NCLEX Practice Test For Medical Surgical Nursing 3 (Exam Mode) By Rnpedia.Com

1. 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:

Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle

Appear cheerful and non-critical regardless of his response to attempts at intervention

Give him explanations of why there is a need to quickly increase his activity

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.

Explanation

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.

2. 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:

Will help prevent erratic heart beats

Relieves pain and decreases level of anxiety

Decreases anxiety

Dilates coronary blood vessels

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.

Explanation

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.

3. 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:

SGPT

LDH

CK-MB

AST

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.

Explanation

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.

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

Increase his activity level and ambulate frequently

Sleep with the head of his bed slightly elevated

Drink citrus juices frequently for nourishment

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.

Explanation

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.

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

Agree with and encourage the client’s denial

Reassure the client that everything will be okay

Allow the denial but be available to discuss death

Leave the client alone to discuss the loss

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.

Explanation

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.

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

A crash cart with bed board

A tracheostomy set and oxygen

An airway and rebreathing mask

Two ampules of sodium bicarbonate

Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.

Explanation

Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.

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

Magnesium

Sodium

Potassium

Calcium

Restriction of sodium reduces the amount of water retention that reduces the cardiac workload

Explanation

Restriction of sodium reduces the amount of water retention that reduces the cardiac workload

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

Ability to chew and speak distinctly

Degree of anxiety about her diagnosis

Ability to smile an to close her eyelids

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

Explanation

Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

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

Urinary output is 30 ml in an hour

Central venous pressure reading of 2 cm H2O

Pulse rates of 120 and 110 in a 15 minute period

Blood pressure readings of 50/30 and 70/40 within 30 minutes

A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.

Explanation

A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.

10. 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:

When she feels fatigued

During exacerbations of anemia

Until her symptoms subside

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.

Explanation

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.

11. 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:

Encourage bed rest with active and passive range of motion exercises

Encourage frequent coughing and deep breathing

Turn him from side to side at least every 2 hours

Continue observing for dyspnea and crepitus

This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

Explanation

This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

12. 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:

Reaction formation

Sublimation

Intellectualization

Projection

People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.

Explanation

People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.

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

Extent of body change present

Suddenness of the change

Obviousness of the change

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.

Explanation

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.

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

Sepsis

Hemorrhage

Leakage around the catheter

Urinary retention with overflow

After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.

Explanation

After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.

15. 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:

Urinary control may be permanently lost to some degree

Urinary drainage will be dependent on a urethral catheter for 24 hours

Frequency and burning on urination will last while the cystotomy tube is in place

His ability to perform sexually will be permanently impaired

An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.

Explanation

An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.

16. 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:

The medications he has been taking

Any recent foreign travel

His usual dietary pattern

His working patterns

Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use

Explanation

Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use

17. 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:

Store vitamin B12

Digest vitamin B12

Absorb vitamin B12

Produce 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.

Explanation

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.

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

Develop a teaching plan

Facilitate psychologic adjustment

Maintain the present muscle strength

Prepare for the appearance of myasthenic crisis

Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

Explanation

Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

19. 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:

18 gtt/min

28 gtt/min

32 gtt/min

36 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)

Explanation

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)

20. 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:

25 gtt/min

30 gtt/min

35 gtt/min

45 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)

Explanation

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)

21. 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:

Facilitate his verbal communication

Maintain sterility of the ventilation system

Assess his response to the equipment

Prepare him for emergency surgery

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

Explanation

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

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

“Your laugher is a cover for your fear.”

“He who laughs on the outside, cries on the inside.”

“Why are you always laughing?”

“Does it help you to joke about your illness?”

This non-judgmentally on the part of the nurse points out the client’s behavior.

Explanation

This non-judgmentally on the part of the nurse points out the client’s behavior.

23. 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:

Administer the medication exactly on time

Administer the medication with food or mild

Evaluate the client’s muscle strength hourly after medication

Evaluate the client’s emotional side effects between doses

Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

Explanation

Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

24. 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:

Increasing HCO3

Decreasing PCO2

Decreasing pH

Decreasing PO2

Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

Explanation

Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

25. 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:

Complete safety of the procedure

Expectation of postoperative bleeding

Risk of the procedure with his other injuries

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.

Explanation

Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.

26. 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:

Lethargy, weight gain, and forgetfulness

Weight loss, protruding eyeballs, and lethargy

Weight loss, exopthalmos and restlessness

Constipation, dry skin, and weight gain

Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.

Explanation

Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.

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

An anaphylactic transfusion reaction

An allergic transfusion reaction

A hemolytic transfusion reaction

A pyrogenic transfusion reaction

This non-judgmentally on the part of the nurse points out the client’s behavior.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.

