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15 NCLEX Questions and questions on ICP

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1 15 NCLEX Questions and questions on ICP on Thu Nov 03, 2011 2:18 pm

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Abdominal Aneurysm Repair and Recent Right Leg Amputation

1. A nurse reports to a physician that a 75-year-old client continues to experience phantom limb pain following an above-the-knee amputation (AKA) despite nursing interventions of distraction and administering the prescribed morphine sulfate. Which interventions to minimize the altered sensory perceptions should the nurse anticipate that the physician might prescribe?
1. Local anesthetic to the residual limb
2. Transcutaneous electrical nerve stimulation (TENS)
3. A beta-blocker medication such as atenolol (Tenormin)
4. An ant seizure medication such as oxcarbazepine
5. Reducing the client’s activity level until the sensation resolve
6. A different analgesic, such as hesperidins hydrochloride (Demerol)

Answer: 1, 2, 3, 4
Rationale: A local anesthetic or TENS provide pain relief for some. Beta -blockers may relieve dull, burning discomfort, and ant seizure medications control stabbing and cramping pain. Additional medications include tricyclic antidepressants to improve mood and coping ability
Source: Davis Q&A pg. 383 # 826.

2. A client with a lower leg amputation, is experiencing edema, so a nursing assistant (NA) elevates the client’s residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client’s leg has been elevated?
1. Thank the NA for being so observant and intervening appropriately.
2. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
3. Inform the NA that this was the correct action at this time in the client’s recovery, but once the client’s incision heals the leg should not be elevated.
4. Report the incident to the surgeon and tell the NA to complete a variance report because the client’s leg should no have been elevated.

Answer: 2
Rationale: Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.
Source: Davis Q&A pg. 384 #827

3. A nurse admits a client to a hospital and obtains a nursing history. The client tells the nurse that he had an endovascular repair of an abdominal aortic aneurysm found 1 year earlier during a routine screening. The nurse understands this procedure consists of:
1. Excision of the aneurysm and placement of a graft percutaneously.
2. An angioplasty with placement of a stent around the outside of the aorta.
3. Placement of a filter within the aneurysm to block clots from becoming emboli.
4. Placement of a stent graft inside the aorta that excludes the aneurysm from circulation.

Answer: 4
Rationale: The endovascular repair consists of placement of the endovascular stent graft inside the aorta extending above and below the aneurysm area to seal it off from the circulation.
Source: Davis Q&A pg. 458 #1013

4. A client with an abdominal aortic aneurysm is having a high resolution computed tmography (CT) scan to determine the feasibility for an endovascular repair. Which collaborative interventions should a nurse anticipate to decrease the client’s likelihood of developing nephrotoxicity ? Select all that apply
1. Administration of sodium bicarbonate 1 hour before injection of the IV contrast dye
2. Administration of 0.9% NaCl at 100ml per hour before and after the CT scan
3. Administration of acetylcyst eine (Mucomyst) orally before and after the study
4. Monitoring aPTT level before and after the CT scan
5. Placing the client on a low potassium diet

Answer: 1,2,3
Rationale: The contrast dye used in a high resolution presents a risk to the client’s renal function. Intravenous fluids are administered to maintain hydration and enhance excretion of the dye. Sodium bicarbonate is administered 1 hour before and 6 hours after the IV contrast dye. Acetylcysteine is administered orally the day before and the day of the CT scan to prevent acute renal failure. Both sodium bicarbonate and acetylcysteine are free-radical scavengers that sequester the contrast by-products that are destructive to renal cells.
Source: Davis Q&A pg. 459 #1014

5. A nurse is preparing a client for a thoracic aneurysm repair. Which assessment findings lead the nurse to suspect that a rupture has occurred? Select all that apply
1. Severe chest pain radiating to the back
2. Abdominal distention
3. Hypotension
4. Dyspnea
5. Oliguria

Answer: 1,3,4,5
Rationale: A thoracic aneurysm that ruptures will cause pain in the thoracic area. Blood loss will lead to low blood pressure and scant urinary output. The pressure form the hemorrhage will interfere with the client’s breathing
Source: Davis Q&A pg. 459 #1015

