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  1. Home
  2. NCLEX Certification
  3. NCLEX-RN Exam
  4. NCLEX.NCLEX-RN.v2024-01-19.q623 Dumps
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Question 406

A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as
"a cramp in my leg." An appropriate nursing action is to:

Correct Answer: B
Explanation
(A) Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall.
(C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.
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Question 407

A client is pleased about being pregnant, yet states, "It is really not the best time, but I guess it will be OK." The nurse's assessment of this response is:

Correct Answer: C
Explanation/Reference:
Explanation:
(A) Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of "not now" in the first trimester. The statement still leaves room for exploration. (B) There are no data to support this. This statement by the mother still leaves room for exploration. (C) Ambivalenceis normal during the first trimester. Reva Rubin addresses the issue of "not now." This fact should be shared with the mother during further exploration of the comment. (D) It is not abnormal. If it were, another month would also be too long to wait.
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Question 408

A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nagele's rule, the nurse estimates her date of delivery to be:

Correct Answer: A
(A) According to Nagele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 -3 mo = September 17). (B, C, D) These answers are incorrect.
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Question 409

Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:

Correct Answer: D
(A) S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.
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Question 410

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?

Correct Answer: D
Section: Questions Set C
Explanation:
(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Debridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection. (D) Emergency care of a thermal burn is immersing both legs in cool water.
Cool water permits gradual temperature change and prevents further thermal damage.
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