Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 66

1. A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?

A) Collection bottle for drainage
B) Pressure regulator
C) Preventing accumulation of blood around the heart
D) Preventing air from entering the chest upon inspiration

2. Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

A) Creatinine
B) Sodium
C) Calcium
D) Potassium

3. While changing the dressing on a clients central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?

A) Discontinue the central line.
B) Begin a peripheral IV.
C) Document in the nurse - s notes and notify the physician after redressing the site.
D) Clean the site well and redress.

4. The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?

A) The client aspirated tube feeding.
B) The nurse has placed the suction catheter in the esophagus.
C) This is a normal finding.
D) The feeding is infusing into the trachea.

5. The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?

A) Morphine sulfate
B) Kerolac tromethamine (Toradol)
C) Promethazine (Phenergan)
D) Meperidine (Demerol)

1. Right Answer: D
Explanation: (A) There is a separate collection bottle for drainage as part of a chest drainage system. (B) In a three-bottle chest drainage system, one bottle serves only as a pressure regulator. (C) Mediastinal chest tubes prevent accumulation of blood around the heart immediately following heart surgery. (D) The purpose of the water- seal bottle in any chest drainage setup is to allow air out of the chest, but not back in. This negative pressure promotes lung expansion.

2. Right Answer: A
Explanation: (A) A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine. (B) Serum sodium has no relationship to gentamicin. (C) Serum calcium has no relationship to gentamicin. (D) Serum potassium has no relationship to gentamicin. If a client has impaired renal function secondary to gentamicin administration, he or she may also have hyperkalemia as a secondary disorder.

3. Right Answer: C
Explanation: (A) The nurse may never discontinue a central line without a physicians order. (B) The nurse may never initiate a peripheral IV without a physicians order except in an emergency situation. (C) The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued. (D) Besides cleaning and redressing, the nurse should always document the findings.

4. Right Answer: A
Explanation: (A) Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the clients stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a clients airway, it would not be possible to place the catheter in the esophagus. (C) Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea.

5. Right Answer: D
Explanation: (A) Morphine sulfate is contraindicated in clients with pancreatitis because it may cause spasms of the sphincter of Oddi and increase pancreatic pain. (B)Ketorolac tromethamine is currently not approved by the Food and Drug Administration for IV use. (C) Promethazine is a medication that has no analgesic properties. (D) Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain.

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