PNLE III Nursing Practice

The scope of this Nursing Test III is parallel to the NP3 NLE Coverage:

  • Medical Surgical Nursing

1. The nurse is going to replace the Pleur-O-Vac attached to the client with a small, persistent left upper lobe pneumothorax with a Heimlich Flutter Valve. Which of the following is the best rationale for this?

  1. Promote air and pleural drainage
  2. Prevent kinking of the tube
  3. Eliminate the need for a dressing
  4. Eliminate the need for a water-seal drainage

2. The client with acute pancreatitis and fluid volume deficit is transferred from the ward to the ICU. Which of the following will alert the nurse?

  1. Decreased pain in the fetal position
  2. Urine output of 35mL/hr
  3. CVP of 12 mmHg
  4. Cardiac output of 5L/min

3. The nurse in the morning shift is making rounds in the ward. The nurse enters the client’s room and found the client in discomfort condition. The client complains of stiffness in the joints. To reduce the early morning stiffness of the joints of the client,the nurse can encourage the client to:

  1. Sleep with a hot pad
  2. Take to aspirins before arising, and wait 15 minutes before attempting locomotion
  3. Take a hot tub bath or shower in the morning
  4. Put joints through passive ROM before trying to move them actively

4. The nurse is planning of care to a client with peptic ulcer disease. To avoid the worsening condition of the client, the nurse should carefully plan the diet of the client. Which of the following will be included in the diet regime of the client?

  1. Eating mainly bland food and milk or dairy products
  2. Reducing intake of high-fiber foods
  3. Eating small, frequent meals and a bedtime snack
  4. Eliminating intake of alcohol and coffee

5. The physician has given instruction to the nurse that the client can be ambulated on crutches, with no weight bearing on the affected limb. The nurse is aware that the appropriate crutch gait for the nurse to teach the client would be:

  1. Tripod gait
  2. Two-point gait
  3. Four-point gait
  4. Three-point gait

6. The client is transferred to the nursing care unit from the operating room after a transurethral resection of the prostate. The client is complaining of pain in the abdomen area. The nurse suspects of bladder spasms, which of the following is the best nursing action to minimize the pain felt by the client?

  1. Advising the client not to urinate around catheter
  2. Intermittent catheter irrigation with saline
  3. Giving prescribed narcotics every 4 hour
  4. Repositioning catheter to relieve pressure

7. A client is diagnosed with peptic ulcer. The nurse caring for the client expects the physician to order which diet?

  1. NPO
  2. Small feedings of bland food
  3. A regular diet given frequently in small amounts
  4. Frequent feedings of clear liquids

8. The nurse is going to insert a Miller-Abbott tube to the client. Before insertion of the tube, the balloon is tested for patency and capacity and then deflated. Which of the following nursing measure will ease the insertion to the tube?

  1. Positioning the client in Semi-Fowler’s position
  2. Administering a sedative to reduce anxiety
  3. Chilling the tube before insertion
  4. Warming the tube before insertion

9. The physician ordered a low-sodium diet to the client. Which of the following food will the nurse avoid to give to the client?

  1. Orange juice.
  2. Whole milk.
  3. Ginger ale.
  4. Black coffee.

10. Mr. Bean, a 70-year-old client is admitted in the hospital for almost one month. The nurse understands that prolonged immobilization could lead to decubitus ulcers. Which of the following would be the least appropriate nursing intervention in the prevention of decubitus?

  1. Giving backrubs with alcohol
  2. Use of a bed cradle
  3. Frequent assessment of the skin
  4. Encouraging a high-protein diet

11. The physician prescribed digoxin 0.125 mg PO qd to a client and instructed the nurse that the client is on high-potassium diet. High potassium foods are recommended in the diet of a client taking digitalis preparations because a low serum potassium has which of the following effects?

  1. Potentiates the action of digoxin
  2. Promotes calcium retention
  3. Promotes sodium excretion
  4. Puts the client at risk for digitalis toxicity

12. The nurse is caring for a client who is transferred from the operating room for pneumonectomy. The nurse knows that immediately following pneumonectomy; the client should be in what position?

