a nurse assesses a 83 year old females venous ulcer for the second time that is located near the right medial malleolus the wound is exhibiting purule
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Nursing Elites

NCLEX-PN

NCLEX-PN Quizlet 2023

1. A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?

Correct answer: A

Rationale: The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.

2. The client with a history of advanced chronic obstructive pulmonary disease (COPD) had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?

Correct answer: C

Rationale: The priority intervention for preventing respiratory complications in a client with advanced COPD who underwent gallbladder surgery is to get the client out of bed 4 times daily. This helps prevent pooling of secretions in the lungs and promotes better lung expansion. Incentive spirometry, coughing, and deep breathing are essential interventions; however, they should be performed more frequently, ideally every 1 to 2 hours, rather than every 4 hours or 4 times daily. Giving oxygen at 4 L/minute could potentially decrease the client's respiratory drive, which is not the priority in this case.

3. Post thyroidectomy the nurse assesses for complications by performing which of the following assessments?

Correct answer: B

Rationale: The correct answer is Chvostek's. A positive Chvostek's and Trousseau's sign is indicative of tetany, which is associated with low calcium levels. This can occur if parathyroid glands are accidentally removed during thyroidectomy. Accu-Chek is a brand of blood glucose monitor used for checking blood sugar levels and is not relevant in this context. Ballottement is a technique used in physical examination to assess for fluid in the body, typically in the abdomen or joints. Ice water colonic is not a standard medical assessment and is not relevant to post-thyroidectomy complications.

4. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?

Correct answer: D

Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.

5. Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?

Correct answer: A

Rationale: The correct answer is, "This diet can be used when there is close medical supervision."? Very low-calorie diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality protein, and has a minimum of carbohydrates to spare protein and prevent ketosis. Choice B is incorrect because VLCDs are typically short-term interventions. Choice C is incorrect because VLCDs usually consist of nutritionally complete liquid formulations, not solid food items that are pureed. Choice D is incorrect because VLCDs actually contain a high quality of protein, although the overall caloric content is very low.

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