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NCLEX-PN Exam Questions - Part 141
1. A client is 36 hours post-op a TKR surgery. 270 cc - s of sero-sanguinous accumulates in the surgical drains. What action should the nurse take?
A) Notify the doctor
B) Empty the drain
C) Do nothing
D) Remove the drain
2. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient the nurse notes a BP of 169/93, pulse 145 bpm and regular. What action should the nurse take?
A) Reassure patient that pain is normal following surgery.
B) Administer prn Nifedipine and assess client - s response.
C) Administer prn Meperidine HCL and assess client - s response.
D) Recheck BP and pulse rate every 20 minutes for the next hour.
3. A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
A) Verbal teaching in short sessions throughout the day
B) Pre-operative booklet on the surgery in Braille
C) Provide a tape for the client
D) Have the blind patient - s family member instruct the patient.
4. A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse - s appropriate documentation?
A) Note in medication records the drug given
B) The client was not hurt, no need for documentation
C) Note the client - s orientation
D) Completely fill out an incident report
5. A violation of a patient - s confidentiality occurs if two nurses are discussing client information in which of the following scenarios?
A) With a physical therapist treating the patient
B) With a social worker planning for discharge
C) With another nurse on duty to plan for break time
D) In the hallway outside the patient - s room.
A) Notify the doctor
B) Empty the drain
C) Do nothing
D) Remove the drain
2. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient the nurse notes a BP of 169/93, pulse 145 bpm and regular. What action should the nurse take?
A) Reassure patient that pain is normal following surgery.
B) Administer prn Nifedipine and assess client - s response.
C) Administer prn Meperidine HCL and assess client - s response.
D) Recheck BP and pulse rate every 20 minutes for the next hour.
3. A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
A) Verbal teaching in short sessions throughout the day
B) Pre-operative booklet on the surgery in Braille
C) Provide a tape for the client
D) Have the blind patient - s family member instruct the patient.
4. A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse - s appropriate documentation?
A) Note in medication records the drug given
B) The client was not hurt, no need for documentation
C) Note the client - s orientation
D) Completely fill out an incident report
5. A violation of a patient - s confidentiality occurs if two nurses are discussing client information in which of the following scenarios?
A) With a physical therapist treating the patient
B) With a social worker planning for discharge
C) With another nurse on duty to plan for break time
D) In the hallway outside the patient - s room.
1. Right Answer: A
Explanation: The physician should be notified if excessive drainage is noted from the surgical site.
2. Right Answer: C
Explanation: A sinus tachycardia is a physiological response to pain. Treating the cause of the increased pulse rate requires pain medication.
3. Right Answer: A
Explanation: Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a one on one format.
4. Right Answer: D
Explanation: The incident report should always be filled out involving medication errors.
5. Right Answer: D
Explanation: Hallway discussions should not occur, because you do not who is listening, even though it may be a professional discussion.
Explanation: The physician should be notified if excessive drainage is noted from the surgical site.
2. Right Answer: C
Explanation: A sinus tachycardia is a physiological response to pain. Treating the cause of the increased pulse rate requires pain medication.
3. Right Answer: A
Explanation: Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a one on one format.
4. Right Answer: D
Explanation: The incident report should always be filled out involving medication errors.
5. Right Answer: D
Explanation: Hallway discussions should not occur, because you do not who is listening, even though it may be a professional discussion.
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