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Free NCLEX-RN Exam Braindumps (page: 173)

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A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

  1. Reinforce the dressing.
  2. Continue to monitor the dressing.
  3. Notify the physician.
  4. Note the time and amount of blood.

Answer(s): C

Explanation:

(A) The dressing should not be reinforced without first notifying the physician. The decision may be made by the physician to reinforce the dressing after assessing the amount of bleeding. (B) Blood on the dressing is unusual and should make the nurse aware that something more than continuing to monitor the dressing should be done. (C) The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. (D) The time and amount of blood do need to be recorded after the physician is notified.



A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

  1. Reinforce the dressing.
  2. Continue to monitor the dressing.
  3. Notify the physician.
  4. Note the time and amount of blood.

Answer(s): C

Explanation:

(A) The dressing should not be reinforced without first notifying the physician. The decision may be made by the physician to reinforce the dressing after assessing the amount of bleeding. (B) Blood on the dressing is unusual and should make the nurse aware that something more than continuing to monitor the dressing should be done. (C) The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. (D) The time and amount of blood do need to be recorded after the physician is notified.



A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:

  1. Flight of ideas
  2. Delusions
  3. Hallucinations
  4. Echolalia

Answer(s): A

Explanation:

(A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas. (B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ("hearing voices"). (D) Repeating words is called echolalia.



A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:

  1. Flight of ideas
  2. Delusions
  3. Hallucinations
  4. Echolalia

Answer(s): A

Explanation:

(A) Rapidly moving from one topic to another without following any logical sequence is called flight of ideas. (B) False beliefs are delusions. (C) False sensory perceptions are hallucinations ("hearing voices"). (D) Repeating words is called echolalia.






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