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NCLEX-PN

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Extract:

Two hours post below knee amputation, the patient's dressing was saturated with serosanguinous secretions.


Question 1 of 5

In addition to notifying the surgeon, the priority nursing action would include:

Correct Answer: C

Rationale: Reinforcing the dressing helps control bleeding while awaiting further instructions from the surgeon, addressing the immediate issue of saturated dressings.

Extract:


Question 2 of 5

A primigravida, 26 years old and 33 weeks gestation, is admitted to the hospital with painless vaginal bleeding. She reports that the bleeding, which started 2 hours ago, has lessened in amount. Which of the following measures should be included in the client's care?

Correct Answer: B

Rationale: Counting the number of pads used quantifies blood loss, aiding in the assessment of conditions like placenta previa, which causes painless bleeding.

Question 3 of 5

A 9-year old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham's chorea?

Correct Answer: A

Rationale: Sydenham's chorea, a manifestation—of rheumatic fever, causes irregular movements and facial grimacing. Other options describe rheumatoid arthritis or other conditions.

Extract:

One of the following is not a symptom of the patient with right sided heart failure:


Question 4 of 5

Weight gain

Correct Answer: C

Rationale: Right-sided heart failure causes jugular vein distension, not flattened neck veins.

Extract:


Question 5 of 5

While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?

Correct Answer: A

Rationale: Shutting off the bed's electricity should be the initial step. The nurse should not touch the client until the bed is checked for faulty grounding.

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