LATEST 2023 NCLEX PN Test-Bank WITH BEST ORGANISED QUESTIONS AND ANSWERS

LATEST 2023 NCLEX PN Test-Bank WITH BEST ORGANISED QUESTIONS AND ANSWERS  A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teachinghow toirrigatetheilleostomy B. Stoppingelectrolyteloss intheincisionalarea C. Encouragingahigh-fiberdiet D. Facilitatingperineal wounddrainage Answer D:Theclient withaperineal resection willhaveaperineal incision. Drainswill be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiberdiet, inanswer C, isnotorderedat this time.  The nurse is performing discharge teaching on aclient with diverticulitiswho has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet? A. Roastedchicken B. Noodles C. Cookedbroccoli D. Custard Answer C:Theclient withdiverticulitis shouldavoideatingfoodsthatare gasformingandthat increaseabdominaldiscomfort,suchascookedbroccoli.Foods suchas those listed inanswers A, B,and D areallowed.  The nurse iscaring fora new mother.The motherasks why her baby haslost weight since he was born. The best explanation of the weight loss is: A. Thebabyisdehydratedduetopolyuria. B. Thebabyishypoglycemicduetolackofglucose. C. Thebaby is allergic totheformulathe mother is givinghim. D. The baby can lose up to 10% of weight due to meconium stool, loss ofextracellularfluid, andinitiationofbreast-feeding. Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation ofbreastfeedingcausethe infant tolosebody mass.Thereisnoevidencetoindicatedehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect.  The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common forthis diagnosis? A. Foulbreath B. Dysphagia C. Diarrhea D. Chronichiccups Answer C: Diarrheaisnotcommoninclients with mouthandthroatcancer. All thefindings inanswers A, B, and D areexpected findings.  A removal of the left lowerlobe of the lung is performed on aclient withlung cancer. Which post-operative measure would usually be included in the plan? A. Closedchestdrainage B. A tracheostomy C. A mediastinal tube D. Percussionvibrationanddrainage Answer A: The client with a lung resection will have chest tubes and a drainage-collectiondevice. He probably willnothaveatracheostomyor mediastinal tube,and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C,and D are incorrect.  Six hours after birth, the infant is found to have an area of swelling over the right parietal areathat does notcrossthe suture line.The nurse should chartthis finding as: A. A cephalohematoma B. Molding C. Subduralhematoma D. Caputsuccedaneum Answer A: A swelling over the right parietal area is a cephalohematoma, an area ofbleedingoutsidethe cranium.This typeofhematomadoesnotcross thesutureline because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the sutureline and is edema.  The nurse isassisting the RN with discharge instructions foraclient withan implantable defibrillator. What discharge instruction is essential? A. “Youcannoteat foodpreparedina microwave.” B. “Youshouldavoid movingtheshoulderonthesideof thepacemakersitefor 6 weeks.” C. “Youshoulduseyourcellphoneonyourrightside.” D. “You willnotbeabletoflyonacommercialairliner withthedefibrillator inplace.” Answer C:Theclient withaninternaldefibrillatorshouldlearntouseanybattery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side,andfly inan airplane.  A client in the cardiac step-down unit requires suctioning for excess mucous secretions.The nurse should be mostcareful to monitorthe client forwhich dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Prematureventricularbeats D. Heartblock Answer A: Suctioningcancauseavagalresponseandbradycardia. Answer B isunlikelyand, therefore,not most important,althoughitcanoccur. Answers C and D canoccuras well,but theyareless likely.  Thenurseiscaringforaclientscheduledfor removalofapituitarytumorusingthetranssphenoidal approach.Thenurseshouldbeparticularlyalert for: E. Nasalcongestion F. Abdominal tenderness G. Muscletetany H. Oliguria Answer A: Removal of the pituitary gland is usually done by a transsphenoidal approach, throughthenose. Nasalcongestionfurtherinterferes withtheairway. Answers B, C,and D arenotcorrectbecausetheyare notdirectlyassociated withthepituitarygland.  A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uricacid 7.0, Na+ 136,and platelets 178,000.The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis