Question

Nurse Marianne evaluates a male client with AIDS during a routine visit and checks for cancer development. Which form of cancer is most frequently associated with AIDS?

Answer 1

Correct Answers:

Kaposi’s sarcoma

Rationale :

🩸Kaposi’s sarcoma is the most frequent cancer linked to AIDS due to the client’s severely compromised immune system.

🧬The condition is caused by human herpesvirus 8 (HHV-8) and manifests as vascular tumors on the skin and internal organs.

🔬Immunosuppression in AIDS promotes the rapid spread of this malignancy, making early detection crucial.

👀Typical signs include purplish or dark skin lesions, which may not be painful but signal advanced disease in immunocompromised patients.

📌Core Message

Kaposi’s sarcoma is the most common cancer in AIDS due to immunosuppression and is linked to HHV-8 infection.

Answer 2

Correct Answers:

To prevent cerebrospinal fluid (CSF) leakage.

Rationale :

🛌Spinal anesthesia involves puncturing the dura mater, creating a pathway for CSF to potentially escape.

🧠Proper positioning and flat bed rest after the procedure help reduce the risk of post-dural puncture headache caused by CSF leakage.

🩺Clients are often placed in a supine position without a pillow for several hours to encourage proper sealing of the puncture site.

🧴This positioning also ensures even distribution of the anesthetic in the subarachnoid space.

📌Core Message

Proper positioning after spinal anesthesia helps prevent CSF leakage and its complications like headache.

Answer 3

Correct Answers:

Auscultate bowel sounds.

Rationale :

🎧Auscultating bowel sounds is a non-invasive first step in assessing possible paralytic ileus, a common complication after abdominal surgery.

🔍Nausea and pressure may indicate slowed or absent bowel motility, and listening first avoids causing discomfort or disruption.

❗Palpation or rectal interventions should be delayed until bowel function is evaluated.

📉Post-operative ileus can lead to distention, vomiting, and delayed recovery if not identified early.

📌Core Message

Always begin with auscultation to assess for paralytic ileus in post-abdominal surgery clients reporting GI symptoms.

Answer 4

Correct Answers:

Lying on the left side with knees bent.

Rationale :

🛌The left lateral position with knees flexed allows the colonoscope to be inserted more easily and comfortably into the rectum and sigmoid colon.

📏This position aligns the colon naturally and improves visualization during the procedure.

🩺It also minimizes discomfort and lowers the risk of bowel perforation or procedural complications.

📹Colonoscopy typically starts at the rectum and progresses to the cecum, so positioning is key.

📌Core Message

The left lateral position with knees bent is ideal for colonoscopy to allow safe and smooth scope insertion.

Answer 5

Correct Answers:

Blood supply to the stoma has been interrupted.

Rationale :

🩸A dusky or bluish stoma indicates inadequate perfusion, possibly from vascular compromise.

🚨This finding is considered emergent, as a lack of blood supply can lead to necrosis and tissue death.

📛A healthy stoma should appear bright red or pink and moist—dusky color is never a normal postoperative observation.

💁‍♂️Immediate surgical evaluation may be necessary to restore perfusion and prevent stoma loss.

📌Core Message

A dusky stoma signals compromised blood supply and requires immediate attention to prevent necrosis.

Answer 6

Correct Answers:

Applying knee splints.

Rationale :

🦵Knee splints are used to maintain joint extension and prevent flexion contractures, which are common in leg burns.

🛌Burn injuries can lead to scar tissue formation that limits mobility if not properly managed.

🧍‍♂️Prolonged immobility or incorrect positioning increases the risk of permanent joint deformity.

🛠️Splinting is part of an early rehabilitative strategy in burn care to promote optimal functional recovery.

📌Core Message

Knee splints help prevent contractures in burn clients by maintaining joint extension and reducing scar-related immobility.

Answer 7

Correct Answers:

Urine output of 20 ml/hour.

Rationale :

💧Urine output is a vital indicator of renal perfusion and fluid status, especially in burn clients at risk for hypovolemic shock.

⚠️A rate of <30 ml/hour is concerning and may signal insufficient fluid resuscitation.

🩺This can result from third-spacing, where fluids shift from vessels to tissues, common in burn injuries.

🚨Prompt action is needed to prevent acute kidney injury (AKI) and restore hemodynamic stability.

📌Core Message

Urine output <30 ml/hour in burn patients suggests inadequate perfusion and the risk of renal failure from fluid shifts.

Answer 8

Correct Answers:

Turn him frequently.

Rationale :

🔄Frequent repositioning helps reduce prolonged pressure over bony prominences, a key cause of pressure ulcers.

🛏️Clients with limited mobility are especially vulnerable to skin breakdown from unrelieved pressure.

🧼Repositioning every 2 hours enhances circulation, relieves pressure, and protects tissue integrity.

🧍‍♀️While ROM exercises are important for joint mobility, they don’t replace the need to offload pressure.

📌Core Message

Frequent turning of immobile clients is the most effective way to prevent pressure ulcers by relieving sustained pressure.

