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

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

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Questions and Answers
  • 1. 

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

    • A.

      Providing emotional support to decrease fear

    • B.

      Protecting the client from infection

    • C.

      Encouraging discussion about lifestyle changes

    • D.

      Identifying factors that decreased the immune function

    Correct Answer
    B. Protecting the client 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.

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  • 2. 

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

    • A.

      25 gtt/min

    • B.

      30 gtt/min

    • C.

      35 gtt/min

    • D.

      45 gtt/min

    Correct Answer
    A. 25 gtt/min
    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)

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  • 3. 

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

    • A.

      Fats are controlled in the diet

    • B.

      Eating habits are altered

    • C.

      Carbohydrates are regulated

    • D.

      Exercise is part of the program

    Correct Answer
    B. Eating habits are altered
    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

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  • 4. 

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

    • A.

      Increase her lean body mass

    • B.

      Lower her metabolic rate

    • C.

      Decrease her appetite

    • D.

      Raise her heart rate

    Correct Answer
    A. Increase her lean body mass
    Explanation
    Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.

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  • 5. 

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

    • A.

      Exercising the triceps, finger flexors, and elbow extensors

    • B.

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

    • C.

      Doing isometric exercises on the unaffected leg

    • D.

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

    Correct Answer
    A. Exercising the triceps, finger flexors, and elbow extensors
    Explanation
    These sets of muscles are used when walking with crutches and therefore need strengthening prior to ambulation.

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  • 6. 

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

    • A.

      The palms and axillary regions

    • B.

      Both feet placed wide apart

    • C.

      The palms of her hands

    • D.

      Her axillary regions

    Correct Answer
    C. The palms of her hands
    Explanation
    The palms should bear the client’s weight to avoid damage to the nerves in the axilla (brachial plexus)

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  • 7. 

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

    • A.

      8 minims

    • B.

      10 minims

    • C.

      12 minims

    • D.

      15 minims

    Correct Answer
    C. 12 minims
    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

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  • 8. 

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

    • A.

      Will help prevent erratic heart beats

    • B.

      Relieves pain and decreases level of anxiety

    • C.

      Decreases anxiety

    • D.

      Dilates coronary blood vessels

    Correct Answer
    B. Relieves pain and decreases level of anxiety
    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.

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  • 9. 

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

    • A.

      Converts to an alternate form of matter

    • B.

      Has unstable properties

    • C.

      Supports combustion

    • D.

      Is flammable

    Correct Answer
    C. Supports combustion
    Explanation
    The nurse should know that Oxygen is necessary to produce fire, thus precautionary measures are important regarding its use.

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  • 10. 

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

    • A.

      SGPT

    • B.

      LDH

    • C.

      CK-MB

    • D.

      AST

    Correct Answer
    C. CK-MB
    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.

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  • 11. 

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

    • A.

      Disappearance of Q waves

    • B.

      Elevated ST segments

    • C.

      Absence of P wave

    • D.

      Flattened T waves

    Correct Answer
    B. Elevated ST segments
    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.

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  • 12. 

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

    • A.

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

    • B.

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

    • C.

      Explain how his being upset dangerously disturbs his need for rest

    • D.

      Attempt to explain the purpose of different hospital routines

    Correct Answer
    B. Refocus the conversation on his fears, frustrations and anger about his condition
    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.

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  • 13. 

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

    • A.

      Shortness of breath

    • B.

      Chest pain

    • C.

      Elevated blood pressure

    • D.

      Increased pulse rate

    Correct Answer
    D. Increased pulse rate
    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.

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  • 14. 

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

    • A.

      Suggest he discuss his feelings of vulnerability with his physician.

    • B.

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

    • C.

      Avoid giving him direct information and help him explore his feelings

    • D.

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

    Correct Answer
    C. Avoid giving him direct information and help him explore his feelings
    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.

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  • 15. 

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

    • A.

      Store vitamin B12

    • B.

      Digest vitamin B12

    • C.

      Absorb vitamin B12

    • D.

      Produce vitamin B12

    Correct Answer
    C. Absorb vitamin B12
    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.

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  • 16. 

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

    • A.

      0.5 ml

    • B.

      1.0 ml

    • C.

      1.5 ml

    • D.

      2.0 ml

    Correct Answer
    D. 2.0 ml
    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.

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  • 17. 

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

    • A.

      Oral tablets of Vitamin B12 will control her symptoms

    • B.

      IM injections are required for daily control

    • C.

      IM injections once a month will maintain control

    • D.

