NCLEX Practice Exam for Medical Surgical Nursing 3

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1. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the ff. as a priority in the plan of care?

  1.  providing emotional support to decrease fear
  2.  protecting the client from infection
  3.  encouraging discussion about lifestyle changes
  4. .identifying factors that decreased the immune function

2. Joy, an obese 32 year old, is admitted to the hospital after an automobile accident. She has a fractured hip and is brought to the OR for surgery.
After surgery Joy is to receive a piggy-back of Clindamycin phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the piggyback to flow at:

  1. 25 gtt/min
  2. 30 gtt/min
  3. 5 gtt/min
  4. 45 gtt/min

3. The day after her surgery Joy asks the nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-term weight loss best occurs when:

  1. Fats are controlled in the diet
  2. Eating habits are altered
  3. Carbohydrates are regulated
  4. Exercise is part of the program

4. The nurse teaches Joy, an obese client, the value of aerobic exercises in her weight reduction program. The nurse would know that this teaching was effective when Joy says that exercise will:

  1. Increase her lean body mass
  2. Lower her metabolic rate
  3. Decrease her appetite
  4. Raise her heart rate

5. The physician orders non-weight bearing with crutches for Joy, who had surgery for a fractured hip. The most important activity to facilitate walking with crutches before ambulation begun is:

  1. Exercising the triceps, finger flexors, and elbow extensors
  2. Sitting up at the edge of the bed to help strengthen back muscles
  3. Doing isometric exercises on the unaffected leg
  4. Using the trapeze frequently for pull-ups to strengthen the biceps muscles

6. The nurse recognizes that a client understood the demonstration of crutch walking when she places her weight on:

  1. The palms and axillary regions
  2. Both feet placed wide apart
  3. The palms of her hands
  4. Her axillary regions

7. Joey is a 46 year-old radio technician who is admitted because of mild chest pain. He is 5 feet, 8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate, Diazepam (Valium) and Lidocaine are prescribed.
The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg. The nurse should administer:

  1. 8 minims
  2. 10 minims
  3. 12 minims
  4. 15 minims

8. Joey asks the nurse why he is receiving the injection of Morphine after he was hospitalized for severe anginal pain. The nurse replies that it:

  1. Will help prevent erratic heart beats
  2. Relieves pain and decreases level of anxiety
  3.  Decreases anxiety
  4.  Dilates coronary blood vessels

9. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse institutes safety precautions in the room because oxygen:

  1. Converts to an alternate form of matter
  2. Has unstable properties
  3. Supports combustion
  4. Is flammable

10. Myra is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme test that is the most reliable early indicator of myocardial insult is:

  1. SGPT
  2. LDH
  3. CK-MB
  4. AST

11. An early finding in the EKG of a client with an infarcted mycardium would be:

  1. Disappearance of Q waves
  2. Elevated ST segments
  3. Absence of P wave
  4. Flattened T waves

12. Jose, who had a myocardial infarction 2 days earlier, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:

  1. Allow him to release his feelings and then leave him alone to allow him to regain his composure
  2. Refocus the conversation on his fears, frustrations and anger about his condition
  3. Explain how his being upset dangerously disturbs his need for rest
  4. Attempt to explain the purpose of different hospital routines

13. Twenty four hours after admission for an Acute MI, Jose’s temperature is noted at 39.3 C. The nurse monitors him for other adaptations related to the pyrexia, including:

  1. Shortness of breath
  2. Chest pain
  3. Elevated blood pressure
  4. Increased pulse rate

14. Jose, who is admitted to the hospital for chest pain, asks the nurse, “Is it still possible for me to have another heart attack if I watch my diet religiously and avoid stress?” The most appropriate initial response would be for the nurse to:

  1. Suggest he discuss his feelings of vulnerability with his physician.
  2. Tell him that he certainly needs to be especially careful about his diet and lifestyle.
  3. Avoid giving him direct information and help him explore his feelings
  4. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.

