Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 69

1. A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:

A) 'I know that I am not supposed to irrigate my colostomy.'
B) 'My stool will be soft like paste.'
C) 'My stoma should be red and slightly raised.'
D) 'The skin around my stoma may become irritated from the enzymes in my stool.'

2. A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:

A) Remind the client that he no longer has that part of his leg and assure him he will be OK
B) Call the physician to request a psychological consultation for the client
C) Turn on the television to distract the client - s attention from his amputated leg
D) Give the client his order of Demerol 50 mg IM prn

3. A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is:

A) Respiratory obstruction
B) Hypercalcemia
C) Fistula formation
D) Myxedema

4. A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:

A) Should not be there on the second day
B) Will stop when the Foley catheter is removed
C) Is normal and he need not be concerned about it
D) Can be removed by irrigating the bladder

5. A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:

A) He should not be concerned about it because it will resolve quickly
B) This is usually temporary
C) The nurse will keep him dry, and he should notify the nurse when this happens
D) This is related to the bladder spasms and will soon stop

1. Right Answer: C
Explanation: (A) A left colostomy indicates an ascending colon resection. This type of colostomy can be irrigated. (B) The stool from an ascending colon resection should be formed. (C) The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately. (D) The stool in the ascending colon does not usually have many enzymes in it. Stool from an ileostomy has more enzymes and is more irritating to the skin.

2. Right Answer: D
Explanation: (A) The nurse is ignoring the clients pain. Telling the client that he will be OK will not relieve his phantom pain. (B) The client does not need a psychological consultation. Phantom pain is a normal sensation experienced by clients with amputations. (C) Using the television as a distractor will not relieve the clients phantom pain. (D) Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.

3. Right Answer: A
Explanation: (A) Respiratory obstruction due to edema of the glottis, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complication after a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complication, not hypercalcemia.(C) Fistula formation is not a major complication associated with a thyroidectomy. It is a major complication with a laryngectomy.(D) Myxedema is hypothyroidism that occurs in adults and is not a complication of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess production of thyroid hormone.

4. Right Answer: C
Explanation: (A) Some hematuria is usual for several days after surgery. (B) The client will continue to have a small amount of hematuria even after the Foley catheter is removed. (C) Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases. (D) Irrigating the bladder will not remove the hematuria. Irrigation is done to remove blood clots and facilitate urinary drainage.

5. Right Answer: B
Explanation: (A) This problem is temporary, but it may take some time to resolve, especially in an older man. (B) This problem is usually temporary, but it may take some time to resolve. (C) Keeping the client dry will not relieve his anxiety about his incontinence. (D) The bladder spasms are not the cause of the clients incontinence.

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