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NCLEX Practice Exam for Medical Surgical Nursing 1 (PM)
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Question 1
The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
A
take the pulse rate once a day, in the morning upon awakening
B
may engage in contact sports
C
may be allowed to use electrical appliances
D
have regular follow up care
Question 1 Explanation:
The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
Question 2
Which statement by the client indicates understanding of the possible side effects of Prednisone therapy?
A
“My incision will heal much faster because of this drug.”
B
“This medicine will protect me from getting any colds or infection.”
C
“I should limit my potassium intake because hyperkalemia is a side-effect of this drug.”
D
“I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”
Question 2 Explanation:
The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis
Question 3
A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse’s highest priority of information would be
A
Only ice chips and cold liquids will be allowed initially.
B
Warm saline gargles will be done q 2h.
C
Food and fluids will be withheld for at least 2 hours
D
Coughing and deep-breathing exercises will be done q2h.
Question 3 Explanation:
Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
Question 4
After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care?
A
Take only sips of H2O between bites of solid food
B
Sit upright for at least 30 minutes after meals
C
Eat small meals every 2-3 hours
D
Reduce the amount of simple carbohydrate in the diet
Question 4 Explanation:
The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome.
Question 5
Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication provides little relief and he refuses to move. The nurse should plan to:
A
Complete A.M. care quickly as possible when necessary
B
Let him perform his own activities of daily living
C
Handle him gently when assisting with required care
D
Reassure him that the nurses will not hurt him
Question 5 Explanation:
Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently.
Question 6
Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?
A
“My father died of Myasthenia Gravis.”
B
“I exercise every other day.”
C
“I smoke 1 1/2 packs of cigarettes per day.”
D
“My cholesterol is 180.”
Question 6 Explanation:
Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention.
Question 7
Which of the following would be inappropriate to include in a diabetic teaching plan?
A
Keep the insulin not in use in the refrigerator
B
Change position hourly to increase circulation
C
Inspect feet and legs daily for any changes
D
Keep legs elevated on 2 pillows while sleeping
Question 7 Explanation:
The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.
Question 8
A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food?
A
Canned sardines
B
Plain nuts
C
Whole milk
D
Eggs
Question 8 Explanation:
Canned foods are generally rich in sodium content as salt is used as the main preservative.
Question 9
Included in the plan of care for the immediate post-gastroscopy period will be:
A
Assess gag reflex prior to administration of fluids
B
Maintain NGT to intermittent suction
C
Assess for pain and medicate as ordered
D
Measure abdominal girth every 4 hours
Question 9 Explanation:
The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.
Question 10
After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take?
A
Check the patency of the nasogastric tube for any obstruction.
B
Administer the prescribed antiemetic.
C
Change the patient’s position.
D
Call the physician immediately.
Question 10 Explanation:
Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention.
Question 11
The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet?
A
“Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”
B
“The liver heals better with a high carbohydrates diet rather than protein.”
C
“Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
D
“The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
Question 11 Explanation:
The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production.
Question 12
What instructions should the client be given before undergoing a paracentesis?
A
NPO 12 hours before procedure
B
Empty bowel before procedure
C
Empty bladder before procedure
D
Strict bed rest following procedure
Question 12 Explanation:
Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure.
Question 13
The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:
A
Discontinue the low-intermittent suction
B
Reposition the NGT by advancing it gently NSS
C
Notify the MD of your findings
D
Irrigate the NGT with 50 cc of sterile
Question 13 Explanation:
The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.
Question 14
Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to
A
Gain a more rapid systemic effect
B
Destroy resistant organisms and promote proper blood levels of the drugs
C
Delay resistance and increase the tuberculostatic effect
D
Cause less irritation to the gastrointestinal tract
Question 14 Explanation:
Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance.
Question 15
An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to
A
Ambulate
B
Ask for medications to relax him.
C
Remain on bed rest.
D
Strain all urine.
Question 15 Explanation:
Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination.
Question 16
The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient?
A
Impaired gas exchange.
B
Fluid volume deficit
C
Decreased tissue perfusion.
D
Risk for infection
Question 16 Explanation:
Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess.
Question 17
The nurse enters the room of a client with chronic obstructive pulmonary disease. The client’s nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the respirations are 9 per minute and shallow. What is the nurse’s best initial action?
A
Take heart rate and blood pressure
B
Lower the oxygen rate
C
Position the client in a Fowler’s position.
D
Call the physician
Question 17 Explanation:
The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR.
Question 18
The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is to:
A
Offer the guest a cup of coffee
B
Encourage the guest to eat some baked macaroni
C
Give the guest a glass of orange juice
D
Call the guest’s personal physician
Question 18 Explanation:
In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV.
Question 19
The client has a good understanding of the means to reduce the chances of colon cancer when he states:
A
“I will include more fresh fruits and vegetables in my diet.”
B
“I will have an annual chest x-ray.”
C
“I will include more red meat in my diet.”
D
“I will exercise daily.”
Question 19 Explanation:
Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.
