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NCLEX Practice Exam for Medical Surgical Nursing 1 (PM)
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Question 1
Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to
A
Cover the wound with sterile, moist saline dressing
B
Irrigate the wound with sterile saline
C
Hold the abdominal contents in place with a sterile gloved hand
D
Approximate the wound edges with tapes
Question 1 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 2
Which of the drug of choice for pain controls the patient with acute pancreatitis?
A
NSAIDS
B
NSAIDS
C
Meperidine
D
Codeine
Question 2 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 3
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
Eat small meals every 2-3 hours
C
Sit upright for at least 30 minutes after meals
D
Reduce the amount of simple carbohydrate in the diet
Question 3 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 4
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
Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems
C
Do not give the drug if the apical rate is less than 60 beats per minute.
D
The positive inotropic effect will decrease urine output
Question 4 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 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?
A
"Good evening, Mr. Pablo. Wasn’t it a pleasant day, today?"
B
"Mr, Pablo, you must be so worried, I’ll leave you alone with your thoughts.
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 5 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 6
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
Encourage the guest to eat some baked macaroni
B
Offer the guest a cup of coffee
C
Give the guest a glass of orange juice
D
Call the guest’s personal physician
Question 6 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 7
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
Position the client in a Fowler’s position.
B
Lower the oxygen rate
C
Call the physician
D
Take heart rate and blood pressure
Question 7 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 8
What instructions should the client be given before undergoing a paracentesis?
A
Empty bowel before procedure
B
Strict bed rest following procedure
C
Empty bladder before procedure
D
NPO 12 hours before procedure
Question 8 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 9
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 dissolves existing thrombi.
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 interferes with vitamin K absorption.
Question 9 Explanation:
Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.
Question 10
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
Remain on bed rest.
C
Strain all urine.
D
Ask for medications to relax him.
Question 10 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 11
Which is the most relevant knowledge about oxygen administration to a client with COPD?
A
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
B
Oxygen is administered best using a non-rebreathing mask
C
Blood gases are monitored using a pulse oximeter.
D
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
Question 11 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 12
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
Chrons disease
B
Diverticulitis
C
Peritonitis
D
Ulcerative colitis
Question 12 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 13
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
Put the client in modified Trendelenberg’s position.
C
Monitor urine output every hour.
D
Administer Demerol 50mg IM q4h
Question 13 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 14
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
Plain nuts
B
Whole milk
C
Eggs
D
Canned sardines
Question 14 Explanation:
Canned foods are generally rich in sodium content as salt is used as the main preservative.
Question 15
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
Increase venous return
C
Facilitate ventilation of the left lung.
D
Reduce incisional pain.
Question 15 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 16
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
Insomnia and excitability
B
Dry skin and fatigue
C
Intolerance to heat
D
Progressive weight gain
Question 16 Explanation:
Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.
Question 17
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 17 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 18
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
Let him perform his own activities of daily living
B
Handle him gently when assisting with required care
C
Complete A.M. care quickly as possible when necessary
D
Reassure him that the nurses will not hurt him
Question 18 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 19
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
Place the patient in shock position.
B
Take his vital signs again in 15 minutes.
C
Take his vital signs again in an hour.
D
Notify his physician.
Question 19 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 20
Which statement by the client indicates understanding of the possible side effects of Prednisone therapy?
A
“This medicine will protect me from getting any colds or infection.”
B
“I should limit my potassium intake because hyperkalemia is a side-effect of this drug.”
C
“I must take this medicine exactly as my doctor ordered it. I shouldn’t skip doses.”
D
“My incision will heal much faster because of this drug.”
Question 20 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 21
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 21 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 22
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
Hyperoxygenate the client before and after suctioning
D
Use sterile technique with a two-gloved approach
Question 22 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 23
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
Hand grips
B
Blood glucose
C
Blood pressure
D
Pupil reaction
Question 23 Explanation:
Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.
Question 24
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 needs a higher dose of this drug
B
The patient is anxious about upcoming surgery
C
The patient is having an allergic reaction to the drug.
D
This is normal side-effect of AtSO4
Question 24 Explanation:
Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.
Question 25
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 limit thyroid hormone secretion.”
