NCLEX - Reduction of Risk Potential Day1 (Part 2)

The nurse provides discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching?

• I have to give myself shots in the belly because my spouse is afraid of needles!
• I have to use a walker because I can't bear any weight on this knee yet.
• I will call my health care provider if I get short of breath or sore or swollen below my knee.
• The raised toilet seat makes it easier for me to get on and off the toilet by myself.
• -

Answer explanation

Clients should be bearing weight with assistance post-knee replacement. Saying they can't bear any weight indicates a misunderstanding of recovery expectations.

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply.

• Cleans around the pin sites using sterile water
• Gently tightens the device screws if they become loose
• Holds the frame of the device when logrolling the client
• Places a small pillow under the head when client is supine
• Uses a blow-dryer on the cool setting to dry the vest when wet

Answer explanation

Cleaning pin sites with sterile solution, drying the vest properly, and cushioning the head are appropriate. Screws must not be tightened by nurses, and grabbing the frame during repositioning risks dislodgement.

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?

• Asymmetrical chest expansion and decreased breath sounds on the left
• Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg)
• Client complains of 6/10 pain at the needle insertion site
• Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min
• -

Answer explanation

Asymmetry and reduced breath sounds may signal pneumothorax, a serious complication of thoracentesis. This warrants immediate notification and further evaluation.

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply.

• Ensure the client is given an analgesic 30–60 minutes before tube removal
• Instruct the client to breathe in, hold it, and bear down while the tube is being removed
• Place the client in the Trendelenburg position
• Prepare a sterile airtight petroleum jelly gauze dressing
• Provide the health care provider with sterile suture removal equipment

Answer explanation

Pain control, Valsalva technique, occlusive dressing, and sterile equipment are essential steps for safe chest tube removal. Trendelenburg is incorrect; semi-Fowler's or unaffected side positioning is preferred.

A client is taking lithium for management of bipolar I disorder. The client's most recent serum lithium level is 0.8 mEq/L. Based on this result, what prescription does the nurse anticipate receiving from the health care provider?

• Continue at the current dose
• Decrease the dose
• Discontinue the medication
• Increase the dose
• -

Answer explanation

Lithium level of 0.8 mEq/L is within therapeutic range (0.8–1.2 mEq/L). No dose adjustment is needed. Nurse should monitor for early signs of toxicity, especially during illness or dehydration.

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply.

• Administer prescribed oral narcotics for throat pain
• Administer warmed, humidified oxygen via facemask
• Give the client ice chips to moisten the mouth
• Provide mouth care with oral sponges
• Start the client on incentive spirometer

Answer explanation

After extubation, humidified oxygen, frequent oral care, and spirometer use help maintain airway patency and prevent complications. Oral narcotics and ice chips should be avoided until swallowing is assessed.

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma. Which clinical finding warrants immediate intervention?

• Hairnet-like effect across vision
• Loss of memory about the collision
• Temporal headache
• Tongue laceration oozing blood
• -

Answer explanation

Hairnet-like or curtain-like effect suggests retinal detachment—a vision-threatening emergency requiring immediate evaluation. Other symptoms are less urgent or expected in mild head trauma.

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?

• Check the urethral catheter and drainage tubing
• Irrigate the catheter with 30 mL of sterile normal saline
• Notify the health care provider
• Remove and reinsert the next-larger-size catheter
• -

Answer explanation

The nurse should first inspect for any obstruction or kinking in the tubing before taking further action. Only if the problem persists should irrigation or replacement be considered.

The nurse in the oral surgery clinic is reviewing a client's medical record before a scheduled dental procedure. Which of the following findings in the medical record should the nurse report to the oral surgeon? Select all that apply.

• Daily aspirin use
• History of congenital heart disease
• INR of 3.2
• Presence of a prosthetic heart valve
• WBC count of 9000/mm³

Answer explanation

Clients with heart valve issues or congenital heart disease may require prophylactic antibiotics for infective endocarditis. Elevated INR and aspirin use increase bleeding risk and must be disclosed. WBC is normal.