NCLEX Questions: Take This Practice Paper For Medical Surgical Nursing

1. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking a pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications?

Weight reduction

Decreasing salt intake

Smoking cessation

Decreasing caffeine intake

Smoking should receive highest priority when trying to reduce risk factors for with respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension.

Explanation

Smoking should receive highest priority when trying to reduce risk factors for with respiratory complications. Losing weight and decreasing salt and caffeine intake can help to decrease risk factors for hypertension.

2. The priority nursing diagnosis for the patient with cardiomyopathy is:

Anxiety related to risk of declining health status

Ineffective individual coping related to fear of debilitating illness

Fluid volume excess related to altered compensatory mechanisms.

Decreased cardiac output related to reduced myocardial contractility.

Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a patient with cardiomyopathy. The other options can be addressed once cardiac output and myocardial contractility have been restored.

Explanation

Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a patient with cardiomyopathy. The other options can be addressed once cardiac output and myocardial contractility have been restored.

3. The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP?

Decreased systolic blood pressure

Headache and vomiting

Dilated pupils that don’t react to light

Headache and projectile vomiting are early signs of increased ICP. Decreased systolic blood pressure, unconsciousness, and dilated pupils that don’t reac to light are considered late signs.

Explanation

Headache and projectile vomiting are early signs of increased ICP. Decreased systolic blood pressure, unconsciousness, and dilated pupils that don’t reac to light are considered late signs.

4. An elderly patient may have sustained a basilar skull fracture after slipping and falling on an icy sidewalk. The nurse knows that basilar skull factures:

Are the least significant type of skull fracture.

May have cause cerebrospinal fluid (CSF) leaks from the nose or ears.

Have no characteristic findings.

Are always surgically repaired.

A basilar skull fracture carries the risk of complications of dural tear, causing CSF leakage and damage to cranial nerves I, II, VII, and VIII. Classic findings in this type of fracture may include otorrhea, rhinorrhea, Battle’s signs, and raccoon eyes. Surgical treatment isn’t always required.

Explanation

A basilar skull fracture carries the risk of complications of dural tear, causing CSF leakage and damage to cranial nerves I, II, VII, and VIII. Classic findings in this type of fracture may include otorrhea, rhinorrhea, Battle’s signs, and raccoon eyes. Surgical treatment isn’t always required.

5. After undergoing a transurethral resection of the prostate to treat benign prostatic hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place. One day later, the patient reports bladder pain. What should the nurse do first?

Increase the I.V. flow rate

Notify the doctor immediately

Assess the irrigation catheter for patency and drainage

Administer meperidine (Demerol) as prescribed

Although postoperative pain is expected, the nurse should ensure that other factors, such as an obstructed irrigation catheter, aren’t the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic such as meperidine as prescribed. Increasing the I.V. flow rate may worse the pain. Notifying the doctor isn’t necessary unless the pain is severe or unrelieved by the prescribed medication.

Explanation

Although postoperative pain is expected, the nurse should ensure that other factors, such as an obstructed irrigation catheter, aren’t the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic such as meperidine as prescribed. Increasing the I.V. flow rate may worse the pain. Notifying the doctor isn’t necessary unless the pain is severe or unrelieved by the prescribed medication.

6. While assessing a patient who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects:

A urinary tract infection

Renal calculi

An enlarged kidney

A distended bladder

The bladder isn’t usually palpable unless it is distended. The feeling of pressure is usually relieved with urination. Reduced bladder tone due to general anesthesia is a common postoperative complication that causes difficulty in voiding. A urinary tract infection and renal calculi aren’t palpable. The kidneys aren’t palpable above the symphysis pubis.

Explanation

The bladder isn’t usually palpable unless it is distended. The feeling of pressure is usually relieved with urination. Reduced bladder tone due to general anesthesia is a common postoperative complication that causes difficulty in voiding. A urinary tract infection and renal calculi aren’t palpable. The kidneys aren’t palpable above the symphysis pubis.

7. The nurse considers the patient anuric if the patient;

Voids during the nighttime hours

Has a urine output of less than 100 ml in 24 hours

Has a urine output of at least 100 ml in 2 hours

Has pain and burning on urination

Anuria refers to a urine output of less than 100 ml in 24 hours. The baseline for urine output and renal function is 30 ml of urine per hour. A urine output of at least 100 ml in 2 hours is within normal limits. Voiding at night is called nocturia. Pain and burning on urination is called dysuria.

