NCLEX-PN
Physiological Adaptation NCLEX Questions Questions
Extract:
Question 1 of 5
A client is 36 hours post-op a TKR surgery, 270 cc's of sero-sanguinous accumulates in the surgical drains. What action should the nurse take?
Correct Answer: A
Rationale: The physician should be notified if excessive drainage is noted from the surgical site.
Question 2 of 5
A client is 36 hours post-op a TKR surgery, 270 cc's of sero-sanguinous accumulates in the surgical drains. What action should the nurse take?
Correct Answer: A
Rationale: The physician should be notified if excessive drainage is noted from the surgical site.
Question 3 of 5
Which of the following services is not part of family consultation?
Correct Answer: A
Rationale: Family consultation does not involve vocational rehabilitation. It involves helping families deal with their feelings, focus, and find solutions.
Choices 2, 3, and 4 are components of family consultation.
Question 4 of 5
Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?
Correct Answer: C
Rationale: The intervention priority with a mother who feels incompetent to parent a teenage daughter is to assist the mother to identify what she feels her crisis events are and to help her develop better coping skills and improve her mothering skills. With a teenager, the growth and development parameters have to be concentrated on self as well as acquiring an added event.
Choices 1, 2, and 4 do not directly address the mother's feelings of inadequacy.
Question 5 of 5
A person using over-the-counter nasal decongestant drops who reports unrelieved and worsening nasal congestion should be instructed to:
Correct Answer: B
Rationale: Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alpha-adrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5 days, instead of the nasal membranes constricting, vasodilation occurs, causing increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus.