the nurse is caring for a client who had a total hip replacement seven 7 days ago which statement by the client requires the nurses immediate attentio
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. The client is seven (7) days post total hip replacement. Which statement by the client requires the nurse's immediate attention?

Correct answer: B

Rationale: While all statements by the client require attention, the most critical one that demands immediate action is option B. Clients who have undergone hip or knee surgery are at an increased risk of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are hallmark signs of this condition. Without appropriate prophylaxis such as anticoagulant therapy, deep vein thrombosis (DVT) can develop within 7 to 14 days after surgery, potentially leading to pulmonary embolism. It is crucial for the nurse to recognize signs of DVT, which include pain, tenderness, skin discoloration, swelling, or tightness in the affected leg. Signs of pulmonary embolism include sudden onset dyspnea, tachycardia, confusion, and pleuritic chest pain. Option B indicates a potentially life-threatening situation that requires immediate intervention to prevent serious complications.

2. A client is being instructed in the use of an incentive spirometer. Which of the following statements from the nurse indicates correct teaching about using this device?

Correct answer: D

Rationale: An incentive spirometer is a device used to improve lung function and reduce the risk of atelectasis. The correct way to use the spirometer is by sitting up and taking slow, deep breaths to achieve the set goal, not by lying back in a reclining position or taking rapid, quick breaths. Setting a goal of using the spirometer multiple times a day is beneficial, but it is not the best indicator of correct teaching. After using the spirometer, the client should practice coughing to help clear any loosened secretions that may have occurred during the breathing exercises.

3. Which response would best assist the chemically impaired client in dealing with issues of guilt?

Correct answer: B

Rationale: The correct response is, 'What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?' This response encourages the client to reflect on their actions, identify sources of guilt, and develop a plan to address and reduce these feelings constructively. Choice A is incorrect as it dismisses the client's guilt as typical, potentially invalidating their emotions. Choice C is incorrect as it suggests avoiding guilty feelings by turning to substance use, which is counterproductive. Choice D is incorrect as it focuses on the negative consequences of the client's actions without offering a constructive way to address and alleviate guilt.

4. A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on a 0 to 10 scale) whenever taking a deep breath. Which action will the nurse take next?

Correct answer: A

Rationale: The patient's complaint of sharp pain when taking a deep breath is concerning for pleurisy or pleural effusion. The nurse should auscultate breath sounds to assess for a pleural friction rub or decreased breath sounds, which could indicate these conditions. It is crucial to gather assessment data before initiating any pain medications. Asking the patient to cough forcefully may exacerbate the pain and should be avoided until further assessment. Contacting the healthcare provider should be based on the assessment findings; therefore, it is premature to notify the provider without conducting a thorough assessment first.

5. Which of the following diseases or disorders is acute?

Correct answer: A

Rationale: The correct answer is Pneumonia. Pneumonia is an acute illness characterized by inflammation of the air sacs in the lungs. It comes on suddenly and typically lasts for a short duration. Treatment can help cure pneumonia. Paralysis, Alzheimer's disease, and Diabetes are chronic conditions. Paralysis is the loss of muscle function in part of the body, usually permanent. Alzheimer's disease is a progressive brain disorder leading to memory loss and cognitive decline, and it is incurable. Diabetes is a chronic condition that affects how your body turns food into energy, and it requires lifelong management. Therefore, Pneumonia is the only acute condition among the options provided.

Similar Questions

When asked to describe in layman's terms an overview of the condition called osteomyelitis, what would be the nurse's best response?
The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?
The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
A healthcare provider is assessing vital signs in pediatric patients. Which of the following vital signs is abnormal?
After hydrostatic reduction for intussusception, what client response should the nurse expect to observe?

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