Explanation

Anuria refers to a urine output of less than 100 ml in 24 hours. The baseline for urine output and renal function is 30 ml of urine per hour. A urine output of at least 100 ml in 2 hours is within normal limits. Voiding at night is called nocturia. Pain and burning on urination is called dysuria.

8. When assessing a patient for fluid and electrolyte balance, the nurse is aware that the organs most important in maintaining this balance are the:

Pituitary gland and pancreas

Liver and gallbladder.

Brain stem and heart.

Lungs and kidneys.

The lungs and kidneys are the body’s regulators of homeostasis. The lungs are responsible for removing fluid and carbon dioxide; the kidneys maintain a balance of fluid and electrolytes. The other organs play secondary roles in maintaining homeostasis.

Explanation

The lungs and kidneys are the body’s regulators of homeostasis. The lungs are responsible for removing fluid and carbon dioxide; the kidneys maintain a balance of fluid and electrolytes. The other organs play secondary roles in maintaining homeostasis.

9. A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg appears pink and warm. Her pedal pulse is palpable and there is no edema present. Which step in the nursing process is described above?

Planning

Implementation

Analysis

Evaluation

Evaluation assesses the effectiveness of the treatment plan by determining if the patient has met the expected treatment outcome. Planning refers to designing a plan of action that will help the nurse deliver quality patient care. Implementation refers to all of the nursing interventions directed toward solving the patient’s nursing problems. Analysis is the process of identifying the patient’s nursing problems.

Explanation

Evaluation assesses the effectiveness of the treatment plan by determining if the patient has met the expected treatment outcome. Planning refers to designing a plan of action that will help the nurse deliver quality patient care. Implementation refers to all of the nursing interventions directed toward solving the patient’s nursing problems. Analysis is the process of identifying the patient’s nursing problems.

10. Dr. Bruce Owen, a chemist, sustained a chemical burn to one eye. Which intervention takes priority for a patient with a chemical burn of the eye?

Patch the affected eye and call the ophthalmologist.

Administer a cycloplegic agent to reduce ciliary spasm.

Immediately instill a tropical anesthetic, then irrigate the eye with saline solution.

Administer antibiotics to reduce the risk of infection

A chemical burn to the eye requires immediate instillation of a topical anesthetic followed by irrigation with copious amounts of saline solution. Irrigation should be done for 5 to 10 minutes, and then the pH of the eye should be checked. Irrigation should be continued until the pH of the eye is restored to neutral (pH 7.0): Double eversion of the eyelids should be performed to look for and remove ciliary spasm, and an antibiotic ointment can be administered to reduce the risk of infection. Then the eye should be patched. Parenteral narcotic analgesia is often required for pain relief. An ophthalmologist should also be consulted.

Explanation

A chemical burn to the eye requires immediate instillation of a topical anesthetic followed by irrigation with copious amounts of saline solution. Irrigation should be done for 5 to 10 minutes, and then the pH of the eye should be checked. Irrigation should be continued until the pH of the eye is restored to neutral (pH 7.0): Double eversion of the eyelids should be performed to look for and remove ciliary spasm, and an antibiotic ointment can be administered to reduce the risk of infection. Then the eye should be patched. Parenteral narcotic analgesia is often required for pain relief. An ophthalmologist should also be consulted.

11. Murmurs that indicate heart disease are often accompanied by other symptoms such as:

Dyspnea on exertion.

Subcutaneous emphysema

Thoracic petechiae

Periorbital edema

A murmur that indicates heart disease is often accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and perior-bital edema aren’t associated with murmurs and heart disease.

Explanation

A murmur that indicates heart disease is often accompanied by dyspnea on exertion, which is a hallmark of heart failure. Other indicators are tachycardia, syncope, and chest pain. Subcutaneous emphysema, thoracic petechiae, and perior-bital edema aren’t associated with murmurs and heart disease.

12. The nurse explains to the patient who has an abdominal perineal resection that an indwelling urinary catheter must be kept in place for several days afterward because:

It prevents urinary tract infection following surgery

It prevents urine retention and resulting pressure on the perineal wound

It minimizes the risk of wound contamination by the urine

It determines whether the surgery caused bladder trauma

An indwelling urinary catheter is kept in place several days after this surgery to prevent urine retention that could place pressure on the perineal wound. An indwelling urinary catheter may be a source of postoperative urinary tract infection. Urine won’t contaminate the wound. An indwelling urinary catheter won’t necessarily show bladder

Explanation

An indwelling urinary catheter is kept in place several days after this surgery to prevent urine retention that could place pressure on the perineal wound. An indwelling urinary catheter may be a source of postoperative urinary tract infection. Urine won’t contaminate the wound. An indwelling urinary catheter won’t necessarily show bladder

13. Kelly Smith complains that her headaches are occurring more frequently despite medications. Patients with a history of headaches should be taught to avoid:

Freshly prepared meats.

