone on a low-sodium diet. Fresh fruits like peaches are excellent options for individuals on a low-sodium diet as they are not only low in sodium but also provide essential nutrients and hydration.

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