      Weekly Z-track injections provide needed control

    Correct Answer
    C. IM injections once a month will maintain control
    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

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  • 18. 

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

    • A.

      When she feels fatigued

    • B.

      During exacerbations of anemia

    • C.

      Until her symptoms subside

    • D.

      For the rest of her life

    Correct Answer
    D. For the rest of her 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.

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  • 19. 

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

    • A.

      Reaction Formation

    • B.

      Sublimation

    • C.

      Intellectualization

    • D.

      Projection

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

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  • 20. 

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

    • A.

      When the client would have normally had a bowel movement

    • B.

      After the client accepts he had a bowel movement

    • C.

      Before breakfast and morning care

    • D.

      At least 2 hours before visitors arrive

    Correct Answer
    A. When the client would have normally had a bowel movement
    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.

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  • 21. 

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

    • A.

      Stops the flow of fluid when he feels uncomfortable

    • B.

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

    • C.

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

    • D.

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

    Correct Answer
    C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion
    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.

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  • 22. 

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

    • A.

      Abdominal cramps during fluid inflow

    • B.

      Difficulty in inserting the irrigating tube

    • C.

      Passage of flatus during expulsion of feces

    • D.

      Inability to complete the procedure in half an hour

    Correct Answer
    B. Difficulty in inserting the irrigating tube
    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.

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  • 23. 

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

    • A.

      A reaction formation to his recent altered body image.

    • B.

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

    • C.

      Impotency due to the surgery and needs sexual counseling

    • D.

      Suicide thoughts and should be seen by psychiatrist

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

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  • 24. 

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

    • A.

      Food low in fiber so that there is less stool

    • B.

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

    • C.

      Bland foods so that his intestines do not become irritated

    • D.

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

    Correct Answer
    B. Everything he ate before the operation but will avoid those foods that cause gas
    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.

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  • 25. 

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

    • A.

      Level of consciousness and pupil size

    • B.

      Abdominal contusions and other wounds

    • C.

      Pain, Respiratory rate and blood pressure

    • D.

      Quality of respirations and presence of pulsesQuality of respirations and presence of pulses

    Correct Answer
    D. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses
    Explanation
    Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished

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  • 26. 

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

    • A.

      Facilitate his verbal communication

    • B.

      Maintain sterility of the ventilation system

    • C.

      Assess his response to the equipment

    • D.

      Prepare him for emergency surgery

    Correct Answer
    C. Assess his response to the equipment
    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

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  • 27. 

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

    • A.

      Prepare for chest tube removal

    • B.

      Milk the tube toward the collection container as ordered

    • C.

      Arrange for a stat Chest x-ray film.

    • D.

      Clam the tube immediately

    Correct Answer
    B. Milk the tube toward the collection container as ordered
    Explanation
    This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber

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  • 28. 

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

    • A.

      Increased breath sounds

    • B.

      Constant bubbling in the drainage chamber

    • C.

      Crepitus detected on palpation of chest

    • D.

      Increased respiratory rate

    Correct Answer
    A. Increased breath sounds
    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

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  • 29. 

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

    • A.

      Urinary output is 30 ml in an hour

    • B.

      Central venous pressure reading of 2 cm H2O

    • C.

      Pulse rates of 120 and 110 in a 15 minute period

    • D.

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

    Correct Answer
    A. Urinary output is 30 ml in an hour
    Explanation
    A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.

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  • 30. 

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

    • A.

      Complete safety of the procedure

    • B.

      Expectation of postoperative bleeding

    • C.

      Risk of the procedure with his other injuries

    • D.

      Presence of abdominal drains for several days after surgery

    Correct Answer
    D. Presence of abdominal drains for several days after surgery
    Explanation
    Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.

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  • 31. 

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

    • A.

      Encourage bed rest with active and passive range of motion exercises

    • B.

      Encourage frequent coughing and deep breathing

    • C.

      Turn him from side to side at least every 2 hours

    • D.

      Continue observing for dyspnea and crepitus

    Correct Answer
    B. Encourage frequent coughing and deep breathing
    Explanation
    This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

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  • 32. 

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

    • A.

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

    • B.

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

    • C.

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

    • D.

      Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving

    Correct Answer
    D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving
    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.

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  • 33. 

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

    • A.

      Extent of body change present

    • B.

      Suddenness of the change

    • C.

      Obviousness of the change

    • D.

      Client’s perception of the change

    Correct Answer
    D. Client’s perception of the change
    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.

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  • 34. 

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

    • A.

      Reaction formation

    • B.

      Sublimation

    • C.

      Intellectualization

    • D.

      Projection

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

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  • 35. 

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

    • A.

      Increase his activity level and ambulate frequently

    • B.

      Sleep with the head of his bed slightly elevated

    • C.

      Drink citrus juices frequently for nourishment

    • D.

      Use a soft toothbrush and electric razor

    Correct Answer
    D. Use a soft toothbrush and electric razor
    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.

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  • 36. 

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

    • A.

      An anaphylactic transfusion reaction

    • B.

      An allergic transfusion reaction

    • C.

      A hemolytic transfusion reaction

    • D.

      A pyrogenic transfusion reaction

    Correct Answer
    C. A hemolytic transfusion reaction
    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.

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  • 37. 

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

    • A.

      “Your laugher is a cover for your fear.”

    • B.

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

    • C.

      “Why are you always laughing?”

    • D.

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

    Correct Answer
    D. “Does it help you to joke about your illness?”
    Explanation
    This non-judgmentally on the part of the nurse points out the client’s behavior.

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  • 38. 

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

    • A.

      Agree with and encourage the client’s denial

    • B.

      Reassure the client that everything will be okay

    • C.

      Allow the denial but be available to discuss death

    • D.

      Leave the client alone to discuss the loss

    Correct Answer
    C. Allow the denial but be available to discuss death
    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.

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  • 39. 

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

    • A.

      +55 ml

    • B.

      +137 ml

    • C.

      +235 ml

    • D.

      +485 ml

    Correct Answer
    C. +235 ml
    Explanation
    The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake

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  • 40. 

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

    • A.

      Crushing chest pain

    • B.

      Dyspnea on exertion

    • C.

      Extensive peripheral edema

    • D.

      Jugular vein distention

    Correct Answer
    B. Dyspnea on exertion
    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.

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  • 41. 

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

    • A.

      Distal tubule

    • B.

      Collecting duct

    • C.

      Glomerulus of the nephron

    • D.

      Ascending limb of the loop of Henle

    Correct Answer
    D. Ascending limb of the loop of Henle
    Explanation
    This is the site of action of Lasix being a potent loop diuretic.

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  • 42. 

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

    • A.

      0.5 L

    • B.

      1.0 L

    • C.

      2.0 L

    • D.

      3.5 L

    Correct Answer
    C. 2.0 L
    Explanation
    One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

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  • 43. 

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

    • A.

      Diuretic

    • B.

      Vasodilator

    • C.

      Bed-rest regimen

    • D.

      Cardiac glycoside

    Correct Answer
    D. Cardiac glycoside
    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.

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  • 44. 

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

    • A.

      2200 calories

    • B.

      2000 calories

    • C.

      2800 calories

    • D.

      1600 calories

    Correct Answer
    B. 2000 calories
    Explanation
    There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein

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  • 45. 

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

    • A.

      Magnesium

    • B.

      Sodium

    • C.

      Potassium

    • D.

      Calcium

    Correct Answer
    B. Sodium
    Explanation
    Restriction of sodium reduces the amount of water retention that reduces the cardiac workload

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  • 46. 

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

    • A.

      The medications he has been taking

    • B.

      Any recent foreign travel

    • C.

      His usual dietary pattern

    • D.

      His working patterns

    Correct Answer
    A. The medications he has been taking
    Explanation
    Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use

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  • 47. 

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

    • A.

      Three large meals large enough to supply adequate energy.

    • B.

      Regular meals and snacks to limit gastric discomfort

    • C.

      Limited food and fluid intake when he has pain

    • D.

      A flexible plan according to his appetite

    Correct Answer
    B. Regular meals and snacks to limit gastric discomfort
    Explanation
    Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.

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  • 48. 

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

    • A.

      Increasing HCO3

    • B.

      Decreasing PCO2

    • C.

      Decreasing pH

    • D.

      Decreasing PO2

    Correct Answer
    B. Decreasing PCO2
    Explanation
    Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

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  • 49. 

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

    • A.

      400 Kilocalories

    • B.

      600 Kilocalories

    • C.

      800 Kilocalories

    • D.

      1000 Kilocalories

    Correct Answer
    B. 600 Kilocalories
    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.

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  • 50. 

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

    • A.

      Encouraging adequate fluids

    • B.

      Applying elastic stockings

    • C.

      Massaging gently the legs with lotion

    • D.

      Performing active-assistive leg exercises

    Correct Answer
    D. Performing active-assistive leg exercises
    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

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Feb 14, 2011
    Quiz Created by
    RNpedia.com
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