C
“The medication will increase the synthesis of thyroid hormones.”
D
“The medication will block the cardiovascular symptoms of Grave’s disease.”
Question 25 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 26
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 be allowed to use electrical appliances
C
have regular follow up care
D
may engage in contact sports
Question 26 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 27
Included in the plan of care for the immediate post-gastroscopy period will be:
A
Maintain NGT to intermittent suction
B
Measure abdominal girth every 4 hours
C
Assess for pain and medicate as ordered
D
Assess gag reflex prior to administration of fluids
Question 27 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 28
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
Change the patient’s position.
B
Call the physician immediately.
C
Check the patency of the nasogastric tube for any obstruction.
D
Administer the prescribed antiemetic.
Question 28 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 29
Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva’s maneuver?
A
Use of stool softeners.
B
Lifting heavy objects
C
Enema administration
D
Gagging while toothbrushing.
Question 29 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 30
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
Hold his breath for about 10 seconds before exhaling
B
Breath in and out as fully as possible before placing the mouthpiece inside the mouth.
C
Inhale slowly through the mouth as the canister is pressed down
D
Slowly breath out through the mouth with pursed lips after inhaling the drug.
Question 30 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 31
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
Wheezing sound on inspiration
B
Dyspnea on exertion
C
Foamy, blood-tinged sputum
D
Cough or change in a chronic cough
Question 31 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 32
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
Irrigate the NGT with 50 cc of sterile
C
Reposition the NGT by advancing it gently NSS
D
Notify the MD of your findings
Question 32 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 33
Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?
A
“I exercise every other day.”
B
“My father died of Myasthenia Gravis.”
C
“My cholesterol is 180.”
D
“I smoke 1 1/2 packs of cigarettes per day.”
Question 33 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 34
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 34 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 35
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 have an annual chest x-ray.”
C
“I will exercise daily.”
D
“I will include more fresh fruits and vegetables in my diet.”
Question 35 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 36
Which description of pain would be most characteristic of a duodenal ulcer?
A
A sensation of painful pressure in the midsternal area
B
Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
C
RUQ pain that increases after meal
D
Sharp pain in the epigastric area that radiates to the right shoulder
Question 36 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 37
Which of the following would be inappropriate to include in a diabetic teaching plan?
A
Inspect feet and legs daily for any changes
B
Keep the insulin not in use in the refrigerator
C
Change position hourly to increase circulation
D
Keep legs elevated on 2 pillows while sleeping
Question 37 Explanation:
The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.
Question 38
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
Risk for infection
D
Fluid volume deficit
Question 38 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 39
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 39 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 40
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
“Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
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
“Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”
Question 40 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 41
The nurse needs to carefully assess the complaint of pain of the elderly because older people
A
experience reduced sensory perception
B
have a decreased pain threshold
C
have altered mental function
D
are expected to experience chronic pain
Question 41 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 42
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
Delay resistance and increase the tuberculostatic effect
C
Destroy resistant organisms and promote proper blood levels of the drugs
D
Gain a more rapid systemic effect
Question 42 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 43
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
Warm saline gargles will be done q 2h.
B
Only ice chips and cold liquids will be allowed initially.
C
Food and fluids will be withheld for at least 2 hours
D
Coughing and deep-breathing exercises will be done q2h.
Question 43 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 44
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
Instruct the client about the need for bed rest.
C
Elevate the client’s legs 90 degrees.
D
Apply a heating pad to the involved site.
Question 44 Explanation:
In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.
Question 45
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
abdominal striae and ankle enlargement
B
large thighs and upper arms
C
posterior neck fat pad and thin extremities
D
pendulous abdomen and large hips
Question 45 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 46
Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
A
changing the dressing at least BID
B
encouraging the client to take adequate deep breaths by mouth
C
encouraging the client to cough and deep breathe
D
irrigate the T-tube frequently
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
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
Injection sites can never be reused
C
Lipodystrophic areas can result, causing erratic insulin absorption rates from these
D
Lipodystrophy can result and is extremely painful
Question 47 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 48
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 48 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 49
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
A depressed fontanel
B
An elevated temperature
C
Reactive pupils
D
Bleeding from ears
Question 49 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 50
During the first 24 hours after thyroid surgery, the nurse should include in her care:
A
Supporting the head during mild range of motion exercise
B
Encouraging the client to ventilate her feelings about the surgery
C
Checking the back and sides of the operative dressing
D
Advising the client that she can resume her normal activities immediately
Question 50 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.