Question 20
The nurse needs to carefully assess the complaint of pain of the elderly because older people
A
have altered mental function
B
experience reduced sensory perception
C
are expected to experience chronic pain
D
have a decreased pain threshold
Question 20 Explanation:
Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.
Question 21
Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?
A
“Mr. Pablo, you’ll wear out the hospital floors and yourself at this rate."
B
"Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?"
C
"Good evening, Mr. Pablo. Wasn’t it a pleasant day, today?"
D
"Mr, Pablo, you must be so worried, I’ll leave you alone with your thoughts.
Question 21 Explanation:
The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.
Question 22
A client with COPD is being prepared for discharge. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT
A
Inhale slowly through the mouth as the canister is pressed down
B
Breath in and out as fully as possible before placing the mouthpiece inside the mouth.
C
Slowly breath out through the mouth with pursed lips after inhaling the drug.
D
Hold his breath for about 10 seconds before exhaling
Question 22 Explanation:
If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness.
Question 23
A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching?
A
“Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.”
B
“Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved.
C
“Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down.”
D
“When your chest pain begins, lie down, and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes.”
Question 23 Explanation:
Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention.
Question 24
On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops:
A
Intolerance to heat
B
Progressive weight gain
C
Dry skin and fatigue
D
Insomnia and excitability
Question 24 Explanation:
Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.
Question 25
A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate?
A
Provide active range-of-motion exercises to both legs at least twice every shift.
B
Elevate the client’s legs 90 degrees.
C
Apply a heating pad to the involved site.
D
Instruct the client about the need for bed rest.
Question 25 Explanation:
In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.
Question 26
What is the best reason for the nurse in instructing the client to rotate injection sites for insulin?
A
Injection sites can never be reused
B
Lipodystrophy can result and is extremely painful
C
Poor rotation technique can cause superficial hemorrhaging
D
Lipodystrophic areas can result, causing erratic insulin absorption rates from these
Question 26 Explanation:
Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions.
Question 27
An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease, the best response would be:
A
“The medication limit synthesis of the thyroid hormones.”
B
“The medication will increase the synthesis of thyroid hormones.”
C
“The medication will limit thyroid hormone secretion.”
D
“The medication will block the cardiovascular symptoms of Grave’s disease.”
Question 27 Explanation:
Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease.
Question 28
Which of the drug of choice for pain controls the patient with acute pancreatitis?
A
Meperidine
B
NSAIDS
C
NSAIDS
D
Codeine
Question 28 Explanation:
Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
Question 29
Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse’s best
A
The patient is anxious about upcoming surgery
B
The patient needs a higher dose of this drug
C
The patient is having an allergic reaction to the drug.
D
This is normal side-effect of AtSO4
Question 29 Explanation:
Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.
Question 30
During the first 24 hours after thyroid surgery, the nurse should include in her care:
A
Encouraging the client to ventilate her feelings about the surgery
B
Checking the back and sides of the operative dressing
C
Advising the client that she can resume her normal activities immediately
D
Supporting the head during mild range of motion exercise
Question 30 Explanation:
Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage.
Question 31
Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question?
A
Administer oxygen at 100%.
B
Monitor urine output every hour.
C
Put the client in modified Trendelenberg’s position.
D
Administer Demerol 50mg IM q4h
Question 31 Explanation:
Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.
Question 32
A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity?
A
large thighs and upper arms
B
posterior neck fat pad and thin extremities
C
pendulous abdomen and large hips
D
abdominal striae and ankle enlargement
Question 32 Explanation:
“ Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome
Question 33
Which is the most relevant knowledge about oxygen administration to a client with COPD?
A
Oxygen is administered best using a non-rebreathing mask
B
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
C
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
D
Blood gases are monitored using a pulse oximeter.
Question 33 Explanation:
COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive.
Question 34
When suctioning mucus from a client’s lungs, which nursing action would be least appropriate?
A
Suction until the client indicates to stop or no longer than 20 second
B
Use sterile technique with a two-gloved approach
C
Hyperoxygenate the client before and after suctioning
D
Lubricate the catheter tip with sterile saline before insertion.
Question 34 Explanation:
One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning.
Question 35
A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to:
A
Notify the MD
B
Deflate the esophageal balloon
C
Monitor VS
D
Encourage him to take deep breaths
Question 35 Explanation:
When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction
Question 36
Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in Fowler’s position on either his right
side or on his back to
A
Equalize pressure in the pleural space.
B
Facilitate ventilation of the left lung.
C
Reduce incisional pain.
D
Increase venous return
Question 36 Explanation:
Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
Question 37
Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to
A
Approximate the wound edges with tapes
B
Irrigate the wound with sterile saline
C
Cover the wound with sterile, moist saline dressing
D
Hold the abdominal contents in place with a sterile gloved hand
Question 37 Explanation:
Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process.
Question 38
A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:
A
Instruct the client to swallow 6 radiopaque tablets the evening before the study
B
Place the client on CBR a day before the study
C
Give laxative the night before and a cleansing enema in the morning before the test
D
Render an oil retention enema and give laxative the night before
Question 38 Explanation:
Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema.
