NCLEX Daily Practical Exercise 31

Welcome to our NCLEX Daily Ten Practice! This practice is designed to help you solidify your knowledge, improve your skills, and prepare thoroughly for the NCLEX exam. With ten questions to tackle each day, you’ll have the opportunity to review a broad range of subjects covered in the NCLEX exam.

 

1. Nurse Jenny is instilling an otic solution into an adult male client’s left ear. Nurse Jenny avoids doing which of the following as part of the procedure

Correct Answer: C

Answer Explanation:

The dropper should not touch any object or any part of the client’s ear. Don’t allow the dropper tip to touch the ear, fingers, or any other surface. It could pick up bacteria or other germs that can lead to an ear infection.

Option A: For adults, pull the auricle backward and upward to prepare the ear for insertion of the drop and ensure the drop reaches the required area. If the bottle has a dropper, draw some liquid into the dropper. If the bottle has a dropper tip, you’ll just need to turn the bottle upside down.
Option B: If indicated, the solution can be warmed by rolling the bottle in the hands for several minutes before the instillation. Warm the ear drops by holding the bottle in both hands for one to two minutes. This can help reduce any discomfort that could be caused by cold drops in the ear.
Option D: Side-lying position is the best position for instillation of the drops and this also ensures comfort for the service user. Position the head so that the ear faces upward. If giving the drops to someone else, it may be easiest if the person tilts their head or lies down on their side.

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2. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptoms?

Correct Answer: A

Answer Explanation:

Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed. Sometimes the ileostomy does not function for short periods of time after surgery. This is not usually a problem, but if the stoma is not active for more than 6 hours and the patient experiences cramps or nausea, he may have an obstruction.

Option B: Passage of a moderate amount of stool in the stoma is expected during the first few days after surgery. With no large intestine to absorb as much water from it, stool becomes thinner. Stools may thicken up as the body adapts and the small intestine starts to absorb more water, but this is something that happens long-term. At first, the stool will be thin and output may be high.
Option C: As the body gets used to the stoma and ileostomy, the presence of undigested food every now and then can be normal. However, this piece of food might obstruct the stoma and cause abdominal pain and swelling. Avoid solid foods for the time being and drink plenty of water.
Option D: 37.6ºC is more than the normal range of temperature. Nursing interventions such as a tepid sponge bath may be done to decrease the temperature to the normal range. Pouchitis is when an internal pouch becomes inflamed. It’s a common complication in people with an ileo-anal pouch.

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3. Jerry has been diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The nurse suspects which of the following complications?

Correct Answer: B

Answer Explanation:

Complications of acute appendicitis are peritonitis, perforation and abscess development. Diffuse peritonitis and sepsis can also develop, which may progress to significant morbidity and possible death. Postoperative abscesses, hematomas, and wound complications are all complications that can be seen after appendectomies. If the wound does get infected, one may grow Bacteroides. “Recurrent” appendicitis can occur if too much of the appendiceal stump is left after an appendectomy.

Option A: Signs of intestinal obstruction include crampy abdominal pain, loss of appetite, constipation, vomiting, inability to have a bowel movement or pass gas, and swelling of the abdomen. Complications of appendicitis and appendectomy include surgical site infections, intra-abdominal abscess formation (3% to 4% in open appendectomy and 9% to 24% in laparoscopic appendectomy), prolonged ileus, enterocutaneous fistula, and small bowel obstruction.
Option C: Symptoms of bowel ischemia include sudden abdominal pain, an urgent need to have a bowel movement, frequent, forceful bowel movements, abdominal distention or swelling, bloody stool, and mental confusion in older adults.
Option D: Deficient fluid volume may be characterized by hypotension, concentrated urine, decreased skin turgor, decreased urine output, and dry mucous membranes. If diagnosed and treated early, within 24 to 48 hours, the recovery and prognosis should be very good. Cases that present with advanced abscesses, sepsis, and peritonitis may have a more prolonged and complicated course, possibly requiring additional surgery or other interventions.

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4. Which of the following complications should the nurse carefully monitor a client with acute pancreatitis?

Correct Answer: D

Answer Explanation:

A client with acute pancreatitis is prone to complications associated with the respiratory system. The relationship between Mycoplasma pneumoniae infection and acute pancreatitis has been debated in the literature. In 1973, Mardh et al. reported four adult cases of acute pancreatitis following pneumonia due to MP; in three of the patients, the pancreatitis occurred in the 3rd week after the onset of cough, by which time the respiratory tract symptoms had almost disappeared.

Option A: Myocardial infarction is not a complication of pancreatitis. Acute pancreatitis may cause kidney failure, which can be treated with dialysis if the kidney failure is severe and persistent.
Option B: Kidney failure, not liver failure, can be caused by acute pancreatitis. Acute pancreatitis may cause kidney failure, which can be treated with dialysis if the kidney failure is severe and persistent.
Option C: Pancreatitis cannot cause peptic ulcer. It is most commonly caused by a bacteria called H. pylori. H. pylorus is a gram-negative bacillus that is found within the gastric epithelial cells. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers. H. pylori infection is more prevalent among those with lower socioeconomic status and is commonly acquired during childhood.

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5. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?

Correct Answer: B

Answer Explanation:

Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy. After 3 to 10 days, the urine darkens, followed by jaundice. Systemic symptoms often regress, and patients feel better despite worsening jaundice. The liver is usually enlarged and tender, but the edge of the liver remains soft and smooth. Mild splenomegaly occurs in 15 to 20% of patients. Jaundice usually peaks within 1 to 2 weeks.

Option A: Watery stools or gastroenteritis occurs during the prodromal phase of the disease. Nonspecific symptoms occur; they include profound anorexia, malaise, nausea and vomiting, a newly developed distaste for cigarettes (in smokers), and often fever or right upper quadrant abdominal pain. Urticaria and arthralgias occasionally occur, especially in HBV infection.
Option C: Patients develop pale-colored stools during the icteric phase, not tarry stools. Manifestations of cholestasis may develop during the icteric phase (called cholestatic hepatitis) but usually resolve. When they persist, they cause prolonged jaundice, elevated alkaline phosphatase, and pruritus, despite general regression of inflammation.
Option D: Some may develop an aversion to cigarette smoke during the prodromal phase of the disease, but shortness of breath rarely occurs in this case. Patients experience anorexia, nausea, vomiting, alterations in taste, arthralgias, malaise, fatigue, urticaria, and pruritus, and some develop an aversion to cigarette smoke.

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