NCLEX Practice Test For Medical Surgical Nursing

1. 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?"

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.

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.

2. 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

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.

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.

3. 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.”

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.

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.

4. 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.”

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.

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.

5. 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

Canned foods are generally rich in sodium content as salt is used as the main preservative.

Explanation

Canned foods are generally rich in sodium content as salt is used as the main preservative.

6. 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

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.

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.

7. 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

Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.

Explanation

Atropine sulfate is a vagolytic drug that decreases oropharyngeal secretions and increases the heart rate.

8. 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

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.

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.

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

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

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

10. 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

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.

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.

11. 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

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.

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.

12. 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

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.

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.

13. 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

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.

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.

14. 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.”

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.

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.

15. 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.”

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.

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.

16. 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.

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.

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.

17. 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

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.

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.

18. 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

“ 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

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

19. 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

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.

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.

20. 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.

Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.

Explanation

Heparin is an anticoagulant. It prevents the conversion of prothrombin to thrombin. It does not dissolve a clot.

21. 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

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.

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.

22. 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.

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.

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.

23. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching?

“Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.”

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.

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.

24. 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

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.

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.

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:

“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.”

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.

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.

26. 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

Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.

Explanation

Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure.

27. 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

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.

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.

28. 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

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.

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.

29. 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.”

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

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

30. 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

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.

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.

31. 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.

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.

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.

32. Which of the drug of choice for pain controls the patient with acute pancreatitis?

NSAIDS

Meperidine

Codeine

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.

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.

33. 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

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.

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.

34. 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.

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.

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.

35. 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

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.

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.

36. 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

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.

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.

37. 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

The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.

Explanation

The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.

38. 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

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.

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.

39. 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

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

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

40. 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

Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.

Explanation

Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.

41. 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

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.

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.

42. 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

The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.

Explanation

The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.

43. 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.

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.

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.

44. 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.

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.

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.

45. 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.

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.

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.

46. 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

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.

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.

47. 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

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.

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.

48. 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.

In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.

Explanation

In a client with thrombophlebitis, bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism.

49. 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

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.

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.

50. 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.

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.

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.