Citrus fruits.

Skim milk

Chocolate

Patients with a history of headaches, especially migraines, should be taught to keep a food diary to identify potential food triggers. Typical headache triggers include alcohol, aged cheeses, processed meats, and chocolate and caffeine-containing products.

Explanation

Patients with a history of headaches, especially migraines, should be taught to keep a food diary to identify potential food triggers. Typical headache triggers include alcohol, aged cheeses, processed meats, and chocolate and caffeine-containing products.

14. Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states he'll contact the doctor if:

He experiences abdominal cramping while the irrigant is infusing

He has difficulty inserting the irrigation tube into the stoma

He expels flatus while the return is running out

He’s unable to complete the procedure in 1 hour

The patient should notify the doctor if he has difficulty inserting the irrigation tube into the stoma. Difficulty with insertion may indicate stenosis of the bowel. Abdominal cramping and expulsion of flatus may normally occur with irrigation. The procedure will often take an hour to complete.

Explanation

The patient should notify the doctor if he has difficulty inserting the irrigation tube into the stoma. Difficulty with insertion may indicate stenosis of the bowel. Abdominal cramping and expulsion of flatus may normally occur with irrigation. The procedure will often take an hour to complete.

15. Which nursing action is appropriate to prevent infection when obtaining a sterile urine specimen from an indwelling urinary catheter?

Aspirate urine from the tubing port using a sterile syringe and needle

Disconnect the catheter from the tubing and obtain urine

Open the drainage bag and pour out some urine

Wear sterile gloves when obtaining urine

To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe after cleaning the port. Opening a closed urine drainage system increases the risk of urinary tract infection. Standard precautions specify the use of gloves during contract with body fluids; however, sterile gloves aren’t necessary.

Explanation

To obtain urine properly, the nurse should aspirate it from a port, using a sterile syringe after cleaning the port. Opening a closed urine drainage system increases the risk of urinary tract infection. Standard precautions specify the use of gloves during contract with body fluids; however, sterile gloves aren’t necessary.

16. The nurse is assessing a patient and notes a Brudzinski’s sign and Kernig’s sign. These are two classic signs of which of the following disorders?

Cerebrovascular accident (CVA)

Meningitis

Seizure disorder

Parkinson’s disease

A positive response to one or both tests indicates meningeal irritation that is present with meningitis. Brudzinski’s and Kernig’s signs don’t occur in CVA, seizure disorder, or Parkinson’s disease.

Explanation

A positive response to one or both tests indicates meningeal irritation that is present with meningitis. Brudzinski’s and Kernig’s signs don’t occur in CVA, seizure disorder, or Parkinson’s disease.

17. Immediately following cerebral aneurysm rupture, the patient usually complains of:

Photophobia

Explosive headache

Seizures

Hemiparesis

An explosive headache or “the worst headache I’ve ever had” is typically the first presenting symptom of a bleeding cerebral aneurysm. Photophobia, seizures, and hemiparesis may occur later.

Explanation

An explosive headache or “the worst headache I’ve ever had” is typically the first presenting symptom of a bleeding cerebral aneurysm. Photophobia, seizures, and hemiparesis may occur later.

18. The nurse asks a patient’s husband if he understands why his wife is receiving nimodipine (Nimotop), since she suffered a cerebral aneurysm rupture. Which response by the husband indicates that he understands the drug’s use?

“Nimodipine replaces calcium.”

“Nimodipine promotes growth of blood vessels in the brain.”

“Nimodipine reduces the brain’s demand for oxygen.”

“Nimodipine reduces vasospasm in the brain.”

Nimodipine is a calcium channel blocker that acts on cerebral blood vessels to reduce vasospasm. The drug doesn’t increase the amount of calcium, affect cerebral vasculature growth, or reduce cerebral oxygen demand.