Explanation

This non-judgmentally on the part of the nurse points out the client’s behavior.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.

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

Abdominal cramps during fluid inflow

Difficulty in inserting the irrigating tube

Passage of flatus during expulsion of feces

Inability to complete the procedure in half an hour

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.

Explanation

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.

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

Crushing chest pain

Dyspnea on exertion

Extensive peripheral edema

Jugular vein distention

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.

Explanation

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.

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

Three large meals large enough to supply adequate energy.

Regular meals and snacks to limit gastric discomfort

Limited food and fluid intake when he has pain

A flexible plan according to his appetite

Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.

Explanation

Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.

31. 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:

Shortness of breath

Chest pain

Elevated blood pressure

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.

Explanation

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.

32. 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:

Inhibit bacterial growth

Relieve pain from the burn

Prevent scar tissue formation

Provide chemical debridement

Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes

Explanation

Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes

33. 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?

Providing emotional support to decrease fear

Protecting the client from infection

Encouraging discussion about lifestyle changes

Identifying factors that decreased the immune function

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.

Explanation

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.

34. 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:

Allow him to release his feelings and then leave him alone to allow him to regain his composure

Refocus the conversation on his fears, frustrations and anger about his condition

Explain how his being upset dangerously disturbs his need for rest

Attempt to explain the purpose of different hospital routines

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.

Explanation

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.

35. 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:

400 Kilocalories

600 Kilocalories

800 Kilocalories

1000 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.

Explanation

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.

36. 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:

0.5 ml

1.0 ml

1.5 ml

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.

Explanation

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.

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

Disappearance of Q waves

Elevated ST segments

Absence of P wave

Flattened T waves

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.

Explanation

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.

38. 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:

The entire thyroid gland is removed

A small part of the gland is left intact

One parathyroid gland is also removed

A portion of the thyroid and four parathyroids are removed

Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.

Explanation

Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.

39. 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:

4.5%

9%

18 %

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%

Explanation

The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%

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

Stops the flow of fluid when he feels uncomfortable

Lubricates the tip of the catheter before inserting it into the stoma

Hangs the bag on a clothes hook on the bathroom door during fluid insertion

Discontinues the insertion of fluid after only 500 ml of fluid has been instilled

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.

Explanation

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.

41. 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:

0.5 L

1.0 L

2.0 L

3.5 L

One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

Explanation

One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

42. 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:

Increase her lean body mass

Lower her metabolic rate

Decrease her appetite

Raise her heart rate

Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.

Explanation

Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.

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

Food low in fiber so that there is less stool

Everything he ate before the operation but will avoid those foods that cause gas

Bland foods so that his intestines do not become irritated

Soft foods that are more easily digested and absorbed by the large intestines

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.

Explanation

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.

44. 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:

Brief exaggeration of symptoms

Prolonged symptomatic improvement

Rapid but brief symptomatic improvement

Symptomatic improvement of just the ptosis

Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.

Explanation

Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.

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

Debride necrotic epithelium

Be sutured in place for better adherence

Relieve pain and promote rapid epithelialization

Frequently be used concurrently with topical antimicrobials.

The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.

Explanation

The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.

46. 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:

Flexion, extension and left and right rotation

Abduction, flexion, adduction and extension

Pronation, supination, rotation, and extension

Dorsiflexion, plantar flexion, eversion and inversion

These movements include all possible range of motion for the ankle joint

Explanation

These movements include all possible range of motion for the ankle joint

47. 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:

Observing for signs of tetany

Hecking her throat for swelling

Asking her to state her name out loud

Palpating the side of her neck for blood seepage

If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.

Explanation

If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.

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

Changing the abdominal dressing

Maintaining patency of the cystotomy tube

Maintaining patency of a three-way Foley catheter for cystoclysis

Observing for hemorrhage and wound infection

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

Explanation

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

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

When the client would have normally had a bowel movement

After the client accepts he had a bowel movement

Before breakfast and morning care

At least 2 hours before visitors arrive

Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.

Explanation

Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.

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

The palms and axillary regions

Both feet placed wide apart

The palms of her hands

Her axillary regions

The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)

Explanation

The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)

51. 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:

30 degrees

45 degrees

60 degrees

90 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.

Explanation

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.

52. 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:

Intolerance to heat

Dry skin and fatigue

Progressive weight loss

Insomnia and excitability

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.

Explanation

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.

53. 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:

A reaction formation to his recent altered body image.

A difficult time accepting reality and is in a state of denial.

