a 30 year old man is being admitted to the hospital for elective knee surgery which assessment finding is most important to report to the health care

NCLEX-RN

NCLEX RN Exam Questions

1. A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the healthcare provider?

A. Tympany on percussion of the abdomen
B. Liver edge 3 cm below the costal margin
C. Bowel sounds of 20/minute in each quadrant
D. Aortic pulsations visible in the epigastric area

Correct answer: B

Rationale: The correct answer is 'Liver edge 3 cm below the costal margin.' Normally, the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly, which could indicate an underlying health issue. Tympany on percussion of the abdomen, bowel sounds of 20/minute in each quadrant, and aortic pulsations visible in the epigastric area are all within normal limits for a physical assessment and do not require immediate reporting to the healthcare provider.

2. A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?

A. Heparin will dissolve clots that you have.
B. Heparin will reduce the platelets that make your blood clot.
C. Heparin will work better than warfarin.
D. Heparin will prevent new clots from developing.

Correct answer: D

Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.

3. A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

A. Blood pressure 94/60 mm Hg
B. Heart rate 76 bpm
C. Urine output 50 ml/hour
D. Respiratory rate 16 bpm

Correct answer: A

Rationale: The correct answer is 'Blood pressure 94/60 mm Hg.' Both digoxin and metoprolol decrease the heart rate. Metoprolol specifically affects blood pressure. Therefore, the heart rate and blood pressure need to be within normal range (HR 60-100 bpm; systolic BP above 100 mm Hg) to safely administer both medications. A blood pressure of 94/60 mm Hg indicates hypotension, which could be exacerbated by metoprolol, necessitating immediate reporting to the healthcare provider. Choices B, C, and D are within normal limits and do not pose immediate risks related to the administration of these medications.

4. A patient is being visited at home by a healthcare professional. The patient has been taking Naproxen for back pain. Which statement made by the patient most indicates that the healthcare professional needs to contact the physician?

A. I get an upset stomach if I don't take Naproxen with my meals.
B. My back pain right now is about a 3/10.
C. I get occasional headaches since taking Naproxen
D. I have ringing in my ears.

Correct answer: D

Rationale: The correct answer is 'I have ringing in my ears.' Ringing in the ears is a severe adverse effect of Naproxen, indicating potential toxicity. This symptom warrants immediate medical attention. Choices A, B, and C are less concerning and do not directly indicate a severe adverse effect or toxicity related to Naproxen. Upset stomach, mild back pain, and occasional headaches are common side effects that may not require immediate physician contact.

5. Septic, anaphylactic, and neurogenic shock are all categorized as:

A. Hypovolemic shock
B. Cardiogenic shock
C. Distributive shock
D. Obstructive shock

Correct answer: C

Rationale: Septic, anaphylactic, and neurogenic shock are all types of distributive shock. Distributive shock is characterized by a decrease in systemic vascular resistance, leading to poor tissue perfusion. Septic shock is caused by severe infection, anaphylactic shock is an extreme allergic reaction, and neurogenic shock results from damage to the nervous system. Hypovolemic shock (Choice A) is characterized by a decrease in intravascular volume, cardiogenic shock (Choice B) is due to heart failure, and obstructive shock (Choice D) results from obstruction of blood flow. Therefore, the correct categorization for septic, anaphylactic, and neurogenic shock is distributive shock.