This is a typical NCLEX practice question on prioritizing nursing action. This question is one of the many questions we will be practicing in our new series called “Weekly NCLEX Question”. So, every week be sure to tune into our YouTube Channel for the NCLEX Question of the Week.
In this NCLEX Practice Question of the Week series, I will be going over various types of NCLEX questions from alternate format to topics like medical surgical, maternity, pediatric, fundamentals, etc. I will walk you through how to analyze the scenario and eliminate options.
NCLEX Practice Question on Prioritizing Nursing Action
You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post-op or pre-op for surgery. Which assessment finding requires further nursing action?
A. Orange-colored urine in a patient who is taking Pyridium and is post-op day 3 from a TURP.
B. No stool excretion in a patient who is post-op day 2 from a colostomy.
C. Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy.
D. Pain rating that has decreased from a 10 to 0 in a patient who is awaiting an appendectomy.
First, I like to analyze the scenario and make sure I know what the question is asking. The NCLEX exam loves to give you a lot of “filter” data and lead you down all these different “thinking” paths, which tends to mess people up.
So, this question wants to know what? Which assessment finding, that you discovered during your morning assessments, requires further action by you (the nurse). Based on this scenario, we know that our patients are either post-op or pre-op. Therefore, we need to start thinking about the following:
- Is this a possible complication that can happen after surgery or before surgery that requires further nursing action?
- Is this a “normal” or “abnormal” finding before or after surgery?
- Is this something that requires further nursing action or do we need to continue to monitor?
Now, let’s analyze and eliminate our options:
Option A: Orange-colored urine definitely sounds weird. However, the option tells us the patient is taking Pyridium following a TURP (which is a transurethral resection of the prostate…a urinary procedure to correct urinary issues due to an enlarged prostate). Therefore, many patients take Pyridium to help alleviate pain, spasms, and burning of the urinary tract…it is an analgesic. One thing about Pyridium is that it can turn the urine orange. So, this option can be eliminated.
Option B: No stool excretion after surgery can be worrisome but let’s take a deeper look at the option. The patient is only post-op day 2 from a colostomy. What is a colostomy? It is a procedure that takes part of the colon and brings it to the surface of the skin, and this is where stool will be excreted rather through the rectum/anus. Now, think of where the colon is located….it is the last part of the GI tract system that plays a role in digestion. It is normal for a “new” colostomy not to excrete stool until post-op day 3 or 4. However, if this was an ileostomy (procedure where part of the small intestine, specifically the ileum, is brought to the surface of the skin), stool could be expected as soon as post-op day 1…especially, if the patient has started eating. So, this option can be eliminated.
Option C: Shoulder pain sounds uncomfortable and may be worrisome but again let’s take a deeper look at the option. The patient had a laparoscopic cholecystectomy. A cholecystectomy is the removal of the gallbladder. Many of these procedures are done laparoscopic. In our review about appendicitis, we learned that during a laparoscopic surgery carbon dioxide is used to inflate the abdomen, which will pull the abdominal wall off the organs so the surgeon can visually see the organs to operate. During post-op days 1-3, the patient may report shoulder pain due to the carbon dioxide diffusing out of the body (which affects the shoulders). So, this option is eliminated.
Option D: The patient reports decreased pain from a 10 to 0. This on the surface may sound good….maybe you are thinking the previous shift must have given the patient pain medication that helped control the pain. However, the red flag in this option is that the patient is awaiting an appendectomy. An appendectomy is usually ordered for cases of severe appendicitis. Therefore, if a patient with appendicitis goes from having severe pain to no pain, the nurse must take further action because the appendix has possibly ruptured. Although, the patient feels better right now, peritonitis and sepsis can happen quickly which can lead to death. This is the correct answer.