the nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula surgery is scheduled to be performed in 1 hour
Logo

Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula. Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the primary healthcare provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period?

Correct answer: D

Rationale: Esophageal atresia with tracheoesophageal fistula is a critical neonatal surgical emergency. The highest priority intervention during the preoperative period is to aspirate the NG tube every 5 to 10 minutes to keep the proximal pouch clear of secretions and prevent aspiration. This is crucial in reducing the risk of gastric secretions entering the lungs. Repositioning the infant frequently is not as critical as ensuring the NG tube is aspirated. Monitoring the temperature and blood pressure are important nursing interventions but are not the highest priority in this situation. It is essential to prioritize airway protection and prevent aspiration in this neonate undergoing urgent surgical intervention.

2. Mr. L was working in his garage at home and had an accident with a power saw. He is brought into the emergency department by a neighbor with a traumatic hand amputation. What is the first action of the nurse?

Correct answer: B

Rationale: The correct first action for the nurse in this scenario is to apply direct pressure to the injury. When a client presents with traumatic hand amputation causing excessive bleeding, the immediate goal is to control the bleeding. Applying direct pressure with a sterile dressing helps to stem the flow of blood and stabilize the patient. Placing a tourniquet at the level of the elbow should be avoided initially as it may lead to further complications such as tissue damage. Administering a bolus of 0.9% Normal Saline is not the priority in this situation where hemorrhage control is crucial. Elevating the injured extremity on a pillow does not address the primary concern of controlling the bleeding and stabilizing the patient.

3. The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for lung cancer. Which information should the nurse include about the patient's postoperative care?

Correct answer: C

Rationale: After a pneumonectomy, frequent deep breathing and coughing are essential to prevent atelectasis and promote gas exchange. Patients are typically positioned on the surgical side to aid in gas exchange. Early mobilization is crucial to reduce the risk of postoperative complications such as pneumonia and deep vein thrombosis. While chest tubes may or may not be placed in the surgical space, if used, they are clamped and only adjusted by the surgeon to manage serosanguineous fluid accumulation. Overfilling of the chest cavity can compromise remaining lung function and cardiovascular status. Chest x-rays are useful for monitoring fluid volume and space postoperatively. Therefore, the correct postoperative care instruction for the patient undergoing a left pneumonectomy is the frequent use of an incentive spirometer. Choices A, B, and D are incorrect as positioning on the right side, bed rest for the first 24 hours, and continuous chest tube drainage are not standard postoperative care practices for patients undergoing pneumonectomy.

4. A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

Correct answer: C

Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.

5. What intervention should the nurse implement while a client is having a grand mal seizure?

Correct answer: B

Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.

Similar Questions

The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?
Which of the following medications taken by the patient is least likely to cause urine discoloration?
A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?

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