15. Ana, 55 years old, is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered for Ana. The nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to:

  1. Store vitamin B12
  2. Digest vitamin B12
  3. Absorb vitamin B12
  4. Produce vitamin B12

16. Ana is diagnosed to have Pernicious anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse should administer:

  1. 0.5 ml
  2. 1.0 ml
  3.  1.5 ml
  4. 2.0 ml

17. Health teachings to be given to a client with Pernicious Anemia regarding her therapeutic regimen concerning Vit. B12 will include:

  1.  Oral tablets of Vitamin B12 will control her symptoms
  2.  IM injections are required for daily control
  3.  IM injections once a month will maintain control
  4.  Weekly Z-track injections provide needed control

18. The nurse knows that a client with Pernicious Anemia understands the teaching regarding the vitamin B12 injections when she states that she must take it:

  1.  When she feels fatigued
  2.  During exacerbations of anemia
  3. Until her symptoms subside
  4. For the rest of her life

19. Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:

  1. Reaction Formation
  2. Sublimation
  3. Intellectualization
  4. Projection

20. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:

  1. When the client would have normally had a bowel movement
  2. After the client accepts he had a bowel movement
  3. Before breakfast and morning care
  4. At least 2 hours before visitors arrive

21. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:

  1. Stops the flow of fluid when he feels uncomfortable
  2. Lubricates the tip of the catheter before inserting it into the stoma
  3. Hangs the bag on a clothes hook on the bathroom door during fluid insertion
  4. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled

22. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :

  1. Abdominal cramps during fluid inflow
  2. Difficulty in inserting the irrigating tube
  3.  Passage of flatus during expulsion of feces
  4.  Inability to complete the procedure in half an hour

23. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:

  1. A reaction formation to his recent altered body image.
  2. A difficult time accepting reality and is in a state of denial.
  3. Impotency due to the surgery and needs sexual counseling
  4. Suicide thoughts and should be seen by psychiatrist

24. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:

  1. Food low in fiber so that there is less stool
  2. Everything he ate before the operation but will avoid those foods that cause gas
  3. Bland foods so that his intestines do not become irritated
  4. Soft foods that are more easily digested and absorbed by the large intestines

25. Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated. When Eddie arrives in the emergency room, the assessment that assume the greatest priority are:

  1. Level of consciousness and pupil size
  2. Abdominal contusions and other wounds
  3. Pain, Respiratory rate and blood pressure
  4. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses

26. Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:

  1. Facilitate his verbal communication
  2. Maintain sterility of the ventilation system
  3. Assess his response to the equipment
  4. Prepare him for emergency surgery

27. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to

  1. Prepare for chest tube removal
  2. Milk the tube toward the collection container as ordered
  3. Arrange for a stat Chest x-ray film.
  4. Clam the tube immediately

28. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is:

  1. Increased breath sounds
  2. Constant bubbling in the drainage chamber
  3. Crepitus detected on palpation of chest
  4. Increased respiratory rate

29. In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:

  1. Urinary output is 30 ml in an hour
  2. Central venous pressure reading of 2 cm H2O
  3. Pulse rates of 120 and 110 in a 15 minute period
  4. Blood pressure readings of 50/30 and 70/40 within 30 minutes

30. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:

  1. Complete safety of the procedure
  2. Expectation of postoperative bleeding
  3. Risk of the procedure with his other injuries
  4. Presence of abdominal drains for several days after surgery

31. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:

  1. Encourage bed rest with active and passive range of motion exercises
  2. Encourage frequent coughing and deep breathing
  3. Turn him from side to side at least every 2 hours
  4. Continue observing for dyspnea and crepitus

32. A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:

  1. Give him explanations of why there is a need to quickly increase his activity
  2. Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle
  3. Appear cheerful and non-critical regardless of his response to attempts at intervention
  4. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving

33. The key factor in accurately assessing how body image changes will be dealt with by the client is the:

  1. Extent of body change present
  2. Suddenness of the change
  3. Obviousness of the change
  4. Client’s perception of the change

34. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as:

  1. Reaction formation
  2. Sublimation
  3. Intellectualization
  4. Projection

35. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to:

  1. Increase his activity level and ambulate frequently
  2. Sleep with the head of his bed slightly elevated
  3. Drink citrus juices frequently for nourishment
  4. Use a soft toothbrush and electric razor

36. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing:

  1. An anaphylactic transfusion reaction
  2. An allergic transfusion reaction
  3. A hemolytic transfusion reaction
  4. A pyrogenic transfusion reaction

37. A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:

  1. “Your laugher is a cover for your fear.”
  2. “He who laughs on the outside, cries on the inside.”
  3.  “Why are you always laughing?”
  4.  “Does it help you to joke about your illness?”

38. In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to:

  1. Agree with and encourage the client’s denial
  2. Reassure the client that everything will be okay
  3. Allow the denial but be available to discuss death
  4. Leave the client alone to discuss the loss

39. During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be:

  1. +55 ml
  2.  +137 ml
  3.  +235 ml
  4.  +485 ml

40. Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find:

  1. Crushing chest pain
  2. Dyspnea on exertion
  3. Extensive peripheral edema
  4. Jugular vein distention

41. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the:

  1. Distal tubule
  2. Collecting duct
  3. Glomerulus of the nephron
  4. Ascending limb of the loop of Henle

42. Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:

  1. 0.5 L
  2. 1.0 L
  3. 2.0 L
  4. 3.5 L

43. Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the:

  1. Diuretic
  2. Vasodilator
  3. Bed-rest regimen
  4. Cardiac glycoside

44. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately:

  1. 2200 calories
  2. 2000 calories
  3. 2800 calories
  4. 1600 calories

45. After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of:

  1. Magnesium
  2. Sodium
  3. Potassium
  4. Calcium

46. Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:

  1.  The medications he has been taking
  2. Any recent foreign travel
  3. His usual dietary pattern
  4.  His working patterns

47. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is:

  1. Three large meals large enough to supply adequate energy.
  2. Regular meals and snacks to limit gastric discomfort
  3. Limited food and fluid intake when he has pain
  4. A flexible plan according to his appetite

48. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:

  1. Increasing HCO3
  2. Decreasing PCO2
  3. Decreasing pH
  4. Decreasing PO2

49. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:

  1. 400 Kilocalories
  2. 600 Kilocalories
  3. 800 Kilocalories
  4. 1000 Kilocalories

50. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:

  1. Encouraging adequate fluids
  2. Applying elastic stockings
  3. Massaging gently the legs with lotion
  4. Performing active-assistive leg exercises

51. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:

  1. Emptying the drainage bag frequently
  2. Collecting a weekly urine specimen
  3. Maintaining the ordered hydration
  4. Assessing urine specific gravity

52. The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:

  1. Flexion, extension and left and right rotation
  2. Abduction, flexion, adduction and extension
  3. Pronation, supination, rotation, and extension
  4. Dorsiflexion, plantar flexion, eversion and inversion

53. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of:

  1. 30 degrees
  2. 45 degrees
  3. 60 degrees
  4. 90 degrees

54. Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery:

  1. Urinary control may be permanently lost to some degree
  2. Urinary drainage will be dependent on a urethral catheter for 24 hours
  3. Frequency and burning on urination will last while the cystotomy tube is in place
  4. His ability to perform sexually will be permanently impaired

55. The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:

  1. Changing the abdominal dressing
  2. Maintaining patency of the cystotomy tube
  3. Maintaining patency of a three-way Foley catheter for cystoclysis
  4. Observing for hemorrhage and wound infection

56. In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is:

  1. Sepsis
  2. Hemorrhage
  3. Leakage around the catheter
  4. Urinary retention with overflow

57. Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:

  1. Limit discomfort
  2. Provide hemostasis
  3. Reduce bladder spasms
  4. Promote urinary drainage

58. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to:

  1. Irrigate the catheter with saline
  2. Milk the catheter tubing
  3. Remove the catheter
  4. Notify the physician

59. The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:”

  1. Get out of bed into a chair for several hours daily
  2. Call the physician if my urinary stream decreases
  3. Attempt to void every 3 hours when I’m awake
  4. Avoid vigorous exercise for 6 months after surgery

60. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find:

  1. Lethargy, weight gain, and forgetfulness
  2. Weight loss, protruding eyeballs, and lethargy
  3. Weight loss, exopthalmos and restlessness
  4. Constipation, dry skin, and weight gain

61. Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy:

  1. The entire thyroid gland is removed
  2. A small part of the gland is left intact
  3. One parathyroid gland is also removed
  4. A portion of the thyroid and four parathyroids are removed

62. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include:

  1. A crash cart with bed board
  2. A tracheostomy set and oxygen
  3. An airway and rebreathing mask
  4. Two ampules of sodium bicarbonate

63. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:

  1. Observing for signs of tetany
  2. Checking her throat for swelling
  3. Asking her to state her name out loud
  4. Palpating the side of her neck for blood seepage