Question 39
The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease?
A
Diverticulitis
B
Peritonitis
C
Chrons disease
D
Ulcerative colitis
Question 39 Explanation:
Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem.
Question 40
A client, who is suspected of having Pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential for the nurse to make first?
A
Blood pressure
B
Hand grips
C
Blood glucose
D
Pupil reaction
Question 40 Explanation:
Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.
Question 41
The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Which of the following statements indicate an understanding of this data?
A
No treatment is necessary at this time
B
Treatment will include Ranitidine and Antibiotics
C
This result indicates gastric cancer caused by the organism
D
Surgical treatment is necessary
Question 41 Explanation:
One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer.
Question 42
Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be:
A
“Pain will become less each day.”
B
“I will give you the pain medication the physician ordered.”
C
“With a pillow, apply pressure against the incision.”
D
“This is a normal reaction after surgery.”
Question 42 Explanation:
Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.
Question 43
Which description of pain would be most characteristic of a duodenal ulcer?
A
Sharp pain in the epigastric area that radiates to the right shoulder
B
RUQ pain that increases after meal
C
Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
D
A sensation of painful pressure in the midsternal area
Question 43 Explanation:
Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.
Question 44
The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? :
A
Foamy, blood-tinged sputum
B
Dyspnea on exertion
C
Cough or change in a chronic cough
D
Wheezing sound on inspiration
Question 44 Explanation:
Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection.
Question 45
A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client?
A
It interferes with vitamin K absorption.
B
It inactivates thrombin that forms and dissolves existing thrombi.
C
It prevents conversion of factors that are needed in the formation of clots.
D
It dissolves existing thrombi.
Question 45 Explanation:
Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.
Question 46
Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
A
changing the dressing at least BID
B
irrigate the T-tube frequently
C
encouraging the client to cough and deep breathe
D
encouraging the client to take adequate deep breaths by mouth
Question 46 Explanation:
Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications.
Question 47
Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug?
A
Do not give the drug if the apical rate is less than 60 beats per minute.
B
It has positive inotropic and negative chronotropic effects
C
The positive inotropic effect will decrease urine output
D
Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems
Question 47 Explanation:
Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output.
Question 48
A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate?
A
Notify his physician.
B
Take his vital signs again in 15 minutes.
C
Take his vital signs again in an hour.
D
Place the patient in shock position.
Question 48 Explanation:
Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring.
Question 49
Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva’s maneuver?
A
Enema administration
B
Use of stool softeners.
C
Lifting heavy objects
D
Gagging while toothbrushing.
Question 49 Explanation:
Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver.
Question 50
A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
A
Bleeding from ears
B
An elevated temperature
C
A depressed fontanel
D
Reactive pupils
Question 50 Explanation:
The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation
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NCLEX Practice Exam for Medical Surgical Nursing 1 (EM)
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Question 1
After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take?
A
Administer the prescribed antiemetic.
B
Call the physician immediately.
C
Change the patient’s position.
D
Check the patency of the nasogastric tube for any obstruction.
Question 1 Explanation:
Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention.
Question 2
The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
A
have regular follow up care
B
may engage in contact sports
C
may be allowed to use electrical appliances
D
take the pulse rate once a day, in the morning upon awakening
Question 2 Explanation:
The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
Question 3
Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in Fowler’s position on either his right
side or on his back to
A
Facilitate ventilation of the left lung.
B
Increase venous return
C
Reduce incisional pain.
D
Equalize pressure in the pleural space.
Question 3 Explanation:
Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
Question 4
A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity?
A
large thighs and upper arms
B
abdominal striae and ankle enlargement
C
posterior neck fat pad and thin extremities
D
pendulous abdomen and large hips
Question 4 Explanation:
“ Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome
Question 5
On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops:
A
Dry skin and fatigue
B
Insomnia and excitability
C
Intolerance to heat
D
Progressive weight gain
Question 5 Explanation:
Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.
Question 6
The client has a good understanding of the means to reduce the chances of colon cancer when he states:
A
“I will include more red meat in my diet.”
B
“I will exercise daily.”
C
“I will have an annual chest x-ray.”
D
“I will include more fresh fruits and vegetables in my diet.”
Question 6 Explanation:
Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.
Question 7
The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:
A
Irrigate the NGT with 50 cc of sterile
B
Discontinue the low-intermittent suction
C
Notify the MD of your findings
D
Reposition the NGT by advancing it gently NSS
Question 7 Explanation:
The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.
Question 8
Which statement by the client indicates understanding of the possible side effects of Prednisone therapy?
A
“I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”
B
“I should limit my potassium intake because hyperkalemia is a side-effect of this drug.”
C
“This medicine will protect me from getting any colds or infection.”
D
“My incision will heal much faster because of this drug.”
Question 8 Explanation:
The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis
Question 9
What instructions should the client be given before undergoing a paracentesis?
A
Strict bed rest following procedure
B
NPO 12 hours before procedure
C
Empty bowel before procedure
D
Empty bladder before procedure
Question 9 Explanation:
Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure.
Question 10
During the first 24 hours after thyroid surgery, the nurse should include in her care:
A
Advising the client that she can resume her normal activities immediately
B
Supporting the head during mild range of motion exercise
C
Encouraging the client to ventilate her feelings about the surgery
D
Checking the back and sides of the operative dressing
Question 10 Explanation:
Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage.
Question 11
A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate?
A
Elevate the client’s legs 90 degrees.
B
Apply a heating pad to the involved site.
C
Provide active range-of-motion exercises to both legs at least twice every shift.
D
Instruct the client about the need for bed rest.
Question 11 Explanation:
In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.
Question 12
Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva’s maneuver?
A
Enema administration
B
Use of stool softeners.
C
Gagging while toothbrushing.
D
Lifting heavy objects
Question 12 Explanation:
Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver.
Question 13
A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to:
A
Notify the MD
B
Encourage him to take deep breaths
C
Deflate the esophageal balloon
D
Monitor VS
Question 13 Explanation:
When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction
Question 14
The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Which of the following statements indicate an understanding of this data?
A
This result indicates gastric cancer caused by the organism
B
No treatment is necessary at this time
C
Surgical treatment is necessary
D
Treatment will include Ranitidine and Antibiotics
Question 14 Explanation:
One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer.
Question 15
A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client?
A
It prevents conversion of factors that are needed in the formation of clots.
B
It dissolves existing thrombi.
C
It interferes with vitamin K absorption.
D
It inactivates thrombin that forms and dissolves existing thrombi.
Question 15 Explanation:
Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.
Question 16
A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate?
A
Take his vital signs again in an hour.
B
Notify his physician.
C
Take his vital signs again in 15 minutes.
D
Place the patient in shock position.
Question 16 Explanation:
Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring.
Question 17
When suctioning mucus from a client’s lungs, which nursing action would be least appropriate?
A
Suction until the client indicates to stop or no longer than 20 second
B
Lubricate the catheter tip with sterile saline before insertion.
C
Use sterile technique with a two-gloved approach
D
Hyperoxygenate the client before and after suctioning
Question 17 Explanation:
One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning.
Question 18
After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care?
A
Eat small meals every 2-3 hours
B
Take only sips of H2O between bites of solid food
C
Reduce the amount of simple carbohydrate in the diet
D
Sit upright for at least 30 minutes after meals
Question 18 Explanation:
The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome.
Question 19
Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to
A
Cause less irritation to the gastrointestinal tract
B
Destroy resistant organisms and promote proper blood levels of the drugs
C
Gain a more rapid systemic effect
D
Delay resistance and increase the tuberculostatic effect
Question 19 Explanation:
Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance.
Question 20
Which description of pain would be most characteristic of a duodenal ulcer?
A
Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
B
RUQ pain that increases after meal
C
Sharp pain in the epigastric area that radiates to the right shoulder
D
A sensation of painful pressure in the midsternal area
Question 20 Explanation:
Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.
Question 21
Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be:
A
“I will give you the pain medication the physician ordered.”
B
“With a pillow, apply pressure against the incision.”
C
“This is a normal reaction after surgery.”
D
“Pain will become less each day.”
Question 21 Explanation:
Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.
Question 22
Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?
A
"Mr, Pablo, you must be so worried, I’ll leave you alone with your thoughts.
B
"Good evening, Mr. Pablo. Wasn’t it a pleasant day, today?"
C
"Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?"
D
“Mr. Pablo, you’ll wear out the hospital floors and yourself at this rate."
Question 22 Explanation:
The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.
Question 23
The nurse needs to carefully assess the complaint of pain of the elderly because older people
A
are expected to experience chronic pain
B
have a decreased pain threshold
C
experience reduced sensory perception
D
have altered mental function
Question 23 Explanation:
Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.
Question 24
A client, who is suspected of having Pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential for the nurse to make first?
A
Blood glucose
B
Blood pressure
C
Pupil reaction
D
Hand grips
Question 24 Explanation:
Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.
Question 25
A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching?
A
“When your chest pain begins, lie down, and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes.”
B
“Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.”
C
“Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved.
D
“Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down.”
Question 25 Explanation:
Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention.
Question 26
Which of the drug of choice for pain controls the patient with acute pancreatitis?
A
NSAIDS
B
Meperidine
C
NSAIDS
D
Codeine
Question 26 Explanation:
Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
Question 27
A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food?
A
Canned sardines
B
Eggs
C
Whole milk
D
Plain nuts
Question 27 Explanation:
Canned foods are generally rich in sodium content as salt is used as the main preservative.
Question 28
What is the best reason for the nurse in instructing the client to rotate injection sites for insulin?
A
Poor rotation technique can cause superficial hemorrhaging
B
Lipodystrophy can result and is extremely painful
C
Injection sites can never be reused
D
Lipodystrophic areas can result, causing erratic insulin absorption rates from these
Question 28 Explanation:
Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions.
Question 29
Included in the plan of care for the immediate post-gastroscopy period will be:
A
Measure abdominal girth every 4 hours
B
Assess for pain and medicate as ordered
C
Assess gag reflex prior to administration of fluids
D
Maintain NGT to intermittent suction
Question 29 Explanation:
The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.