  1. Supine on the unaffected side
  2. Low-Fowler’s on the back
  3. Semi-Fowler’s on the affected side
  4. Semi-Fowler’s on the unaffected side

13. A client is placed on digoxin, high potassium foods are recommended in the diet of the client. Which of the following foods willthe nurse give to the client?

  1. Whole grain cereal, orange juice, and apricots
  2. Turkey, green bean, and Italian bread
  3. Cottage cheese, cooked broccoli, and roast beef
  4. Fish, green beans and cherry pie

14. The nurse is assigned to care to a client who undergone thyroidectomy. What nursing intervention is important during the immediate postoperative period following a thyroidectomy?

  1. Assess extremities for weakness and flaccidity
  2. Support the head and neck during position changes
  3. Position the client in high Fowler’s
  4. Medicate for restlessness and anxiety

15. What would be the recommended diet the nurse will implement to a client with burns of the head, face, neck and anterior chest?

  1. Serve a high-protein, high-carbohydrate diet
  2. Encourage full liquid diet
  3. Serve a high-fat diet, high-fiber diet
  4. Monitor intake to prevent weight gain

16. A client with multiple fractures of both lower extremities is admitted for 3 days ago and is on skeletal traction. The client is complaining of having difficulty in bowel movement. Which of the following would be the most appropriate nursing intervention?

  1. Administer an enema
  2. Perform range-of-motion exercise to all extremities
  3. Ensure maximum fluid intake (3000ml/day)
  4. Put the client on the bedpan every 2 hours

17. John is diagnosed with Addison’s disease and admitted in the hospital. What would be the appropriate nursing care for John?

  1. Reducing physical and emotional stress
  2. Providing a low-sodium diet
  3. Restricting fluids to 1500ml/day
  4. Administering insulin-replacement therapy

18. Mr. Smith is scheduled for an above-the-knee amputation. After the surgery he was transferred to the nursing care unit. The nurse assigned to him knows that 72 hours after the procedure the client should be positioned properly to prevent contractures. Which of the following is the best position to the client?

  1. Side-lying, alternating left and right sides
  2. Sitting in a reclining chair twice a day
  3. Lying on abdomen several times daily
  4. Supine with stump elevated at least 30 degrees

19. A client is scheduled to have an inguinal herniorraphy in the outpatient surgical department. The nurse is providing health teaching about post surgical care to the client. Which of the following statement if made by the client would reflect the need for more teaching?

  1. “I should call the physician if I have a cough or cold before surgery”
  2. “I will be able to drive soon after surgery”
  3. “I will not be able to do any heavy lifting for 3-6 weeks after surgery”
  4. “I should support my incision if I have to cough or turn”

20. Ms Jones is brought to the emergency room and is complaining of muscle spasms, numbness, tremors and weakness in the arms and legs. The client was diagnosed with multiple sclerosis. The nurse assigned to Ms. Jones is aware that she has to prevent fatigue to the client to alleviate the discomfort. Which of the following teaching is necessary to prevent fatigue?

  1. Avoid extremes in temperature
  2. Install safety devices in the home
  3. Attend support group meetings
  4. Avoid physical exercise

21. Mr. Stewart is in sickle cell crisis and complaining pain in the joints and difficulty of breathing. On the assessment of the nurse, his temperature is 38.1 ºC. The physician ordered Morphine sulfate via patient-controlled analgesia (PCA), and oxygen at 4L/min. A priority nursing diagnosis to Mr. Stewart is risk for infection. A nursing intervention to assist in preventing infection is:

  1. Using standard precautions and medical asepsis
  2. Enforcing a “no visitors” rule
  3. Using moist heat on painful joints
  4. Monitoring a vital signs every 2 hour

22. Mrs. Maupin is a professor in a prestigious university for 30 years. After lecture, she experience blurring of vision and tiredness. Mrs. Maupin is brought to the emergency department. On assessment, the nurse notes that the blood pressure of the client is 139/90. Mrs. Maupin has been diagnosed with essential hypertension and placed on medication to control her BP. Which potential nursing diagnosis will be a priority for discharge teaching?

  1. Sleep Pattern disturbance
  2. Impaired physical mobility
  3. Noncompliance
  4. Fluid volume excess

23. Following a needle biopsy of the kidney, which assessment is an indication that the client is bleeding?

  1. Slow, irregular pulse
  2. Dull, abdominal discomfort
  3. Urinary frequency
  4. Throbbing headache

24. A client with acute bronchitis is admitted in the hospital. The nurse assigned to the client is making a plan of care regarding expectoration of thick sputum. Which nursing action is most effective?

  1. Place the client in a lateral position every 2 hour
  2. Splint the patient’s chest with pillows when coughing
  3. Use humified oxygen
  4. Offer fluids at regular intervals

25. The nurse is going to assess the bowel sound of the client. For accurate assessment of the bowel sound, the nurse should listen for at least:

  1. 5 minutes
  2. 60 seconds
  3. 30 seconds
  4. 2 minutes

26. The nurse encourages the client to wear compression stockings. What is the rationale behind in using compression stockings?

  1. Compression stockings promote venous return
  2. Compression stockings divert blood to major vessels
  3. Compression stockings decreases workload on the heart
  4. Compression stockings improve arterial circulation

27. Mr. Whitman is a stroke client and is having difficulty in swallowing. Which is the best nursing intervention is most likely to assist the client?

  1. Placing food in the unaffected side of the mouth
  2. Increasing fiber in the diet
  3. Asking the patient to speak slowly
  4. Increasing fluid intake

28. Following nephrectomy, the nurse closely monitors the urinary output of the client. Which assessment finding is an early indicator of fluid retention in the postoperative period?

  1. Periorbital edema
  2. Increased specific gravity of urine
  3. A urinary output of 50mL/hr
  4. Daily weight gain of 2 lb or more

29. A nurse is completing an assessment to a client with cirrhosis. Which of the following nursing assessment is important to notify the physician?

  1. Expanding ecchymosis
  2. Ascites and serum albumin of 3.2 g/dl
  3. Slurred speech
  4. Hematocrit of 37% and hemoglobin of 12g/dl

30. Mr. Park is 32-year-old, a badminton player and has a type 1 diabetes mellitus. After the game, the client complains of becoming diaphoretic and light-headedness. The client asks the nurse how to avoid this reaction. The nurse will recommend to:

  1. Allow plenty of time after the insulin injection and before beginning the match
  2. Eat a carbohydrate snack before and during the badminton match
  3. Drink plenty of fluids before, during, and after bed time
  4. Take insulin just before starting the badminton match

31. A client is rushed to the emergency room due to serious vehicle accident. The nurse is suspecting of head injury. Which of the following assessment findings would the nurse report to the physician?

  1. CVP of 5mmHa
  2. Glasgow Coma Scale score of 13
  3. Polyuria and dilute urinary output
  4. Insomnia

32. Mrs. Moore, 62-year-old, with diabetes is in the emergency department. She stepped on a sharp sea shells while walking barefoot along the beach. Mrs. Moore did not notice that the object pierced the skin until later that evening. What problem does the client most probably have?

  1. Nephropathy
  2. Macroangiopathy
  3. Carpal tunnel syndrome
  4. Peripheral neuropathy

33. A client with gangrenous foot has undergone a below-knee amputation. The nurse in the nursing care unit knows that the priority nursing intervention in the immediate post operative care of this client is:

  1. Elevate the stump on a pillow for the first 24 hours
  2. Encourage use of trapeze
  3. Position the client prone periodically
  4. Apply a cone-shaped dressing

34. A client with a diagnosis of gastric ulcer is complaining of syncope and vertigo. What would be the initial nursing intervention by the nurse?

  1. Monitor the client’s vital signs
  2. Keep the client on bed rest
  3. Keep the patient on bed rest
  4. Give a stat dose of Sucralfate (Carafate)

35. After a right lower lobectomy on a 55-year-old client, which action should the nurse initiate when the client is transferred from the post anesthesia care unit?

  1. Notify the family to report the client’s condition
  2. Immediately administer the narcotic as ordered
  3. Keep client on right side supported by pillows
  4. Encourage coughing and deep breathing every 2 hours

36. The nurse is providing a discharge instruction about the prevention of urinary stasis to a client with frequent bladder infection. Which of the following will the nurse include in the instruction?

