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NCLEX RN Exam Review Answers
1. The parents of an infant who underwent surgical repair of bladder exstrophy ask if the infant will be able to control their bladder as they get older. How should the nurse respond?
- A. Your child will need catheterization until bladder control is gained.
- B. Your child will be able to control their bladder like other children.
- C. You should potty train your child at the same time you normally would.
- D. Your child will not have a sphincter mechanism for the first 3 to 5 years, so urine will drain freely.
Correct answer: Your child will not have a sphincter mechanism for the first 3 to 5 years, so urine will drain freely.
Rationale: Bladder exstrophy is a congenital defect where the infant is born with the bladder located on the outside of the body. Surgical repair typically occurs within the first 1 to 2 days of life. In the following 3 to 5 years post-surgery, urine will drain freely from the urethra due to the absence of a sphincter mechanism. This period allows the bladder to develop capacity as the child grows. Subsequent surgical interventions will be required to establish a functioning sphincter mechanism. Therefore, the correct response is that the child will not have a sphincter mechanism for the first 3 to 5 years, leading to urine draining freely. Options A, B, and C are incorrect as they do not align with the physiological process and management of bladder exstrophy.
2. The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for lung cancer. Which information should the nurse include about the patient's postoperative care?
- A. Positioning on the right side
- B. Bed rest for the first 24 hours
- C. Frequent use of an incentive spirometer
- D. Chest tube placement with continuous drainage
Correct answer: Frequent use of an incentive spirometer
Rationale: After a pneumonectomy, frequent deep breathing and coughing are essential to prevent atelectasis and promote gas exchange. Patients are typically positioned on the surgical side to aid in gas exchange. Early mobilization is crucial to reduce the risk of postoperative complications such as pneumonia and deep vein thrombosis. While chest tubes may or may not be placed in the surgical space, if used, they are clamped and only adjusted by the surgeon to manage serosanguineous fluid accumulation. Overfilling of the chest cavity can compromise remaining lung function and cardiovascular status. Chest x-rays are useful for monitoring fluid volume and space postoperatively. Therefore, the correct postoperative care instruction for the patient undergoing a left pneumonectomy is the frequent use of an incentive spirometer. Choices A, B, and D are incorrect as positioning on the right side, bed rest for the first 24 hours, and continuous chest tube drainage are not standard postoperative care practices for patients undergoing pneumonectomy.
3. A client who is newly diagnosed with multiple sclerosis is obviously upset and asks, 'Am I going to die?' Which response would the nurse make?
- A. Most individuals with your disease live a normal life span.
- B. Is your family here? I would like to explain your disease to all of you.
- C. The prognosis varies, as most individuals have remissions and exacerbations.
- D. Why don't you speak with your health care provider to get more details?
Correct answer: The prognosis varies, as most individuals have remissions and exacerbations.
Rationale: The most appropriate response to the client's question regarding their prognosis is to acknowledge the variable nature of multiple sclerosis by stating that 'The prognosis varies, as most individuals have remissions and exacerbations.' This response provides realistic information while offering some hope. Choice A ('Most individuals with your disease live a normal life span.') gives false reassurance as repeated exacerbations may affect life span. Choice B ('Is your family here? I would like to explain your disease to all of you.') does not directly address the client's question and involves the family unnecessarily. Choice D ('Why don't you speak with your health care provider to get more details?') deflects the responsibility and does not address the client's immediate concerns about their prognosis.
4. Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
- A. Increased serum albumin level
- B. Decreased indirect bilirubin level
- C. Improved alertness and orientation
- D. Fewer episodes of bleeding varices
Correct answer: Fewer episodes of bleeding varices
Rationale: The correct answer is 'Fewer episodes of bleeding varices.' A transjugular intrahepatic portosystemic shunt (TIPS) is used to reduce pressure in the portal venous system, thus decreasing the risk of bleeding from esophageal varices. This outcome would indicate the effectiveness of the TIPS procedure. The other choices are incorrect because: Increased serum albumin level and decreased indirect bilirubin level are not direct indicators of TIPS effectiveness. Improved alertness and orientation could be influenced by various factors and may not directly correlate with the effectiveness of the TIPS procedure. Additionally, TIPS can actually increase the risk of hepatic encephalopathy, which contradicts the choice of improved alertness and orientation.
5. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
- A. Instruct the client to maintain a regular diet the day prior to the examination
- B. Restrict the client's fluid intake 4 hours prior to the examination
- C. Administer a laxative to the client the evening before the examination
- D. Inform the client that only 1 x-ray of his abdomen is necessary
Correct answer: Administer a laxative to the client the evening before the examination
Rationale: Administering a laxative to the client the evening before the examination is the correct action. Bowel prep is crucial for an Intravenous Pyelogram (IVP) as it helps in achieving better visualization of the bladder and ureters. Instructing the client to maintain a regular diet the day prior to the examination (Choice A) is not the appropriate preparation for an IVP. Restricting the client's fluid intake 4 hours prior to the examination (Choice B) is not necessary for this test. Informing the client that only 1 x-ray of his abdomen is necessary (Choice D) is not relevant to the preparation process for an IVP.
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