Question 30
Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug?
A
It has positive inotropic and negative chronotropic effects
B
The positive inotropic effect will decrease urine output
C
Do not give the drug if the apical rate is less than 60 beats per minute.
D
Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems
Question 30 Explanation:
Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output.
Question 31
Which is the most relevant knowledge about oxygen administration to a client with COPD?
A
Oxygen is administered best using a non-rebreathing mask
B
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
C
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
D
Blood gases are monitored using a pulse oximeter.
Question 31 Explanation:
COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive.
Question 32
The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient?
A
Decreased tissue perfusion.
B
Impaired gas exchange.
C
Fluid volume deficit
D
Risk for infection
Question 32 Explanation:
Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess.
Question 33
The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? :
A
Foamy, blood-tinged sputum
B
Cough or change in a chronic cough
C
Dyspnea on exertion
D
Wheezing sound on inspiration
Question 33 Explanation:
Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection.
Question 34
The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease?
A
Ulcerative colitis
B
Chrons disease
C
Peritonitis
D
Diverticulitis
Question 34 Explanation:
Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem.
Question 35
A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse’s highest priority of information would be
A
Coughing and deep-breathing exercises will be done q2h.
B
Only ice chips and cold liquids will be allowed initially.
C
Food and fluids will be withheld for at least 2 hours
D
Warm saline gargles will be done q 2h.
Question 35 Explanation:
Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
Question 36
A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
A
Bleeding from ears
B
A depressed fontanel
C
Reactive pupils
D
An elevated temperature
Question 36 Explanation:
The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation
Question 37
Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
A
encouraging the client to take adequate deep breaths by mouth
B
changing the dressing at least BID
C
irrigate the T-tube frequently
D
encouraging the client to cough and deep breathe
Question 37 Explanation:
Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications.
Question 38
The nurse enters the room of a client with chronic obstructive pulmonary disease. The client’s nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the respirations are 9 per minute and shallow. What is the nurse’s best initial action?
A
Take heart rate and blood pressure
B
Position the client in a Fowler’s position.
C
Call the physician
D
Lower the oxygen rate
Question 38 Explanation:
The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR.
Question 39
An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to
A
Ask for medications to relax him.
B
Strain all urine.
C
Remain on bed rest.
D
Ambulate
Question 39 Explanation:
Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination.
Question 40
Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to
A
Hold the abdominal contents in place with a sterile gloved hand
B
Irrigate the wound with sterile saline
C
Cover the wound with sterile, moist saline dressing
D
Approximate the wound edges with tapes
Question 40 Explanation:
Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process.
Question 41
A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:
A
Place the client on CBR a day before the study
B
Render an oil retention enema and give laxative the night before
C
Give laxative the night before and a cleansing enema in the morning before the test
D
Instruct the client to swallow 6 radiopaque tablets the evening before the study
Question 41 Explanation:
Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema.
Question 42
Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse’s best
A
The patient is anxious about upcoming surgery
B
This is normal side-effect of AtSO4
C
The patient is having an allergic reaction to the drug.
D
The patient needs a higher dose of this drug
Question 42 Explanation:
Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.
Question 43
The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is to:
A
Offer the guest a cup of coffee
B
Encourage the guest to eat some baked macaroni
C
Give the guest a glass of orange juice
D
Call the guest’s personal physician
Question 43 Explanation:
In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV.
Question 44
Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication provides little relief and he refuses to move. The nurse should plan to:
A
Handle him gently when assisting with required care
B
Complete A.M. care quickly as possible when necessary
C
Let him perform his own activities of daily living
D
Reassure him that the nurses will not hurt him
Question 44 Explanation:
Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently.
Question 45
Which of the following would be inappropriate to include in a diabetic teaching plan?
A
Change position hourly to increase circulation
B
Keep legs elevated on 2 pillows while sleeping
C
Keep the insulin not in use in the refrigerator
D
Inspect feet and legs daily for any changes
Question 45 Explanation:
The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.
Question 46
An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease, the best response would be:
A
“The medication limit synthesis of the thyroid hormones.”
B
“The medication will block the cardiovascular symptoms of Grave’s disease.”
C
“The medication will increase the synthesis of thyroid hormones.”
D
“The medication will limit thyroid hormone secretion.”
Question 46 Explanation:
Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease.
Question 47
A client with COPD is being prepared for discharge. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT
A
Slowly breath out through the mouth with pursed lips after inhaling the drug.
B
Hold his breath for about 10 seconds before exhaling
C
Inhale slowly through the mouth as the canister is pressed down
D
Breath in and out as fully as possible before placing the mouthpiece inside the mouth.
Question 47 Explanation:
If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness.
Question 48
The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet?
A
“Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”
B
“The liver heals better with a high carbohydrates diet rather than protein.”
C
“The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
D
“Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
Question 48 Explanation:
The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production.
Question 49
Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?
A
“My cholesterol is 180.”
B
“I smoke 1 1/2 packs of cigarettes per day.”
