NCLEX Daily Ten Question Practical Exercise 9

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. In a postoperative unit, a nurse is caring for a client who has recently undergone a laminectomy to relieve spinal cord compression. The client is alert but has been instructed to minimize movement to prevent post-surgical complications. In addition to monitoring for the usual postoperative signs such as infection or bleeding, which technique should the nurse use to reposition the client to promote comfort and prevent injury safely?

Correct Answer: A

Answer Explanation:

After a laminectomy, it is essential to avoid twisting the spine to prevent damage to the surgical site. Logrolling is a technique used to turn the client while keeping the spine neutral. The additional choices, while they may be appropriate for other postoperative scenarios, do not specifically address the needs of a client who has had a laminectomy.

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2. A 55-year-old client who just had cataract removal with an intraocular lens implant is being prepared for discharge. The client has a history of hypertension and is moderately active. The client’s postoperative recovery has been uneventful, but they express anxiety about ensuring a proper recovery. The nurse needs to provide comprehensive discharge instructions. In addition to avoiding activities that could increase ocular pressure, which of the following should be included in the discharge education?

Correct Answer: E

Answer Explanation:

After cataract surgery, clients must avoid activities that can increase intraocular pressure, affecting the surgical site and the newly placed intraocular lens. Straining during bowel movements and bending at the waist can increase intraocular pressure and, therefore, should be avoided.

Option A: Typically, the client is instructed to avoid lifting objects weighing more than 15 lb (7kg) – not 5lb.
Option B: Instruct the client when lying in bed to lie on either the side or back.
Option C: The client should avoid bright light by wearing sunglasses.
Option D: Excessively bright light should be avoided, but appropriate ambient lighting is necessary to prevent accidents and ensure safety.

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3. George, a 17-year-old individual, is attending a health education session at a community clinic. The clinic is conducting screenings and teaching about early detection of common health issues in young adults. George has a family history of testicular cancer and is seeking information on how to reduce his risk. The nurse should include education on testicular self-examinations as part of the session. At what age should the nurse emphasize the initiation of regular testicular self-examinations?

Correct Answer: D

Answer Explanation:

Educating George and other young individuals about the importance of regular testicular self-examinations can lead to the early detection of abnormalities, which is crucial for early intervention, especially given George’s family history of testicular cancer. Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.

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4. A 50-year-old male client with a history of colorectal cancer has recently undergone a colon resection. Postoperatively, while assisting the client to turn in bed for routine care, the nurse notices the surgical wound site has suddenly dehisced, and there is evisceration of abdominal contents. In prioritizing the immediate actions to take, which step should the nurse perform first to address this acute complication?

Correct Answer: B

Answer Explanation:

This action is critical to maintain the viability of the exposed organs and prevent further contamination and infection. It is the most immediate and appropriate first step in the event of evisceration. Once this is done, the nurse should then perform other actions, such as notifying the surgeon (A), assessing vital signs (C), and preparing the client for emergency intervention (E). Attempting to close the wound (D) or administering pain medication (F) should only be done under the direct instruction of a physician, as they are not initial emergency measures.

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5. The nurse is monitoring a 78-year-old male patient who has experienced a significant cerebrovascular accident resulting in extensive brain damage. During a comprehensive evaluation, the nurse observes the patient’s respiratory pattern and identifies a cycle of respirations that increase and decrease in depth and rate, culminating in periods where breathing temporarily ceases. This observation is most consistent with which of the following descriptions?

Correct Answer: A

Answer Explanation:

The pattern described is indicative of Cheyne-Stokes respirations, which are often seen in patients with conditions that affect the brain’s respiratory centers, such as following a severe stroke.

Option B: Biot’s respirations are rapid, deep breathing with abrupt pauses between each breath and equal depth between each breath.
Option C: Kussmaul’s respirations are rapid, deep breathing without pauses.
Option D: Tachypnea is shallow breathing with increased respiratory rate.

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