the nurse is providing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia the nurse determi
Logo

Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?

Correct answer: C

Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.

2. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

Correct answer: B

Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.

3. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:

Correct answer: B

Rationale: Administering stool softeners daily is crucial to prevent straining during defecation, which can lead to the Valsalva maneuver. Straining can increase intrathoracic pressure, decrease venous return to the heart, and reduce cardiac output, potentially worsening the client's condition. If constipation occurs, the use of laxatives may be necessary to avoid straining. Administering antidysrhythmics on an as-needed basis is not indicated for preventing the Valsalva maneuver; they are used to manage dysrhythmias. Strict bed rest is not necessary and may lead to complications such as deconditioning, DVT, and respiratory issues in the absence of specific medical indications.

4. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?

Correct answer: B

Rationale: The correct answer is that oral contraceptives should not be used by smokers. The use of oral contraceptives in a woman who smokes increases the risk of cardiovascular problems, such as thromboembolic disorders. This is due to the combined effect of smoking and hormonal contraceptives. Choices A, C, and D are incorrect because they do not address the specific risk associated with smoking and oral contraceptives. Norplant's safety and ease of removal, Depo-Provera's convenience with few side effects, and the IUD's protection against pregnancy and infection are important points but not directly related to the increased risks for smokers using oral contraceptives.

5. A client who has undergone radiation therapy presents with itching, redness, burning pain, and skin sloughing on the chest and abdomen. Which nursing intervention is most appropriate for this client?

Correct answer: B

Rationale: For a client experiencing skin symptoms like redness, itching, burning pain, and sloughing after radiation therapy, it is crucial to maintain proper skin care. Applying ointments, lotions, or powders can worsen the condition by trapping moisture and leading to further skin irritation. The most appropriate intervention is to wash the affected area gently with water to cleanse it without further irritating the skin. Using mild antiseptic soap or talcum powder can also be harsh on the compromised skin. Patting the skin dry helps prevent friction and trauma to the affected area, promoting healing and comfort.

Similar Questions

While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
The physician has decided to perform a thoracentesis based on Mr. R's assessment. Which of the following actions from the nurse is most appropriate?
A mother has recently been informed that her child has Down syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down syndrome?
The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices?

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