NCLEX-RN Exam Questions - Part 71

1. A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:

A) Activity intolerance
B) Ineffective airway clearance
C) High risk for infection
D) Altered oral mucous membrane



2. A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:

A) Providing opportunities to ask questions and talk about concerns
B) Providing distractors such as reading or watching television
C) Telling her that she should not be so nervous and assuring her that everything will be OK
D) Reminding her that this surgery is not as extensive as her past surgery was



3. On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty.He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?

A) 'You will not be allowed to remain in your room if you continue to bother things.'
B) 'I can see how uncomfortable you are, but I would like you to walk with me so I can show you around the unit.'
C) 'Tell me why your room needs to be so clean.'
D) 'I - ve inspected this room and it is perfectly clean.'



4. The physician prescribes amitriptyline (Elavil) for a client. What does the patient need to know about this medication?

A) Prolonged use of this medication will result in extrapyramidal side effects.
B) When the medication is effective, he will experience no anxiety.
C) The medication should relieve his symptoms of depression.
D) Blood must be drawn weekly to test for toxicity.



5. The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:

A) Reduce his anxiety
B) Avoid going to psychotherapy
C) Manipulate the health team members
D) Increase his self-image by showing higher standards than the fellow clients