C
“I exercise every other day.”
D
“My father died of Myasthenia Gravis.”
Question 49 Explanation:
Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention.
Question 50
Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question?
A
Put the client in modified Trendelenberg’s position.
B
Monitor urine output every hour.
C
Administer oxygen at 100%.
D
Administer Demerol 50mg IM q4h
Question 50 Explanation:
Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.
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1. Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be:
“Pain will become less each day.”
“This is a normal reaction after surgery.”
“With a pillow, apply pressure against the incision.”
“I will give you the pain medication the physician ordered.”
2. The nurse needs to carefully assess the complaint of pain of the elderly because older people
are expected to experience chronic pain
have a decreased pain threshold
experience reduced sensory perception
have altered mental function
3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse’s best
The patient is having an allergic reaction to the drug.
The patient needs a higher dose of this drug
This is normal side-effect of AtSO4
The patient is anxious about upcoming surgery
4. Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question?
Put the client in modified Trendelenberg’s position.
Administer oxygen at 100%.
Monitor urine output every hour.
Administer Demerol 50mg IM q4h
5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?
“Good evening, Mr. Pablo. Wasn’t it a pleasant day, today?”
“Mr, Pablo, you must be so worried, I’ll leave you alone with your thoughts.
“Mr. Pablo, you’ll wear out the hospital floors and yourself at this rate.”
“Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?”
6. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take?
Call the physician immediately.
Administer the prescribed antiemetic.
Check the patency of the nasogastric tube for any obstruction.
Change the patient’s position.
7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication provides little relief and he refuses to move. The nurse should plan to:
Reassure him that the nurses will not hurt him
Let him perform his own activities of daily living
Handle him gently when assisting with required care
Complete A.M. care quickly as possible when necessary
8. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate?
Notify his physician.
Take his vital signs again in 15 minutes.
Take his vital signs again in an hour.
Place the patient in shock position.
9. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
Reactive pupils
A depressed fontanel
Bleeding from ears
An elevated temperature
10. Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?
“I exercise every other day.”
“My father died of Myasthenia Gravis.”
“My cholesterol is 180.”
“I smoke 1 1/2 packs of cigarettes per day.”
11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug?
It has positive inotropic and negative chronotropic effects
The positive inotropic effect will decrease urine output
Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems
Do not give the drug if the apical rate is less than 60 beats per minute.
12. Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva’s maneuver?
Use of stool softeners.
Enema administration
Gagging while toothbrushing.
Lifting heavy objects
13. The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
take the pulse rate once a day, in the morning upon awakening
may be allowed to use electrical appliances
have regular follow up care
may engage in contact sports
14. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching?
“When your chest pain begins, lie down, and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes.”
“Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.”
“Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down.”
“Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved.
15. A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food?
Whole milk
Canned sardines
Plain nuts
Eggs
16. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate?
Apply a heating pad to the involved site.
Elevate the client’s legs 90 degrees.
Instruct the client about the need for bed rest.
Provide active range-of-motion exercises to both legs at least twice every shift.
17. A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client?
It dissolves existing thrombi.
It prevents conversion of factors that are needed in the formation of clots.
It inactivates thrombin that forms and dissolves existing thrombi.
It interferes with vitamin K absorption.
18. The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? :
Dyspnea on exertion
Foamy, blood-tinged sputum
Wheezing sound on inspiration
Cough or change in a chronic cough
19. Which is the most relevant knowledge about oxygen administration to a client with COPD?
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
Oxygen is administered best using a non-rebreathing mask
Blood gases are monitored using a pulse oximeter.
20. When suctioning mucus from a client’s lungs, which nursing action would be least appropriate?
Lubricate the catheter tip with sterile saline before insertion.
Use sterile technique with a two-gloved approach
Suction until the client indicates to stop or no longer than 20 second
Hyperoxygenate the client before and after suctioning
21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to
Cause less irritation to the gastrointestinal tract
Destroy resistant organisms and promote proper blood levels of the drugs
Gain a more rapid systemic effect
Delay resistance and increase the tuberculostatic effect
22. Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in Fowler’s position on either his right
side or on his back to
Reduce incisional pain.
Facilitate ventilation of the left lung.
Equalize pressure in the pleural space.
Increase venous return
23. A client with COPD is being prepared for discharge. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT
Breath in and out as fully as possible before placing the mouthpiece inside the mouth.
Inhale slowly through the mouth as the canister is pressed down
Hold his breath for about 10 seconds before exhaling
Slowly breath out through the mouth with pursed lips after inhaling the drug.
24. A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse’s highest priority of information would be
Food and fluids will be withheld for at least 2 hours.
Warm saline gargles will be done q 2h.
Coughing and deep-breathing exercises will be done q2h.
Only ice chips and cold liquids will be allowed initially.
25. The nurse enters the room of a client with chronic obstructive pulmonary disease. The client’s nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the respirations are 9 per minute and shallow. What is the nurse’s best initial action?
Take heart rate and blood pressure.
Call the physician.
Lower the oxygen rate.
Position the client in a Fowler’s position.
26. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient?
Fluid volume deficit
Decreased tissue perfusion.
Impaired gas exchange.
Risk for infection
27. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity?
large thighs and upper arms
pendulous abdomen and large hips
abdominal striae and ankle enlargement
posterior neck fat pad and thin extremities
28. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy?
“I should limit my potassium intake because hyperkalemia is a side-effect of this drug.”
“I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”
“This medicine will protect me from getting any colds or infection.”
“My incision will heal much faster because of this drug.”
29. A client, who is suspected of having Pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential for the nurse to make first?
Pupil reaction
Hand grips
Blood pressure
Blood glucose
30. The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is to:
Encourage the guest to eat some baked macaroni
Call the guest’s personal physician
Offer the guest a cup of coffee
Give the guest a glass of orange juice
31. An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease, the best response would be:
“The medication will limit thyroid hormone secretion.”
“The medication limit synthesis of the thyroid hormones.”
“The medication will block the cardiovascular symptoms of Grave’s disease.”
“The medication will increase the synthesis of thyroid hormones.”
32. During the first 24 hours after thyroid surgery, the nurse should include in her care:
Checking the back and sides of the operative dressing
Supporting the head during mild range of motion exercise
Encouraging the client to ventilate her feelings about the surgery
Advising the client that she can resume her normal activities immediately
33. On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops:
Intolerance to heat
Dry skin and fatigue
Progressive weight gain
Insomnia and excitability
34. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin?
Lipodystrophy can result and is extremely painful
Poor rotation technique can cause superficial hemorrhaging
Lipodystrophic areas can result, causing erratic insulin absorption rates from these
Injection sites can never be reused
35. Which of the following would be inappropriate to include in a diabetic teaching plan?
Change position hourly to increase circulation
Inspect feet and legs daily for any changes
Keep legs elevated on 2 pillows while sleeping
Keep the insulin not in use in the refrigerator
36. Included in the plan of care for the immediate post-gastroscopy period will be:
Maintain NGT to intermittent suction
Assess gag reflex prior to administration of fluids
Assess for pain and medicate as ordered
Measure abdominal girth every 4 hours
37. Which description of pain would be most characteristic of a duodenal ulcer?
Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
RUQ pain that increases after meal
Sharp pain in the epigastric area that radiates to the right shoulder
A sensation of painful pressure in the midsternal area
38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:
Reposition the NGT by advancing it gently NSS
Notify the MD of your findings
Irrigate the NGT with 50 cc of sterile
Discontinue the low-intermittent suction
39. After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care?
Sit upright for at least 30 minutes after meals
Take only sips of H2O between bites of solid food
Eat small meals every 2-3 hours
Reduce the amount of simple carbohydrate in the diet
40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Which of the following statements indicate an understanding of this data?
Treatment will include Ranitidine and Antibiotics
No treatment is necessary at this time
This result indicates gastric cancer caused by the organism
Surgical treatment is necessary
41. What instructions should the client be given before undergoing a paracentesis?
NPO 12 hours before procedure
Empty bladder before procedure
Strict bed rest following procedure
Empty bowel before procedure
42. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet?
“The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
“The liver heals better with a high carbohydrates diet rather than protein.”
“Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
“Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”
43. Which of the drug of choice for pain controls the patient with acute pancreatitis?
Morphine
NSAIDS
Meperidine
Codeine
44. Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
encouraging the client to take adequate deep breaths by mouth
encouraging the client to cough and deep breathe
changing the dressing at least BID
irrigate the T-tube frequently
45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to:
Deflate the esophageal balloon
Monitor VS
Encourage him to take deep breaths
Notify the MD
46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease?
Chrons disease
Ulcerative colitis
Diverticulitis
Peritonitis
47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:
Give laxative the night before and a cleansing enema in the morning before the test
Render an oil retention enema and give laxative the night before
Instruct the client to swallow 6 radiopaque tablets the evening before the study
Place the client on CBR a day before the study
48. The client has a good understanding of the means to reduce the chances of colon cancer when he states:
“I will exercise daily.”
“I will include more red meat in my diet.”
“I will have an annual chest x-ray.”
“I will include more fresh fruits and vegetables in my diet.”
49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to
Cover the wound with sterile, moist saline dressing
Approximate the wound edges with tapes
Irrigate the wound with sterile saline
Hold the abdominal contents in place with a sterile gloved hand
50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to
Strain all urine.
Ambulate.
Remain on bed rest.
Ask for medications to relax him.
Answers and Rationales
Answer: (C) “With a pillow, apply pressure against the incision.” Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.
Answer: (C) experience reduced sensory perception . Degenerative changes occur in the elderly. The response to pain in the elderly maybe lessened because of reduced acuity of touch, alterations in neural pathways and diminished processing of sensory data.
Answer: (C) This is normal side-effect of AtSO4. Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.
Answer: (D) Administer Demerol 50mg IM q4h. Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse.
Answer: (D) “Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?”. The client is showing signs of anxiety reaction to a stressful event. Recognizing the client’s anxiety conveys acceptance of his behavior and will allow for verbalization of feelings and concerns.
