NCLEX Secrets - Level of Cognitive Ability
36. A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?
a) red, hard skin
b) serous drainage
c) purulent drainage
d) warm, tender skin
37.A nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication?
a) increasing restlessness
b) a negative Homan's sign
c) hypoactive bowel sounds in all four quadrants
d) a blood pressure of 110/70 mmHg and a pulse of 86 bpm
38. A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify that which of he following medications should be given to the client and not withheld?
a) ferrous sulfate
b) prednisone (deltasone)
c) cyclobenzaprine (flexeril)
d) conjugated estrogen (premarin)
39. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which of the following results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?
a) sodium, 141 mEq/L
b) hemoglobing, 8.0 g/dL
c) platelets, 210,000 mm3
d) serum creatinine, 0.8 mg/dL
40. A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour?
a) urinary output of 20 ml/hr
b) temperature of 37.6 C (99.6F)
c) blood pressure of 100/70 mmHg
d) serous drainage on he surgical dressing
NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE
36) B
- serous drainage is expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique and a contaminated wound before surgical exploration. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills.
37) A
- increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock or pulmonary embolism. Hypoactive bowel sounds heard in all quadrants are a normal occurrence, as in a negative Homan's sign. (A positive Homan's sign may indicate thrombophlebitis.) A blood pressure of 110/70 mmHg with a pulse of 86 bpm is within normal limits.
38) B
- prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These other three medications may be withheld before surgery without undue effects on the client.
39) B
- routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range, except the hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
40) A
- urine output should be maintained at a minimum of 30 ml/hr for an adult. An output of less than 30 ml for each of 2 consecutive hours should be reported to the physician. A temperature higher than 37.7C (100F) or lower than 36.1C (97F) and a falling systolic blood pressure, lower than 90 mmHg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
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NCLEX Secrets - Level of Cognitive Ability (Analysis 36-40)
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