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.