the nurse is caring for a client following an appendectomy the client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale the
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NCLEX-PN

NCLEX PN 2023 Quizlet

1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response?

Correct answer: C

Rationale: The appropriate nurse response is to explain to the employer that private information cannot be released and ask the employer to step out while conducting the assessment. This approach respects the client's privacy while still acknowledging the employer. The employer's payment for insurance does not grant rights to confidential information. Sharing information without permission violates the client's right to privacy under HIPAA. Option A is incorrect as it compromises the client's confidentiality by sharing private medical information. Option B is inappropriate and unprofessional as it does not address the situation respectfully. Option D is incorrect as it does not prioritize the client's immediate needs and assumes the client's consent without proper communication.

2. Chemotherapeutic agents often produce a degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days or weeks because:

Correct answer: D

Rationale: Leukopenia does not present immediately after chemotherapy because time is required to clear circulating cells before the effect on precursor cell maturation in the bone marrow becomes evident. Leukopenia is characterized by an abnormally low white blood cell count. The correct answer is D because the white cell count is not immediately affected by chemotherapy. Choices A, B, and C are incorrect as they pertain to red blood cells (hemoglobin and hematocrit), which are not directly related to the delayed onset of leukopenia.

3. The newborn nursery is filled to capacity. Which newborn should the nurse assess first?

Correct answer: A

Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.

4. Which of the following situations requires nurse intervention?

Correct answer: C

Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public. Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention. Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.

5. Which intervention should the nurse stop the nursing assistant from performing?

Correct answer: C

Rationale: Placing traction weights on the bed to transfer the client to X-ray is an intervention that the nurse should stop the nursing assistant from performing. Traction should never be relieved without a doctor's order as it can result in muscle spasm and tissue damage. The other choices are appropriate nursing interventions and should not be stopped. Emptying the Jackson-Pratt drainage, performing passive range of motion, and collecting the first urine void for a 24-hour urine test are all within the scope of practice and do not pose immediate risks to the client's well-being.

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