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Questions 227

NCLEX-PN

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Extract:

After a craniotomy for the removal of hematoma sustained in a fall, the patient is returned to the recovery room.


Question 1 of 5

The nurse places the child in a semi-fowler's position to

Correct Answer: A

Rationale: This position utilizes gravity to drain fluid from the head and prevent fluid accumulation, reducing the risk of increased intracranial pressure.

Extract:


Question 2 of 5

A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves:

Correct Answer: D

Rationale: The rhythm method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period. This method helps identify safe and unsafe periods for sexual intercourse. A natural family planning method, the rhythm method doesn't involve use of chemical barriers, hormones, or mechanical barriers.

Question 3 of 5

During a first aid class, the nurse instructs clients on the emergency care of second-degree burns. The nurse knows that which of the following interventions for second-degree burns of the chest and arms will BEST prevent infection?

Correct Answer: B

Rationale: After extinguishing the fire, removing clothing and wrapping the victim in a clean sheet prevents contamination and infection in second-degree burns. Soap or ointments (A,
C) are contraindicated in emergencies, and delaying action (
D) increases infection risk.

Question 4 of 5

A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?

Correct Answer: B

Rationale: Respect for differences is demonstrated by incorporating traditional cultural practices for staying healthy into professional prescriptions and interventions. The challenge for the health care provider is to understand the client's perspective. 'Culture care preservation or maintenance refers to those assistive, supporting, facilitative or enabling professional actions and decisions that help people of a particular culture to retain and/or preserve relevant care values to that they can maintain their well-being, recover from illness or face handicaps and/or death.'

Question 5 of 5

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significant problem during this procedure?

Correct Answer: B

Rationale: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.8 mEq/L is an acceptable value. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

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