Explanation

Nimodipine is a calcium channel blocker that acts on cerebral blood vessels to reduce vasospasm. The drug doesn’t increase the amount of calcium, affect cerebral vasculature growth, or reduce cerebral oxygen demand.

19. Tiffany Black is diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this patient?

Put on a mask and gown before entering the patient’s room.

Wear gloves and a gown when removing the patient’s bedpan.

Prevent the droplet spread of the organism

Use caution when bringing food to the patient.

The nurse should wear gloves and a gown when removing the patient’s bedpan because the type A hepatitis virus occurs in stools. It may also occur in blood, nasotracheal secretions, and urine. Type A hepatitis isn’t transmitted through the air by way of droplets. Special precautions aren’t needed when feeding the patient, but disposable utensils should be used.

Explanation

The nurse should wear gloves and a gown when removing the patient’s bedpan because the type A hepatitis virus occurs in stools. It may also occur in blood, nasotracheal secretions, and urine. Type A hepatitis isn’t transmitted through the air by way of droplets. Special precautions aren’t needed when feeding the patient, but disposable utensils should be used.

20. A patient comes to the hospital complaining of severe pain in the right flank, nausea, and vomiting. The doctor tentatively diagnoses right ureter-olithiasis (renal calculi). When planning this patient’s care, the nurse should assign highest priority to which nursing diagnosis?

Pain

Risk of infection

Altered urinary elimination

Altered nutrition: less than body requirements

Ureterolithiasis typically causes such acute, severe pain that the patient can’t rest and becomes increasingly anxious. Therefore, the nursing diagnosis of pain takes highest priority. Risk for infection and altered urinary elimination are appropriate once the patient’s pain is controlled. Altered nutrition: less than body requirements isn’t appropriate at this time.

Explanation

Ureterolithiasis typically causes such acute, severe pain that the patient can’t rest and becomes increasingly anxious. Therefore, the nursing diagnosis of pain takes highest priority. Risk for infection and altered urinary elimination are appropriate once the patient’s pain is controlled. Altered nutrition: less than body requirements isn’t appropriate at this time.

21. What is the ratio of chest compressions to ventilations when one rescuer performs cardiopulmonary resuscitation (CPR) on an adult?

15:1

15:2

12:1

12:2

The correct ratio of compressions to ventilations when one rescuer performs CPR is 15:2

Explanation

The correct ratio of compressions to ventilations when one rescuer performs CPR is 15:2

22. Which assessment finding indicates dehydration?

Tenting of chest skin when pinched

Rapid filling of hand veins

A pulse that isn’t easily obliterated

Neck vein distention

Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isn’t easily obliterated and neck vein distention indicate fluid overload, not dehydration.

Explanation

Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isn’t easily obliterated and neck vein distention indicate fluid overload, not dehydration.

23. A patient with metabolic acidosis has a preexisting problem with the kidneys. Which other organ helps regulate blood pH?

Liver

Pancreas

Lungs

Heart

The respiratory and renal systems act as compensatory mechanisms to counteract-base imbalances. The lungs alter the carbon dioxide levels in the blood by increasing or decreasing the rate and depth of respirations, thereby increasing or decreasing carbon dioxide elimination. The liver, pancreas, and heart play no part in compensating for acid-base imbalances.

Explanation

The respiratory and renal systems act as compensatory mechanisms to counteract-base imbalances. The lungs alter the carbon dioxide levels in the blood by increasing or decreasing the rate and depth of respirations, thereby increasing or decreasing carbon dioxide elimination. The liver, pancreas, and heart play no part in compensating for acid-base imbalances.

24. A patient comes to the hospital complaining of sudden onset of sharp, severe pain originating in the lumbar region and radiating around the side and toward the bladder. The patient also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The doctor tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?

Kidney

Ureter

Urethra

Renal calculi most commonly from in the kidney. They may remain there or become lodged anywhere along the urinary tract. The ureter, bladder, and urethra are less common sites of renal calculi formation.

Explanation

Renal calculi most commonly from in the kidney. They may remain there or become lodged anywhere along the urinary tract. The ureter, bladder, and urethra are less common sites of renal calculi formation.

25. Ivy Hopkins, age 25, suffered a cervical fracture requiring immobilization with halo traction. When caring for the patient in halo traction, the nurse must:

Keep a wrench taped to the halo vest for quick removal if cardiopulmonary resuscitation is necessary.

Remove the brace once a day to allow the patient to rest.

Encourage the patient to use a pillow under the ring.

Remove the brace so that the patient can shower.