Answer 9

Correct Answers:

In long, even, outward, and downward strokes in the direction of hair growth.

Rationale :

🧴Topical agents should be applied in the direction of hair growth to avoid follicular irritation and promote absorption.

🧬Dexamethasone, a corticosteroid, reduces inflammation and is best delivered evenly to the affected area.

🔬Using long, downward strokes also helps minimize skin trauma and enhances medication efficacy.

🖐️Avoiding circular or upward strokes reduces the chance of further irritation, especially on sensitive skin.

📌Core Message

Apply topical corticosteroids in downward strokes aligned with hair growth to ensure effective absorption and minimize skin irritation.

Answer 10

Correct Answers:

Beta-adrenergic blockers

Rationale :

❤️Beta blockers decrease myocardial oxygen demand by slowing heart rate and reducing contractility.

💊They counteract the effects of catecholamines (like epinephrine) that increase cardiac workload.

📉By minimizing sympathetic nervous system activity, they reduce ischemia and help prevent reinfarction in cardiac clients.

🧠These medications are essential in post-MI management to enhance cardiac stability.

📌Core Message

Beta-blockers protect the ischemic heart by reducing oxygen demand and blocking sympathetic stimulation.

NCLEX PN-Readiness Assessment Test-6

No.

1 :
Nurse Marianne evaluates a male client with AIDS during a routine visit and checks for cancer development. Which form of cancer is most frequently associated with AIDS?

2 :
Ricardo is scheduled for surgery using spinal anesthesia. What is the reason behind the special positioning needed for this procedure?

3 :
A male client two days post-nephrectomy complains of abdominal pressure and nausea. What is the nurse's initial action?

4 :
Wilfredo, who recently had rectal bleeding, is about to undergo a colonoscopy. What position should the nurse place him in for the start of the procedure?

5 :
A male client has just undergone ileostomy surgery, and Nurse Oliver observes that the stoma is dusky. How should this finding be interpreted?

6 :
Anthony sustained leg burns. What nursing measure best helps to reduce the risk of contractures?

7 :
Nurse Ron examines a client with facial, chest, and arm burns. Which assessment finding indicates a possible serious complication?

8 :
Mr. Mendoza had a stroke and cannot reposition himself. What is the most effective nursing measure to prevent pressure injuries?

9 :
Nurse Maria is applying dexamethasone cream to a client with chest dermatitis. What is the correct method of application?

10 :
Which medication class protects the ischemic heart by blocking sympathetic stimulation and catecholamines?

NCLEX PN-Readiness Assessment Test-6

No.

1 : Nurse Marianne evaluates a male client with AIDS during a routine visit and checks for cancer development. Which form of cancer is most frequently associated with AIDS?

2 : Ricardo is scheduled for surgery using spinal anesthesia. What is the reason behind the special positioning needed for this procedure?

3 : A male client two days post-nephrectomy complains of abdominal pressure and nausea. What is the nurse's initial action?

4 : Wilfredo, who recently had rectal bleeding, is about to undergo a colonoscopy. What position should the nurse place him in for the start of the procedure?

5 : A male client has just undergone ileostomy surgery, and Nurse Oliver observes that the stoma is dusky. How should this finding be interpreted?

6 : Anthony sustained leg burns. What nursing measure best helps to reduce the risk of contractures?

7 : Nurse Ron examines a client with facial, chest, and arm burns. Which assessment finding indicates a possible serious complication?

8 : Mr. Mendoza had a stroke and cannot reposition himself. What is the most effective nursing measure to prevent pressure injuries?

9 : Nurse Maria is applying dexamethasone cream to a client with chest dermatitis. What is the correct method of application?

10 : Which medication class protects the ischemic heart by blocking sympathetic stimulation and catecholamines?

1 :
Nurse Marianne evaluates a male client with AIDS during a routine visit and checks for cancer development. Which form of cancer is most frequently associated with AIDS?

2 :
Ricardo is scheduled for surgery using spinal anesthesia. What is the reason behind the special positioning needed for this procedure?

3 :
A male client two days post-nephrectomy complains of abdominal pressure and nausea. What is the nurse's initial action?

4 :
Wilfredo, who recently had rectal bleeding, is about to undergo a colonoscopy. What position should the nurse place him in for the start of the procedure?

5 :
A male client has just undergone ileostomy surgery, and Nurse Oliver observes that the stoma is dusky. How should this finding be interpreted?

6 :
Anthony sustained leg burns. What nursing measure best helps to reduce the risk of contractures?

7 :
Nurse Ron examines a client with facial, chest, and arm burns. Which assessment finding indicates a possible serious complication?

8 :
Mr. Mendoza had a stroke and cannot reposition himself. What is the most effective nursing measure to prevent pressure injuries?

9 :
Nurse Maria is applying dexamethasone cream to a client with chest dermatitis. What is the correct method of application?

10 :
Which medication class protects the ischemic heart by blocking sympathetic stimulation and catecholamines?