6. A client with symptoms of intermittent claudification receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. During a follow-up home visit, a nurse determines that the client is making lifestyle changes to decrease the likelihood of re-stenosis and arterial occlusion. Which observations of the client’s actions support this conclusion? Select all that apply
1. States participating in an exercise program
2. Abstaining from nicotine
3. Wearing support hose
4. States receiving foot care from a podiatrist
5. Following a low saturated fat diet
6. Taking the medication rosuvastatin calcium (Crestor)

Answer: 1,2,5,6
Rationale: Reducing client risk factors in order to slow the arteriosclerotic process may delay progression of the disease. Exercising promotes collateral circulation. Smoking cessation, following a low saturated fat diet, and taking medications to lower cholesterol also deter the arteriosclerotic process. There is evidence that more than 30% of clients having procedures to improve claudification seek further intervention within the year.
Source: Davis Q&A pg. 459 #1016

7. After a amputation, what postoperative measures should the nurse provide to the client to avoid hip or knee flexion contractures?
A. Elevate residual limb on pillow
B. Have the client lie in a prone position
C. Wrap stump using a figure-eight pattern
D. Encourage use of over bed trapeze

Answer: B
Rationale: The client should be placed in the prone position several times a day to prevent hip flexion contractions. Elevating the residual on a pillow may increase the risk for hip flexion contracture. Wrapping the stump will decrease swelling, but this will not prevent contractures. Lastly, use of the over-bed trapeze by the client will promote independence and mobility, but it will not prevent contractures.
Source: Med/Surg ATI pg. 923 #1

8. Which of the following postoperative assessments following an amputation should the nurse perform over for the next few days? Select all that apply
1. Presence and amount of drainage (especially bloody drainage)
2. Indications of infection (foul odor, purulent drainage, increased pain, fever)
3. Measurement of prosthesis
4. Presence of stump swelling
5. Assessment of type of pain

Answer: 1,2,4,5
Rationale: The client’s incision and residual limb should be monitored closely for drainage, infection, and swelling. The type of pain experienced is important to assess so it can be appropriately managed (incision versus phantom limb pain). Measurement for a prosthesis does not occur until the wound has healed and the residual limb has shrunk.
Source: Med/Surg ATI pg. 923 #2

9. The client reports that he is experiencing pain in the foot that is no longer there. How can the nurse best explain this phenomenon to the client?
A. Incisional pain from the amputated limb
B. Phantom limb pain, which is common after amputations
C. Referred pain from the bone that was cut
D. Imaginary pain because the limb is no longer there

Answer: B
Rationale: Phantom limb pain is real pain that is experienced by clients who have undergone amputations. Its exact cause is unknown. Incisional pain would be experienced at the incision site, not in the amputated foot. Referred pain is not a complication after amputation of a limb.
Source: Med/Surg ATI pg. 924 #3

10. Which of the following is the priority intervention for Aneurysm?
A. Give pain medication
B. Obtain blood specimen
C. Administer IV fluids
D. Initiate a 12-lead ECG

Answer: C
Rationale: Using the ABC priority setting framework, the greatest risk to the client is inadequate circulatory volume. Therefore, the highest priority intervention is to administer IV fluids. Giving pain medication, obtaining a blood specimen, and initiating a 12-lead ECG are important actions, but not the priority.
Source: Med/Surg pg. 514 #4

11. Which of the following are priority interventions postoperatively (related to Aneurysm repair)?
1. Assess temperature, circulation, and function of extremities
2. Monitor and report increased pain at graft site
3. Maintain a cold environment
4. Restrict fluids due to the risk of pulmonary congestion
5. Administer anticoagulants and or ant platelet agents
6. Report an hourly urine output of 60ml

Answer: 1,2,5
Rationale: The client’s extremities should be assessed for signs of complications, such as occlusion of the graft. Pain can be an indicator of graft occlusion or rupture. IV fluids are given (not restricted) to maintain renal perfusion. Anticoagulants and or ant platelet agents are used to prevent thrombus formation. A warm environment is maintained to prevent temperature-induced thrombus formation. An hourly urine output of 60ml/hr is an expected finding.
Source: Med/Surg pg. 514 #5

12. When teaching a client with an aneurysm what signs and symptoms may indicate impending rupture, the nurse considers which of the following?
1. Medication therapy the client is receiving
2. Client’s usual blood pressure
3. Age and gender of the client
4. Size and location of the aneurysm