64. On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:

  1. Intolerance to heat
  2. Dry skin and fatigue
  3. Progressive weight loss
  4. Insomnia and excitability

65. A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should:

  1. Elevate the head of my bed at night
  2. Avoid moving my extra-ocular muscles
  3. Avoid using a sleeping mask at night
  4.  Avoid excessive blinking

66. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is:

  1. 4.5%
  2.  9%
  3. 18 %
  4. 22.5%

67. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:

  1.  Inhibit bacterial growth
  2.  Relieve pain from the burn
  3.  Prevent scar tissue formation
  4.  Provide chemical debridement

68. Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

  1. 18 gtt/min
  2. 28 gtt/min
  3. 32 gtt/min
  4. 36 gtt/min

69. Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will:

  1. Debride necrotic epithelium
  2. Be sutured in place for better adherence
  3. Relieve pain and promote rapid epithelialization
  4. Frequently be used concurrently with topical antimicrobials.

70. A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the:

  1. Semi-fowler’s position
  2. Sims’ position
  3. Orthopneic position
  4. Supine position

71. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

  1. Brief exaggeration of symptoms
  2. Prolonged symptomatic improvement
  3. Rapid but brief symptomatic improvement
  4. Symptomatic improvement of just the ptosis

72. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:

  1. Develop a teaching plan
  2. Facilitate psychologic adjustment
  3.  Maintain the present muscle strength
  4. Prepare for the appearance of myasthenic crisis

73. The most significant initial nursing observations that need to be made about a client with myasthenia include:

  1. Ability to chew and speak distinctly
  2. Degree of anxiety about her diagnosis
  3. Ability to smile an to close her eyelids
  4. Respiratory exchange and ability to swallow

74. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:

  1. Administer the medication exactly on time
  2. Administer the medication with food or mild
  3. Evaluate the client’s muscle strength hourly after medication
  4. Evaluate the client’s emotional side effects between doses

75. Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:

  1. Change her diet order from soft foods to clear liquids
  2. Place an emergency tracheostomy set in her room
  3. Assess her respiratory status before and after meals
  4. Coordinate her meal schedule with the peak effect of her medication, Mestinon
Answers and Rationales
  1. Answer: (B) protecting the client from infection. Immunodeficiency is an absent or depressed immune response that increases susceptibility to infection. So it is the nurse’s primary responsibility to protect the patient from infection.
  2. Answer: (A) 25 gtt/min . To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor (10) and divide the result by the amount of time in minutes (20)
  3. Answer: (B) Eating habits are altered . For weight reduction to occur and be maintained, a new dietary program, with a balance of foods from the basic four food groups, must be established and continued
  4. Answer: (A) Increase her lean body mass . Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.
  5. Answer: (A) Exercising the triceps, finger flexors, and elbow extensors . These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.
  6. Answer: (C) The palms of her hands .The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)
  7. Answer: (C) 12 minims . Using ratio and proportion 8 mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims intravenously equivalent to 8mg Morphine Sulfate
  8. Answer: (B) Relieves pain and decreases level of anxiety. Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction. It also decreases anxiety and apprehension and prevents cardiogenic shock by decreasing myocardial oxygen demand.
  9. Answer: (C) Supports combustion. The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.
  10. Answer: (C) CK-MB. The cardiac marker, Creatinine phosphokinase (CPK) isoenzyme levels, especially the MB sub-unit which is cardio-specific, begin to rise in 3-6 hours, peak in 12-18 hours and are elevated 48 hours after the occurrence of the infarct. They are therefore most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial tissue damage.
  11. Answer: (B) Elevated STsegments . This is a typical early finding after a myocardial infarct because of the altered contractility of the heart. The other choices are not typical of MI.
  12. Answer: (B) Refocus the conversation on his fears, frustrations and anger about his condition . This provides the opportunity for the client to verbalize feelings underlying behavior and helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympathoadrenal response causing the release of catecholamines that can increase cardiac contractility and workload that can further increase myocardial oxygen demand.
  13. Answer: (D) Increased pulse rate . Fever causes an increase in the body’s metabolism, which results in an increase in oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.
  14. Answer: (C) Avoid giving him direct information and help him explore his feelings . To help the patient verbalize and explore his feelings, the nurse must reflect and analyze the feelings that are implied in the client’s question. The focus should be on collecting data to minister to the client’s psychosocial needs.
  15. Answer: (C) Absorb vitamin B12 . Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is administered and its absorption and excretion can be ascertained through the urine.
  16. Answer: (D) 2.0 ml . First convert milligrams to micrograms and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml 100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.
  17. Answer: (C) IM injections once a month will maintain control . Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow
  18. Answer: (D) For the rest of her life . Since the intrinsic factor does not return to gastric secretions even with therapy, B12 injections will be required for the remainder of the client’s life.
  19. Answer: (D) Projection. Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.
  20. Answer: (A) When the client would have normally had a bowel movement . Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.
  21. Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion . The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.
  22. Answer: (B) Difficulty in inserting the irrigating tube . Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.
  23. Answer: (B) A difficult time accepting reality and is in a state of denial. As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported
  24. Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas . There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.
  25. Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses . Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished
  26. Answer: (C) Assess his response to the equipment . It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding
  27. Answer: (B) Milk the tube toward the collection container as ordered . This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber
  28. Answer: (A) Increased breath sounds . The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function
  29. Answer: (A) Urinary output is 30 ml in an hour . A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.
  30. Answer: (D) Presence of abdominal drains for several days after surgery . Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.
  31. Answer: (B) Encourage frequent coughing and deep breathing . This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.
  32. Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving . The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.
  33. Answer: (D) Client’s perception of the change . It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.
  34. Answer: (C) Intellectualization . People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.
  35. Answer: (D) Use a soft toothbrush and electric razor . Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.
  36. Answer: (C) A hemolytic transfusion reaction . This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.
  37. Answer: (D) “Does it help you to joke about your illness?” . This non-judgmentally on the part of the nurse points out the client’s behavior.
  38. Answer: (C) Allow the denial but be available to discuss death . This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.
  39. Answer: (C) +235 ml . The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake
  40. Answer: (B) Dyspnea on exertion . Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.
  41. Answer: (D) Ascending limb of the loop of Henle . This is the site of action of Lasix being a potent loop diuretic.
  42. Answer: (C) 2.0 L . One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.
  43. Answer: (D) Cardiac glycoside . A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.
  44. Answer: (B) 2000 calories . There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein
  45. Answer: (B) Sodium . Restriction of sodium reduces the amount of water retention that reduces the cardiac workload
  46. Answer: (A) The medications he has been taking . Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use
  47. Answer: (B) Regular meals and snacks to limit gastric discomfort . Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.
  48. Answer: (B) Decreasing PCO2 . Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.
  49. Answer: (B) 600 Kilocalories . Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.
  50. Answer: (D) Performing active-assistive leg exercises . Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon
  51. Answer: (C) Maintaining the ordered hydration . Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection
  52. Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion . These movements include all possible range of motion for the ankle joint
  53. Answer: (A) 30 degrees . Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.
  54. Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours . An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.
  55. Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis . Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis
  56. Answer: (B) Hemorrhage . After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.
  57. Answer: (B) Provide hemostasis . The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.
  58. Answer: (B) Milk the catheter tubing . Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.
  59. Answer: (B) Call the physician if my urinary stream decreases . Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.
  60. Answer: (C) Weight loss, exopthalmos and restlessness . Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.
  61. Answer: (B) A small part of the gland is left intact . Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.
  62. Answer: (B) A tracheostomy set and oxygen . Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.
  63. Answer: (C) Asking her to state her name out loud . If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.
  64. Answer: (B) Dry skin and fatigue . Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.
  65. Answer: (C) Avoid using a sleeping mask at night . The mask may irritate or scratch the eye if the client turns and lies on it during the night.
  66. Answer: (D) 22.5% . The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%
  67. Answer: (A) Inhibit bacterial growth . Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes
  68. Answer: (B) 28 gtt/min . This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)
  69. Answer: (C) Relieve pain and promote rapid epithelialization . The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.
  70. Answer: (C) Orthopneic position . The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion
  71. Answer: (C) Rapid but brief symptomatic improvement . Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.
  72. Answer: (C) Maintain the present muscle strength . Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy
  73. Answer: (D) Respiratory exchange and ability to swallow . Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration
  74. Answer: (C) Evaluate the client’s muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.
  75. Answer: (D) Coordinate her meal schedule with the peak effect of her medication, Mestinon . Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.

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