  1. Drink 3-4 quarts of fluid every day
  2. Empty the bladder every 2-4 hours while awake
  3. Encourage the use of coffee, tea, and colas for their diuretic effect
  4. Teach Kegel exercises to control bladder flow

37. A male client visits the clinic for check-up. The client tells the nurse that there is a yellow discharge from his penis. He also experiences a burning sensation when urinating. The nurse is suspecting of gonorrhea. What teaching is necessary for this client?

  1. Sex partner of 3 months ago must be treated
  2. Women with gonorrhea are symptomatic
  3. Use a condom for sexual activity
  4. Sex partner needs to be evaluated

38. A client with AIDS is admitted in the hospital. He is receiving intravenous therapy. While the nurse is assessing the IV site, the client becomes confused and restless and the intravenous catheter becomes disconnected and minimal amount of the client’s blood spills onto the floor. Which action will the nurse take to remove the blood spill?

  1. Promptly clean with a 1:10 solution of household bleach and water
  2. Promptly clean up the blood spill with full-strength antimicrobial cleaning solution
  3. Immediately mop the floor with boiling water
  4. Allow the blood to dry before cleaning to decrease the possibility of cross-contamination

39. Before surgery, the physician ordered pentobarbital sodium (Nembutal) for the client to sleep. The night before the scheduled surgery, the nurse gave the pre-medication. One hour later the client is still unable to sleep. The nurse review the client’s chart and note the physician’s prescription with an order to repeat. What should the nurse do next?

  1. Rub the client’s back until relaxed
  2. Prepare a glass of warm milk
  3. Give the second dose of pentobarbital sodium
  4. Explore the client’s feelings about surgery

40. The nurse on the night shift is making rounds in the nursing care unit. The nurse is about to enter to the client’s room when a ventilator alarm sounds, what is the first action the nurse should do?

  1. Assess the lung sounds
  2. Suction the client right away
  3. Look at the client
  4. Turn and position the client

41. What effective precautions should the nurse use to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA)?

  1. Use gloves and handwashing before and after client contact
  2. Do nasal cultures on healthcare providers
  3. Place the client on total isolation
  4. Use mask and gown during care of the MRSA client

42. The postoperative gastrectomy client is scheduled for discharge. The client asks the nurse, “When I will be allowed to eat three meals a day like the rest of my family?”. The appropriate nursing response is:

  1. “You will probably have to eat six meals a day for the rest of your life.”
  2. “Eating six meals a day can be a bother, can’t it?”
  3. “Some clients can tolerate three meals a day by the time they leave the hospital. Maybe it will be a little longer for you.”
  4. “ It varies from client to client, but generally in 6-12 months most clients can return to their previous meal patterns”

43. A male client with cirrhosis is complaining of belly pain, itchiness and his breasts are getting larger and also the abdomen. The client is so upset because of the discomfort and asks the nurse why his breast and abdomen are getting larger. Which of the following is the appropriate nursing response?

  1. “How much of a difference have you noticed”
  2. “It’s part of the swelling your body is experiencing”
  3. “It’s probably because you have been less physically active”
  4. “Your liver is not destroying estrogen hormones that all men produce”

44. A client is diagnosed with detached retina and scheduled for surgery. Preoperative teaching of the nurse to the client includes:

  1. No eye pain is expected postoperatively
  2. Semi-fowler’s position will be used to reduce pressure in the eye.
  3. Eye patches may be used postoperatively
  4. Return of normal vision is expected following surgery

45. A 70-year-old client is brought to the emergency department with a caregiver. The client has manifestations of anorexia, wasting of muscles and multiple bruises. What nursing interventions would the nurse implement?

  1. Talk to the client about the caregiver and support system
  2. Complete a gastrointestinal and neurological assessment
  3. Check the lab data for serum albumin, hematocrit and hemoglobin
  4. Complete a police report on elder abuse

46. A nurse is providing a discharge instruction to the client about the self-catheterization at home. Which of the following instructions would the nurse include?

  1. Wash the catheter with soap and water after each use
  2. Lubricate the catheter with Vaseline
  3. Perform the Valsalva maneuver to promote insertion
  4. Replace the catheter with a new one every 24 hour

47. The nurse in the nursing care unit is assigned to care to a client who is Immunocompromised. The client tells the nurse that his chest is painful and the blisters are itchy. What would be the nursing intervention to this client?

  1. Call the physician
  2. Give a prn pain medication
  3. Clarify if the client is on a new medication
  4. Use gown and gloves while assessing the lesions

48. A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered nurse visits the staff nurse caring to the client. What statement made by the nurse reflects an understanding of the management of this client?

  1. speech pattern may be altered
  2. Respiratory isolation is necessary for 24 hours after antibiotics are started
  3. Perform skin culture on the macular popular rash
  4. Expect abnormal general muscle contractions

49. A 18-year-old male client had sustained a head injury from a motorbike accident. It is uncertain whether the client may have minimal but permanent disability. The family is concerned regarding the client’s difficulty accepting the possibility of long term effects. Which nursing diagnosis is best for this situation?

  1. Nutrition, less than body requirements
  2. Injury, potential for sensory-perceptual alterations
  3. Impaired mobility, related to muscle weakness
  4. Anticipatory grieving, due to the loss of independence

50. A client with AIDS is scheduled for discharge. The client tells the nurse that one of his hobbies at home is gardening. What will be the discharge instruction of the nurse to the client knowing that the client is prone to toxoplasmosis?

  1. Wash all vegetables before cooking
  2. Wear gloves when gardening
  3. Wear a mask when travelling to foreign countries
  4. Avoid contact with cats and birds
Answers and Rationales
  1. D. The Heimlich flutter valve has a one-way valve that allows air and fluid to drain. Underwater seal drainage is not necessary. This can be connected to a drainage bag for the patient’s mobility. The absence of a long drainage tubing and the presence of a one-way valve promote effective therapy
  2. C. C = the normal CVP is 0-8 mmHg. This value reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be notified.
  3. C. A hot tub bath or shower in the morning helps many patients limber up and reduces the symptoms of early morning stiffness. Cold and ice packs are used to a lesser degree, though some clients state that cold decreases localized pain, particularly during acute attacks.
  4. D. These substances stimulate the production of hydrochloric acid, which is detrimental in peptic ulcer disease.
  5. D. The three-point gait is appropriate when weight bearing is not allowed on the affected limb. The swing-to and swing-through crutch gaits may also be used when only one leg can be used for weight bearing
  6. A. The client needs to be told before surgery that the catheter causes the urge to void. Attempts to void around the catheter cause the bladder muscles to contract and result in painful spasms.
  7. B. Bland feedings should be given in small amounts on a frequent basis to neutralize the hydrochloric acid and to prevent overload
  8. C. Chilling the tube before insertion assists in relieving some of the nasal discomfort. Water-soluble lubricants along with viscous lidocaine (Xylocaine) may also be used. It is usually only lightly lubricated before insertion
  9. B. Whole milk should be avoided to include in the client’s diet because it has 120 mg of sodium in 8 0z of milk.
  10. A. Alcohol is extremely drying and contributes to skin break down. An emollient lotion should be used.
  11. D.  Potassium influences the excitability of nerves and muscles. When potassium is low and the client is on digoxin, the risk of digoxin toxicity is increased.
  12. C. This position allows maximum expansion, ventilation, and perfusion of the remaining lung.
  13. A. These foods are high in potassium
  14. B. Stress on the suture line should be avoided. Prevent flexion or hyperextension of the neck, and provide a small pillow under thehead and neck. Neck muscles have been affected during a thyroidectomy, support essential for comfort and incisional support.
  15. A. A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.
  16. C. The best early intervention would be to increase fluid intake, because constipation is common when activity is decreased or usual routines have been interrupted.
  17. A. Because the client’s ability is to react to stress is decreased, maintaining a quiet environment becomes A nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial. To promote optimal hydration and sodium intake, fluid intake is increased, particularly fluid containing electrolytes, such as broths, carbonated beverages, and juices.
  18. C. At about 48-72 hours, the client must be turned onto the abdomen to prevent flexion contractures.
  19. B. The client should not drive for 2 weeks after surgery to avoid stress on the incision. This reflects a need for additional teaching.
  20. A. Extremes in heat and cold will exacerbate symptoms. Heat delays transmission of impulses and increases fatigue.
  21. A. Vigilant implementation of standard precautions and medical asepsis is an effective means of preventing infection
  22. C. Noncompliance is a major problem in the management of chronic disease. In hypertension, the client often does not feel ill and thus does not see a need to follow a treatment regimen.
  23. B. An accumulation of blood from the kidney into the abdomen would manifest itself with these symptoms
  24. D. Fluids liquefy secretions and therefore make it easier to expectorate
  25. D. Physical assessment guidelines recommend listening for atleast 2 minutes in each quadrant (and up to 5 minutes, not at least 5 minutes).
  26. A. Compression stockings promote venous return and prevent peripheral pooling.
  27. A. Placing food in the unaffected side of the mouth assists in the swallowing process because the client has sensation on that side and will have more control over the swallowing process.
  28. D. Daily weights are taken following nephrectomy. Daily increases of 2 lb or more are indicative of fluid retention and should be reported to the physician. Intake and output records may also reflect this imbalance.
  29. A. Clients with cirrhosis have already coagulation due to thrombocytopenia and vitamin K deficiency. This could be a sign of bleeding
  30. B. Exercise enhances glucose uptake, and the client is at risk for an insulin reaction. Snacks with carbohydrates will help.
  31. C. These are symptoms of diabetes insipidus. The patient can become hypovolemic and vasopressin may reverse the Polyuria.
  32. D. Peripheral neuropathy refers to nerve damage of the hands and feet. The client did not notice that the object pierced the skin.
  33. A. The elevation of the stump on a pillow for the first 24 hours decreases edema and increases venous return.
  34. B. The priority is to maintain client’s safety. With syncope and vertigo, the client is at high risk for falling.
  35. D. Coughing and deep breathing are essential for re-expansion of the lung
  36. B. Avoiding stasis of urine by emptying the bladder every 2-4 hours will prevent overdistention of the bladder and future urinary tract infections.
  37. D. If infected, the sex partner must be evaluated and treated
  38. A. A 1:10 solution of household bleach and water is recommended by the Centers for Disease Control and Prevention to kill the human immunodeficiency virus (HIV).
  39. D. Given the data, presurgical anxiety is suspected. The client needs an opportunity to talk about concerns related to surgery before further actions (which may mask the anxiety).
  40. C. A quick look at the client can help identify the type and cause of the ventilator alarm. Disconnection of the tube from the ventilator, bronchospasm, and anxiety are some of the obvious reasons that could trigger an alarm.
  41. A. Contact isolation has been advised by the Centers for Disease Control and Prevention (CDC) to control transmission of MRSA, which includes gloves and handwashing.
  42. D. In response to the question of the client, the nurse needs to provide brief, accurate information. Some clients who have had gastrectomies are able to tolerate three meals a day before discharge from the hospital. However, for the majority of clients, it takes 6-12 months before their surgically reduced stomach has stretched enough to accommodate a larger meal.
  43. A. This allows the client to elaborate his concern and provides the nurse a baseline of assessment
  44. C. Use of eye patches may be continued postoperatively, depending on surgeon preference. This is done to achieve >90% success rate of the surgery.
  45. B. Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, the bruises may be attributed to ataxia, frequent falls, vertigo, or medication.
  46. A. The catheter should be washed with soap and water after withdrawal and placed in a clean container. It can be reused until it is too hard or too soft for insertion. Self-care, prevention of complications, and cost-effectiveness are important in home management.
  47. D. The client may have herpes zoster (shingles), a viral infection. The nurse should use standard precautions in assessing the lesions. Immunocompromised clients are at risk for infection.
  48. B. After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care.
  49. D. Stem of the question supports this choice by stating that the client has difficulty accepting the potential disability.
  50. B. Toxoplasmosis is an opportunistic infection and a parasite of birds and mammals. The oocysts remain infectious in moist soil for about 1 year.