Answer: 4
Rationale: Aneurysms vary by size and location. Signs of rupture depend on the location of the aneurysm. Dissection can occur anywhere but most often occurs in the ascending aorta where pressure is the highest. The medication the client is receiving is vague and is not directly related. The blood pressure relates to whether the aneurysm may rupture, not to the associated signs and symptoms. The age and gender of the client are unrelated to the size and symptoms of aneurysm rupture.
Source: Prentice Hall Nursing Comprehensive Review for NCLEX-RN pg.1072 #15

13. A client had a left above the knee amputation today. For the first 24 hours postoperatively, the nurse makes it a priority to do which if the following to properly manage the surgical site?
1. Elevate the residual limb on a pillow
2. Loosen the stump dressing every 4 hours
3. Maintain the residual limb in a dependent position
4. Change dressings as often as needed

Answer: 1
Rationale: Elevating the limb on a pillow facilitates venous return, decreasing swelling, and promotes comfort. The stump dressing is usually a compression type to mold the stump and to decrease the edema associated with inflammation, so option 2 is an inappropriate intervention. The other options are also inappropriate because option 3 increases risk of edema and option 4 is done as ordered.
Source: Prentice Hall Nursing Comprehensive Review for NCLEX-RN pg.1255 #7

14. The nurse is caring for a preoperative client diagnosed with abdominal aortic aneurysm (AAA). The client reports the onset of severe back pain. What action should the nurse take next?
1. Call the health care provider immediately
2. Provide comfort measures to relieve the back discomfort
3. Monitor the client for one-half hour to see if it continues
4. Determine if hoarseness or dysphasia is present

Answer: 1
Rationale: The primary symptom of dissecting aneurysm is sudden, severe pain commonly located in the back (option 1). This is an emergency, and the client must be taken to surgery immediately as a life-saving measure, not continue to be observed (option 3). Hoarseness and dysphasia (option 4) may be present with an aneurysm but are not indicative of dissection. Comfort measures (option 2) for this client will not relieve the pain.
Source: Prentice Hall Nursing Med/Surg Nursing Review and Rationales pg. 131 #6

15. The nurse is doing an assessment on a client during the first postoperative day after abdominal surgery. Which of the following manifestations does the nurse report immediately?
1. Decreased bowel sounds
2. Mild abdominal distention
3. Inability to void immediately after urinary catheter is removed
4. Leg swelling and calf pain
Answer: 4
Rationale: clients with pelvic or abdominal procedures are at an increased risk of developing deep vein thrombosis (DVT). Unilateral edema and calf pain (option 4) are signs that are consistent with DVT and must be reported immediately so treatment can begin to prevent pulmonary embolus. It is not uncommon for a client to have absent or decreased bowel sounds for the first or second postoperative day. This is related to the anesthesia and inactivity and typically will resolve as activity levels increase (option 1). Abdominal distension (option 2) is also common initially following abdominal surgery and will resolve as the client increases activity and passes flatus. It is not uncommon for a client to have difficult voiding immediately after a catheter is removed. As the volume of urine in the bladder increases and pressure is exerted on the urinary meatus, the urge to void returns. The client has 6 to 8 hours to void following a catheter removal (option 3).
Source: Prentice Hall Nursing Med/Surg Nursing Review and Rationales pg. 131 #4


5 Signs and Symptoms of Increased Intracranial Pressure
1, The earliest signs of increased ICP may be blurred vision, decreased visual acuity, and diplopia because of pressure on the visual pathways.
2. Headache, papilledema, or swelling of the optic disk and vomiting are the next signs
3. The most significant sign of increased ICP are change in LOC as pressure increases from front to back of the brain
LOC deteriorates
4. Deterioration in motor function, abnormal posturing (decerbrate, decorticate, or flaccidity)
5. Altered breathing patterns (cheyne-stokes respirations, central Neutrogena hyperventilation, apnea)

3 Positions that are contraindicated in a Patient with increased ICP
1. Avoid extreme neck or hip flexion/extension
2. Avoid flat positions such as supine or prone it is preferred to elevated head of bed 30 degrees
3. Maintain a neutral neck and head alignment avoid coughing, blowing nose, straining for bowel movements, pushing against the bed rails, or performing isometric exercises ( or any other activity that closes the glottis)

Source: Prentice Hall Nursing Med/Surg Nursing Review and Rationales pg. 175-176

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