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NCLEX Practice Exam for Medical Surgical Nursing 1 (EM)
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Question 1
Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva’s maneuver?
A
Lifting heavy objects
B
Enema administration
C
Use of stool softeners.
D
Gagging while toothbrushing.
Question 1 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 2
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
Plain nuts
B
Canned sardines
C
Eggs
D
Whole milk
Question 2 Explanation:
Canned foods are generally rich in sodium content as salt is used as the main preservative.
Question 3
What instructions should the client be given before undergoing a paracentesis?
A
Strict bed rest following procedure
B
Empty bladder before procedure
C
NPO 12 hours before procedure
D
Empty bowel before procedure
Question 3 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 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
pendulous abdomen and large hips
B
abdominal striae and ankle enlargement
C
large thighs and upper arms
D
posterior neck fat pad and thin extremities
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
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
Call the physician immediately.
B
Change the patient’s position.
C
Check the patency of the nasogastric tube for any obstruction.
D
Administer the prescribed antiemetic.
Question 5 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 6
A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate?
A
Instruct the client about the need for bed rest.
B
Provide active range-of-motion exercises to both legs at least twice every shift.
C
Apply a heating pad to the involved site.
D
Elevate the client’s legs 90 degrees.
Question 6 Explanation:
In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.
Question 7
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 7 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 8
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 8 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 9
Which of the drug of choice for pain controls the patient with acute pancreatitis?
A
Meperidine
B
NSAIDS
C
NSAIDS
D
Codeine
Question 9 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 10
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 10 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 11
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
Peritonitis
B
Diverticulitis
C
Ulcerative colitis
D
Chrons disease
Question 11 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 12
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
Notify the MD of your findings
B
Discontinue the low-intermittent suction
C
Reposition the NGT by advancing it gently NSS
D
Irrigate the NGT with 50 cc of sterile
Question 12 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 13
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
Place the patient in shock position.
B
Notify his physician.
C
Take his vital signs again in 15 minutes.
D
Take his vital signs again in an hour.
Question 13 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 14
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 include more fresh fruits and vegetables in my diet.”
C
“I will exercise daily.”
D
“I will have an annual chest x-ray.”
Question 14 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 15
Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?
A
“I smoke 1 1/2 packs of cigarettes per day.”
B
“My father died of Myasthenia Gravis.”
C
“I exercise every other day.”
D
“My cholesterol is 180.”
Question 15 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 16
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
Approximate the wound edges with tapes
D
Cover the wound with sterile, moist saline dressing
Question 16 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 17
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
Pupil reaction
C
Hand grips
D
Blood glucose
Question 17 Explanation:
Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.
Question 18
A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:
A
Give laxative the night before and a cleansing enema in the morning before the test
B
Instruct the client to swallow 6 radiopaque tablets the evening before the study
C
Place the client on CBR a day before the study
D
Render an oil retention enema and give laxative the night before
Question 18 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 19
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 19 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 20
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 having an allergic reaction to the drug.
B
The patient needs a higher dose of this drug
C
The patient is anxious about upcoming surgery
D
This is normal side-effect of AtSO4
Question 20 Explanation:
Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.
Question 21
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 21 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 22
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
Dry skin and fatigue
C
Insomnia and excitability
D
Progressive weight gain
Question 22 Explanation:
Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.
Question 23
Which description of pain would be most characteristic of a duodenal ulcer?
A
RUQ pain that increases after meal
B
A sensation of painful pressure in the midsternal area
C
Sharp pain in the epigastric area that radiates to the right shoulder
D
Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
Question 23 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 24
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
Delay resistance and increase the tuberculostatic effect
C
Destroy resistant organisms and promote proper blood levels of the drugs
D
Gain a more rapid systemic effect
Question 24 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 25
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 25 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 26
Which of the following would be inappropriate to include in a diabetic teaching plan?
A
Keep legs elevated on 2 pillows while sleeping
B
Change position hourly to increase circulation
C
Inspect feet and legs daily for any changes
D
Keep the insulin not in use in the refrigerator
Question 26 Explanation:
The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.
Question 27
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
Advising the client that she can resume her normal activities immediately
C
Supporting the head during mild range of motion exercise
D
Checking the back and sides of the operative dressing
Question 27 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 28
When suctioning mucus from a client’s lungs, which nursing action would be least appropriate?
A
Hyperoxygenate the client before and after suctioning
B
Use sterile technique with a two-gloved approach
C
Suction until the client indicates to stop or no longer than 20 second
D
Lubricate the catheter tip with sterile saline before insertion.
Question 28 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 29
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 29 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 30
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
Position the client in a Fowler’s position.
B
Lower the oxygen rate
C
Take heart rate and blood pressure
D
Call the physician
Question 30 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 31
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
Treatment will include Ranitidine and Antibiotics
D
Surgical treatment is necessary
Question 31 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 32
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
Inhale slowly through the mouth as the canister is pressed down
C
Hold his breath for about 10 seconds before exhaling
D
Breath in and out as fully as possible before placing the mouthpiece inside the mouth.
Question 32 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 33
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
Do not give the drug if the apical rate is less than 60 beats per minute.
C
Toxixity can occur more easily in the presence of hypokalemia, liver and renal problems
D
The positive inotropic effect will decrease urine output
Question 33 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 34
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
Risk for infection
B
Decreased tissue perfusion.
C
Fluid volume deficit
D
Impaired gas exchange.
Question 34 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 35
What is the best reason for the nurse in instructing the client to rotate injection sites for insulin?
A
Lipodystrophy can result and is extremely painful
B
Lipodystrophic areas can result, causing erratic insulin absorption rates from these
C
Poor rotation technique can cause superficial hemorrhaging
D
Injection sites can never be reused
Question 35 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 36
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 limit thyroid hormone secretion.”
C
“The medication will increase the synthesis of thyroid hormones.”
D
“The medication will block the cardiovascular symptoms of Grave’s disease.”
Question 36 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 37
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
“The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
B
“The liver heals better with a high carbohydrates diet rather than protein.”
C
“Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”
D
“Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
Question 37 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 38
Which is the most relevant knowledge about oxygen administration to a client with COPD?
A
Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
B
Blood gases are monitored using a pulse oximeter.
C
Oxygen is administered best using a non-rebreathing mask
D
Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
Question 38 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 39
Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be:
A
“This is a normal reaction after surgery.”
B
“I will give you the pain medication the physician ordered.”
C
“With a pillow, apply pressure against the incision.”
D
“Pain will become less each day.”
Question 39 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 40
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 40 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 41
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 prevents conversion of factors that are needed in the formation of clots.
C
It dissolves existing thrombi.
D
It inactivates thrombin that forms and dissolves existing thrombi.
Question 41 Explanation:
Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.
Question 42
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
Monitor urine output every hour.
B
Administer oxygen at 100%.
C
Put the client in modified Trendelenberg’s position.
D
Administer Demerol 50mg IM q4h
Question 42 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 43
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 43 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 44
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 44 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 45
After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care?
A
Sit upright for at least 30 minutes after meals
B
Take only sips of H2O between bites of solid food
C
Reduce the amount of simple carbohydrate in the diet
D
Eat small meals every 2-3 hours
Question 45 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 46
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 46 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 47
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
Strain all urine.
B
Remain on bed rest.
C
Ask for medications to relax him.
D
Ambulate
Question 47 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 48
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
Monitor VS
D
Deflate the esophageal balloon
Question 48 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 49
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
Handle him gently when assisting with required care
C
Reassure him that the nurses will not hurt him
D
Let him perform his own activities of daily living
Question 49 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 50
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
“Mr. Pablo, you’ll wear out the hospital floors and yourself at this rate."
C
"Mr. Pablo, you appear anxious to me. How are you feeling about tomorrow’s surgery?"
D
"Good evening, Mr. Pablo. Wasn’t it a pleasant day, today?"
Question 50 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.
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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.