Impotency due to the surgery and needs sexual counseling

Suicide thoughts and should be seen by psychiatrist

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

Explanation

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

54. 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

Prepare for chest tube removal

Milk the tube toward the collection container as ordered

Arrange for a stat Chest x-ray film.

Clam the tube immediately

This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber

Explanation

This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber

55. 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:

Diuretic

Vasodilator

Bed-rest regimen

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.

Explanation

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.

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

Get out of bed into a chair for several hours daily

Call the physician if my urinary stream decreases

Attempt to void every 3 hours when I’m awake

Avoid vigorous exercise for 6 months after surgery

Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.

Explanation

Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.

57. 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:

Emptying the drainage bag frequently

Collecting a weekly urine specimen

Maintaining the ordered hydration

Assessing urine specific gravity

Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection

Explanation

Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection

58. 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:

Change her diet order from soft foods to clear liquids

Place an emergency tracheostomy set in her room

Assess her respiratory status before and after meals

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.

Explanation

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.

59. 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:

+55 ml

+137 ml

+235 ml

+485 ml

The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake

Explanation

The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake

60. 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:

Level of consciousness and pupil size

Abdominal contusions and other wounds

Pain, Respiratory rate and blood pressure

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

Explanation

Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished

61. 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:

Converts to an alternate form of matter

Has unstable properties

Supports combustion

Is flammable

The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.

Explanation

The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.

62. 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:

Distal tubule

Collecting duct

Glomerulus of the nephron

Ascending limb of the loop of Henle

This is the site of action of Lasix being a potent loop diuretic.

Explanation

This is the site of action of Lasix being a potent loop diuretic.

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

Encouraging adequate fluids

Applying elastic stockings

Massaging gently the legs with lotion

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

Explanation

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

64. 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:

Reaction Formation

Sublimation

Intellectualization

Projection

Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.

Explanation

Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.

65. 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:

Semi-fowler’s position

Sims’ position

Orthopneic position

Supine position

The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion

Explanation

The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion

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

Increased breath sounds

Constant bubbling in the drainage chamber

Crepitus detected on palpation of chest

Increased respiratory rate

The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function

Explanation

The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function

67. 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:

Irrigate the catheter with saline

Milk the catheter tubing

Remove the catheter

Notify the physician

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.

Explanation

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.

68. 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:

2200 calories

2000 calories

2800 calories

1600 calories

There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein

Explanation

There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein

69. 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:

Exercising the triceps, finger flexors, and elbow extensors

Sitting up at the edge of the bed to help strengthen back muscles

Doing isometric exercises on the unaffected leg

Using the trapeze frequently for pull-ups to strengthen the biceps muscles

These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.

Explanation

These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.

70. 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:

Fats are controlled in the diet

Eating habits are altered

Carbohydrates are regulated

Exercise is part of the program

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

Explanation

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

71. 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:

Suggest he discuss his feelings of vulnerability with his physician.

Tell him that he certainly needs to be especially careful about his diet and lifestyle.

Avoid giving him direct information and help him explore his feelings

Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.

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.

Explanation

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.

72. 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:

Limit discomfort

Provide hemostasis

Reduce bladder spasms

Promote urinary drainage

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.

Explanation

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.

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

Oral tablets of Vitamin B12 will control her symptoms

IM injections are required for daily control

IM injections once a month will maintain control

Weekly Z-track injections provide needed 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

Explanation

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

74. 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:

Elevate the head of my bed at night

Avoid moving my extra-ocular muscles

Avoid using a sleeping mask at night

Avoid excessive blinking

The mask may irritate or scratch the eye if the client turns and lies on it during the night.

Explanation

The mask may irritate or scratch the eye if the client turns and lies on it during the night.

75. 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:

8 minims

10 minims

12 minims

15 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

Explanation

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

NCLEX Practice Test For Medical Surgical Nursing 3 (Exam Mode) By Rnpedia.Com

1. 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:

2.

What first name or nickname would you like us to use?

2. 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:

3. 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:

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

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

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

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

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

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

10. 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:

11. 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:

12. 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:

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

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

15. 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:

16. 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:

17. 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:

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

19. 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:

21. 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:

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

23. 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:

24. 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:

26. 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:

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

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

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

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

31. 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:

32. 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:

33. 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?

34. 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:

35. 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:

36. 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:

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

38. 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:

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

41. 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:

42. 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:

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

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

46. 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:

47. 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:

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

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

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

51. 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:

52. 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:

53. 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:

54. 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

55. 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:

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

57. 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:

58. 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:

59. 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:

61. 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:

62. 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:

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

64. 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:

65. 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:

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

67. 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:

68. 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:

69. 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:

70. 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:

71. 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:

72. 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:

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

74. 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: