NCLEX RN Review for Reduction of Risk Potential

1. A client’s laboratory results have been returned and the creatinine level is 7 mg/dL. This finding would lead the nurse to place the highest priority on assessing

a. Pupillary reflex.
b. Intake and output.
c. Capillary refill.
d. Temperature.

2. A client requires that a bronchoscopy procedure be done. Due to his physical condition, he will be awake during the procedure. As part of the pretest teaching, the nurse will instruct him that before the scope insertion, his neck will be positioned so that it is

a. In an extended position.
b. In a neutral position.
c. In a flexed position.
d. Hyperextended.

3. To evaluate a client’s condition following cardiac catheterization, the nurse will palpate the pulse

a. At the insertion site.
b. Distal to the catheter insertion.
c. Above the catheter insertion.
d. In all extremities.

4. A 76-year-old woman who has been in good health develops urinary incontinence over a period of several days and is admitted to the hospital for a diagnostic workup. The nurse would assess the client for other indicators of

a. Urinary tract infection.
b. Dementia.
c. Renal failure.
d. Fluid volume excess.

5. The nurse is assigned to care for a 20 year old who has just had chest tubes inserted. An important nursing action is to

a. Check the chest tubes every 2 hours for air leaks.
b. Keep the client flat to avoid leaks in the tubing.
c. Coil the tubes carefully to prevent kinking, which could result in an air leak.
d. Place a hemostat nearby in case of an air leak.

6. A client is on dialysis treatments three times per week. The nurse explains that the main advantage of using an internal arteriovenous fistula rather than an external arteriovenous cannula for dialysis is

a. It is easier to access the blood flow with the internal fistula than through the external cannula.
b. The internal fistula can be utilized immediately after insertion.
c. There is less risk of hemorrhage from the internal fistula.
d. Accessing the internal fistula is less uncomfortable for the client.

7. When evaluating all forms of traction, the nurse knows that the direction of pull is controlled by the

a. Rope/pulley system.
b. Amount of weight.
c. Client’s position.
d. Point of friction.

8. Russell’s traction is easily recognized because it incorporates a

a. Sling under the knee.
b. Pearson attachment.
c. Pelvic girdle.
d. Cervical halter.

9. Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?

a. Hypotension and hypothermia.
b. Serosanguineous drainage from the puncture site.
c. Increased temperature and blood pressure.
d. Increased pulse and pallor.

10. A 60-year-old male client’s physician schedules a prostatectomy and orders a straight urinary drainage system to be inserted preoperatively. For the system to be effective, the nurse would

a. Coil the tubing above the level of the bladder.
b. Check that the collection bag is vented and distensible.
c. Position the collection bag above the level of the bladder.
d. Determine that the tubing is less than 3 feet in length.

11. Which of the following statements is true of skeletal traction?

a. Neurovascular complications are less apt to occur than with skin traction.
b. Fractures can be reduced because more weight can be used than with skin traction.
c. The client has less mobility than he does with skin traction.
d. It is preferred for children because fracture fragment alignment is so important.

12. Following brain surgery, the client suddenly exhibits polyuria and begins voiding 15 to 20 L/day. Specific gravity for the urine is 1.006. The nurse will recognize these symptoms as the possible development of

a. Diabetes, type I.
b. Addison’s disease.
c. Diabetes, insipidus.
d. Diabetes, type II.

13. The nurse enters the room of a client who is in the clonic phase of a tonic-clonic seizure. The initial nursing action should be to

a. Insert a padded mouth gag.
b. Gently restrain the limbs.
c. Obtain equipment for orotracheal suctioning.
d. Place some padding under the head.

14. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to

a. Check that the balloon is deflated on a regular basis.
b. Monitor IV fluids for the shift.
c. Check that a hemostat is at the bedside.
d. Regularly assess respiratory status.

15. Hemorrhage is a major complication following oral surgery and radical neck dissection. If this condition occurs, the most immediate nursing intervention would be to

a. Put pressure over the common carotid and jugular vessels in the neck.
b. Notify the surgeon immediately.
c. Treat the client for shock.
d. Immediately put the client in high-Fowler’s position.

Answers and Rationale for NCLEX RN Review of Reduction of Risk Potential