Answer: (C) Check the patency of the nasogastric tube for any obstruction. Nausea is one of the common complaints of a patient after receiving general anesthesia. But this complaint could be aggravated by gastric distention especially in a patient who has undergone abdominal surgery. Insertion of the NGT helps relieve the problem. Checking on the patency of the NGT for any obstruction will help the nurse determine the cause of the problem and institute the necessary intervention.
Answer: (C) Handle him gently when assisting with required care . Patients with cancer and bone metastasis experience severe pain especially when moving. Bone tumors weaken the bone to appoint at which normal activities and even position changes can lead to fracture. During nursing care, the patient needs to be supported and handled gently.
Answer: (B) Take his vital signs again in 15 minutes. Monitoring the client’s vital signs following surgery gives the nurse a sound information about the client’s condition. Complications can occur during this period as a result of the surgery or the anesthesia or both. Keeping close track of changes in the VS and validating them will help the nurse initiate interventions to prevent complications from occurring.
Answer: (C) Bleeding from ears . The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.
Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.” Smoking has been considered as one of the major modifiable risk factors for coronary artery disease. Exercise and maintaining normal serum cholesterol levels help in its prevention.
Answer: (B) The positive inotropic effect will decrease urine output . Inotropic effect of drugs on the heart causes increase force of its contraction. This increases cardiac output that improves renal perfusion resulting in an improved urine output.
Answer: (A) Use of stool softeners. Straining or bearing down activities can cause vagal stimulation that leads to bradycardia. Use of stool softeners promote easy bowel evacuation that prevents straining or the valsalva maneuver.
Answer: (D) may engage in contact sports . The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.
Answer: (D) “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. Angina pectoris is caused by myocardial ischemia related to decreased coronary blood supply. Giving nitroglycerine will produce coronary vasodilation that improves the coronary blood flow in 3 – 5 mins. If the chest pain is unrelieved, after three tablets, there is a possibility of acute coronary occlusion that requires immediate medical attention.
Answer: (B) Canned sardines . Canned foods are generally rich in sodium content as salt is used as the main preservative.
Answer: (C) Instruct the client about the need for bed rest. In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.
Answer: (B) It prevents conversion of factors that are needed in the formation of clots. Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.
Answer: (D) Cough or change in a chronic cough .Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. The irritation causes the cough which initially maybe dry, persistent and unproductive. As the tumor enlarges, obstruction of the airways occurs and the cough may become productive due to infection.
Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive.
Answer: (C) Suction until the client indicates to stop or no longer than 20 second .One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning.
Answer: (D) Delay resistance and increase the tuberculostatic effect . Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. Using drugs in combination can delay the drug resistance.
Answer: (B) Facilitate ventilation of the left lung. Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.
Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. If the client breathes out through the mouth with pursed lips, this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness.
Answer: (A) Food and fluids will be withheld for at least 2 hours. Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.
Answer: (C) Lower the oxygen rate. The client with COPD is suffering from chronic CO2 retention. The hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR.
Answer: (C) Impaired gas exchange. Pneumonia, which is an infection, causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. Because the patient would require adequate hydration, this makes him prone to fluid volume excess.
Answer: (D) posterior neck fat pad and thin extremities .“ Buffalo hump” is the accumulation of fat pads over the upper back and neck. Fat may also accumulate on the face. There is truncal obesity but the extremities are thin. All these are noted in a client with Cushing’s syndrome.
Answer: (B) “I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.” The possible side effects of steroid administration are hypokalemia, increase tendency to infection and poor wound healing. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis
Answer: (C) Blood pressure . Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.
Answer: (D) Give the guest a glass of orange juice . In diabetic patients, the nurse should watch out for signs of hypoglycemia manifested by dizziness, tremors, weakness, pallor diaphoresis and tachycardia. When this occurs in a conscious client, he should be given immediately carbohydrates in the form of fruit juice, hard candy, honey or, if unconscious, glucagons or dextrose per IV.
Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease.” Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease.
Answer: (A) Checking the back and sides of the operative dressing . Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage.
Answer: (C) Progressive weight gain . Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.
Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption rates from these . Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions.
Answer: (C) Keep legs elevated on 2 pillows while sleeping . The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.
Answer: (B) Assess gag reflex prior to administration of fluids . The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.
Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake . Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.
Answer: (B) Notify the MD of your findings . The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.
Answer: (A) Sit upright for at least 30 minutes after meals . The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome.
Answer: (A) Treatment will include Ranitidine and Antibiotics . One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer.
Answer: (B) Empty bladder before procedure . Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure.
Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production.
Answer: (C) Meperidine . Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
Answer: (B) encouraging the client to cough and deep breathe . Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications.
Answer: (A) Deflate the esophageal balloon . When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction
Answer: (B) Ulcerative colitis . Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem.
Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test .Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema.
Answer: (D) “I will include more fresh fruits and vegetables in my diet.” Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.
Answer: (A) Cover the wound with sterile, moist saline dressing . Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process.
Answer: (B) Ambulate. Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination.