PNLE : Medical Surgical Nursing Exam 4

1. A patient is admitted to the medical surgical unit following surgery. Four days after surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet, productive cough. The nurse assesses the patient with understanding that an infection that is acquired during hospitalization is known as:

  1. a community acquired infection
  2. an iatrogenic infection
  3. a nosocomial infection
  4. an opportunistic infection

2. A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing symptoms of cerebral tissue hypoxia. Which of the following nursing interventions would be most important in providing care?

  1. Providing rest periods throughout the day
  2. Instituting energy conservation techniques
  3. Assisting in ambulation to the bathroom
  4. Checking temperature of water prior to bathing

3. A client was involved in a motor vehicular accident in which the seat belt was not worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of the following assessment findings would concern the nurse most?

  1. Temperature of 102 degrees F and productive cough
  2. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
  3. Trachea deviating to the right
  4. Barrel-chested appearance

4. The proper way to open an envelop-wrapped sterile package after removing the outer package or tape is to open the first position of the wrapper:

  1. away from the body
  2. to the left of the body
  3. to the right of the body
  4. toward the body

5. Assessment of a client with possible thrombophlebitis to the left leg and a deep vein thrombosis is done by pulling up on the toes while gently holding down on the knee. The client complains of extreme pain in the calf. This should be documented as:

  1. positive tourniquet test
  2. positive homan’s sign
  3. negative homan’s sign
  4. negative tourniquet test

6. Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia. The doctor orders a series of laboratory tests to determine whether Mr. Elison’s dementia is treatable. The nurse understands that the most common cause of dementia in this population is:

  1. AIDS
  2. Alzheimer’s disease
  3. Brain tumors
  4. Vascular disease

7. Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis?

  1. Apply heat compress to the affected area
  2. Immobilize the affected area
  3. Administer narcotic analgesics for pain
  4. Administer OTC analgesics for pain

8. A client with congestive heart failure has digoxin (Lanoxin) ordered everyday. Prior to giving the medication, the nurse checks the digoxin level which is therapeutic and ausculates an apical pulse. The apical pulse is 63 bpm for 1 full minute. The nurse should:

  1. Hold the Lanoxin
  2. Give the half dose now, wait an hour and give the other half
  3. Call the physician
  4. Give the Lanoxin as ordered

9. Nurse Marian is caring for a client with haital hernia, which of the following should be included in her teaching plan regarding causes:

  1. To avoid heavy lifting
  2. A dietary plan based on soft foods
  3. Its prevalence in young adults
  4. Its prevalence in fair-skinned individuals

10. Joseph has been diagnosed with hepatic encephalopathy. The nurse observes flapping tremors. The nurse understands that flapping tremors associated with hepatic encephalopathy are also known as:

  1. aphasia
  2. ascites
  3. astacia
  4. asterixis

11. Hyperkalemia can be treated with administration of 50% dextrose and insulin. The 50% dextrose:

  1. causes potassium to be excreted
  2. causes potassium to move into the cell
  3. causes potassium to move into the serum
  4. counteracts the effects of insulin

12. Which of the following findings would strongly indicate the possibility of cirrhosis?

  1. dry skin
  2. hepatomegaly
  3. peripheral edema
  4. pruritus

13. Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma. The nurse assesses the client for which of the following common presenting symptoms of the disorder?

  1. halo vision
  2. dull eye pain
  3. severe eye and face pain
  4. impaired night vision

14. Chvostek’s sign is associated with which electrolyte impabalnce?

  1. hypoclacemia
  2. hypokalemia
  3. hyponatremia
  4. hypophosphatenia

15. What laboratory test is a common measure of the renal function?

  1. CBC
  2. BUN/Crea
  3. Glucose
  4. Alanine amino transferase (ALT)

16. Nurse Edward is performing discharge teaching for a newly diagnosed diabetic patient scheduled for a fasting blood glucose test. The nurse explains to the patient that hyperglycemia is defined as a blood glucose level above:

  1. 100 mg/dl
  2. 120 mg/dl
  3. 130 mg/dl
  4. 150 mg/dl

17. Mang Edison is on bed rest has developed an ulcer that is full thickness and is penetrating the subcutaneous tissue. The nurse documents that this ulcer is in which of the following stages?

  1. Stage 1
  2. Stage 2
  3. Stage 3
  4. Stage 4

18. A 24 year old male patient comes to the clinic after contracting genital herpes. Which of the following intervention would be most appropriate?

  1. Encourage him to maintain bed rest for several days
  2. Monitor temperature every 4 hours
  3. Instruct him to avoid sexual contact during acute phases of illness
  4. Encourage him to use antifungal agents regularly

19. An 8 year old boy is brought to the trauma unit with a chemical burn to the face. Priority assessment would include which of the following?

  1. Skin integrity
  2. BP and pulse
  3. Patency of airway
  4. Amount of pain

20. A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL. Which of the following complaints would be indicative of tissue hypoxia related to anemia?

  1. dizziness
  2. fatigue relieved by rest
  3. skin that is warm and dry to the touch
  4. apathy

21. Hazel Murray, 32 years old complains of abrupt onset of chest and back pain and loss of radial pulses. The nurse suspects that Mrs. Murray may have:

  1. Acute MI
  2. CVA
  3. Dissecting abdominal aorta
  4. Dissecting thoracic aneurysm

22. Nurse Alexandra is establishing a plan of care for a client newly admitted with SIADH. The priority diagnosis for this client would be which of the following?

  1. Fluid volume deficit
  2. Anxiety related to disease process
  3. Fluid volume excess
  4. Risk for injury

23. Nursing management of the client with a UTI should include:

  1. Taking medication until feeling better
  2. Restricting fluids
  3. Decreasing caffeine drinks and alcohol
  4. Douching daily

24. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The nurse understands that a postoperative patient who’s maintained on bed rest is at high risk for developing:

  1. angina
  2. arterial bleeding
  3. deep vein thrombosis (DVT)
  4. dehiscence of the wound

25. Which of the following statement is true regarding the visual changes associated with cataracts?

  1. Both eyes typically cataracts at the same time
  2. The loss of vision is experienced as a painless, gradual blurring
  3. The patient is suddenly blind
  4. The patient is typically experiences a painful, sudden blurring of vision.
Answers and Rationales
  1. C. a nosocomial infection. Nosocomial, or hospital-acquired are infections acquired during hospitalization for which the patient isn’t being primarily treated. Community acquired or opportunistic infections may not be acquired during hospitalization. An iatrogenic infection is caused by the doctor or by medical therapy. And an opportunistic infection affects a compromised host.
  2. C. Assisting in ambulation to the bathroom. Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential risk to the client with dizziness is injury, especially with changes in position. Planning for periods of rest and conserving energy are important with someone with anemia because of his or her fatigue level but most important is safety.
  3. C. Trachea deviating to the right. A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Since the individual was involved in a MVA, assessment would be targeted at acute traumatic injuries to the lungs, heart or chest wall rather than other conditions indicated in the other answers. Option A is common with pneumonia; values in option B are not alarming; and option D is typical of someone with COPD.
  4. A. away from the body. When opening an envelop-wrapped sterile package, reaching across the package and using the first motion to open the top cover away from the body eliminates the need to later reach across the steri9le field while opening the package. To remove equipment from the package, opening the first portion of the package toward, to the left, or to the right of the body would require reaching across a sterile field.
  5. B. positive homan’s sign. Pain in the calf while pulling up on the toes is abnormal and indicates a positive test. If the client feels nothing or just feels like the calf muscle is stretching, it is considered negative. A tourniquet test is used to measure for varicose veins.
  6. B. Alzheimer’s disease. Alzheimer’s disease is the most common cause of dementia in the elderly population. AIDS, brain tumors and vascular disease are all less common causes of progressive loss of mental function in elderly patients.
  7. A. Apply heat compress to the affected area. Options B, C and D are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilation.
  8. D. Give the Lanoxin as ordered. The Lanoxin should be held for a pulse of 60 bpm. Nurses cannot arbitrarily give half of a dose without a physician’s order. Unless specific parameters are given concerning pulse rate, most resources identify 60 as the reference pulse.
  9. A. To avoid heavy lifting. Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors involve limiting fat intake, not restricting client to soft foods. It is more prevalent in individuals who are middle-aged or older. Fair-skinned individuals are not prone to this condition.
  10. D. asterixis. Flapping tremors associated with hepatic encephalophaty are asterixis. Aphasia is the inability to speak. Ascites is an accumulation of fluid in the peritoneal cavity. Astacia is the inability to stand or sit still.
  11. D. counteracts the effects of insulin. The 50% dextrose is given to counteract the effects of insulin. Insulin drives the potassium into the cell, thereby lowering the serum potassium levels. The dextrose doesn’t directly cause potassium excretion or any movement of potassium.
  12. B. hepatomegaly. Although option D is correct, it is not a strong indicator of cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect, fluid accumulations is usually in the form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The spleen may also be enlarged.
  13. C. severe eye and face pain. Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medial emergency. Halo vision, dull eye pain and impaired night vision are symptoms associated with open-angle glaucoma.
  14. A. hypoclacemia. Chvostek’s sign is a spasm of the facial muscles elicited by tapping the facial nerve and is associated with hypocalcemia. Clinical signs of hypokalemia are muscle weakness, leg cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia, nausea and vomiting are clinical signs of hyponatremia. Clinical manifestations associated with hypophosphatemia include muscle pain, confusion, seizures and coma.
  15. B. BUN/Crea. The BUN is primarily used as indicator of kidney function because most renal diseases interfere with its excretion and cause blood vessels to rise. Creatinine is produced in relatively constant amounts, according to the amount of muscle mass and is excreted entirely by the kidneys making it a good indicator of renal function.
  16. B. 120 mg/dl. Hyperglycemia is defined as a blood glucose level greater than 120 mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are considered hyperglycemic. A blood glucose of 100 mg/dl is normal.
  17. C. Stage 3. A stage 3 ulcer is full thickness involving the subcutaneous tissue. A stage 1 ulcer has a defined area of persistent redness in lightly pigmented skin. A stage 2 ulcer involves partial thickness skin loss. Stage 4 ulcers extend through the skin and exhibit tissue necrosis and muscle or bone involvement.
  18. C. Instruct him to avoid sexual contact during acute phases of illness. Herpes is a virus and is spread through direct contact. An antifungal would not be useful; bed rest and temperature measurement are usually not necessary.
  19. C. Patency of airway. A burn face, neck or chest may cause airway closure because of the edema that occurs within hours. Remember the ABC’s: airway, breathing and circulation. Airway always comes first, even before pain. The nurse will also assess options B and D, but these are not the highest priority assessments.
  20. A. dizziness. Central tissue hypoxia is commonly associated with dizziness. Recognition of cerebral hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs.
  21. D. Dissecting thoracic aneurysm. A dissecting thoracic aneurysm may cause loss of radical pulses and severe chest and back pain. An MI typically doesn’t cause loss of radial pulses or severe back pain. CVA and dissecting abdominal aneurysm are incorrect responses.
  22. C. Fluid volume excess. SIADH results in fluid retention and hyponatremia. Correction is aimed at restoring fluid and electrolyte balance. Anxiety and risk for injury should be addressed following fluid volume excess.
  23. C. Decreasing caffeine drinks and alcohol. Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increase the signs and symptoms of UTI. All antibiotics should be taken completely to prevent resistant strains of organisms.
  24. C. deep vein thrombosis (DVT). DVT, is the most probable complication for postoperative patients on bed rest. Options A, B and D aren’t likely complications of the post operative period.
  25. B. The loss of vision is experienced as a painless, gradual blurring. Typically, a patient with cataracts experiences painless, gradual loss of vision. Although both eyes may develop at different rates.