The nurse must have a wrench taped on the vest at all times for quick halo removal in emergent situations. The brace isn’t to be removed for any other reason until the cervical fracture is healed. Placing a pillow under the patient’s head may alter the stability of the brace.

Explanation

The nurse must have a wrench taped on the vest at all times for quick halo removal in emergent situations. The brace isn’t to be removed for any other reason until the cervical fracture is healed. Placing a pillow under the patient’s head may alter the stability of the brace.

26. The nurse is reviewing the report of a patient’s routine urinalysis. Which of the following values should the nurse consider abnormal?

Specific gravity of 1.002

Urine pH of 3

Absence of protein

Absence of glucose

Normal urine pH is 4.5 to 8; therefore, a urine pH of 3 is abnormal and may indicate such conditions as renal tuberculosis, pyrexia, phenylketonuria, alkaptonuria, and acidosis. Urine specific gravity normally ranges from 1.002 to 1.032, making the patient’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals.

Explanation

Normal urine pH is 4.5 to 8; therefore, a urine pH of 3 is abnormal and may indicate such conditions as renal tuberculosis, pyrexia, phenylketonuria, alkaptonuria, and acidosis. Urine specific gravity normally ranges from 1.002 to 1.032, making the patient’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals.

27. The first day after, surgery the nurse finds no measurable fecal drainage from a patient's colostomy stoma. What is the most appropriate nursing intervention?

Call the doctor immediately.

Obtain an order to irrigate the stoma.

Place the patient on bed rest and call the doctor.

Continue the current plan of care.

The colostomy may not function for 2 days or more (48 to 72 hours) after surgery. Therefore, the normal plan of care can be followed. Since no fecal drainage is expected for 48 to 72 hours after a colostomy (only mucous and serosanguineous), the doctor doesn’t have to be notified and the stoma shouldn’t be irrigated at this time.

Explanation

The colostomy may not function for 2 days or more (48 to 72 hours) after surgery. Therefore, the normal plan of care can be followed. Since no fecal drainage is expected for 48 to 72 hours after a colostomy (only mucous and serosanguineous), the doctor doesn’t have to be notified and the stoma shouldn’t be irrigated at this time.

28. Gregg Lohan, age 75, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which assessment finding is most symptomatic of pericarditis?

Pericardial friction rub

Bilateral crackles auscultated at the lung bases

Pain unrelieved by a change in position

Third heart sound (S3)

A pericardial friction rub may be present with the pericardial effusion of pericarditis. The lungs are typically clear when auscultated. Sitting up and leaning forward often relieves pericarditis pain. An S3 indicates left-sided heart failure and isn’t usually present with pericarditis.

Explanation

A pericardial friction rub may be present with the pericardial effusion of pericarditis. The lungs are typically clear when auscultated. Sitting up and leaning forward often relieves pericarditis pain. An S3 indicates left-sided heart failure and isn’t usually present with pericarditis.

29. James King is admitted to the hospital with right-side-heart failure. When assessing him for jugular vein distention, the nurse should position him:

Lying on his side with the head of the bed flat.

Sitting upright.

Flat on his back.

Lying on his back with the head of the bed elevated 30 to 45 degrees.

Assessing jugular vein distention should be done when the patient is in semi-Fowler’s position (head of the bed elevated 30 to 45 degrees). If the patient lies flat, the veins will be more distended; if he sits upright, the veins will be flat.

Explanation

Assessing jugular vein distention should be done when the patient is in semi-Fowler’s position (head of the bed elevated 30 to 45 degrees). If the patient lies flat, the veins will be more distended; if he sits upright, the veins will be flat.

30. Which type of solution causes water to shift from the cells into the plasma?

Hypertonic

Hypotonic

Isotonic

Alkaline

A hypertonic solution causes water to shift from the cells into the plasma because the hypertonic solution has a greater osmotic pressure than the cells. A hypotonic solution has a lower osmotic pressure than that of the cells. It causes fluid to shift into the cells, possibly resulting in rupture. An isotonic solution, which has the same osmotic pressure as the cells, wouldn’t cause any shift. A solution’s alkalinity is related to the hydrogen ion concentration, not its osmotic effect.

Explanation

A hypertonic solution causes water to shift from the cells into the plasma because the hypertonic solution has a greater osmotic pressure than the cells. A hypotonic solution has a lower osmotic pressure than that of the cells. It causes fluid to shift into the cells, possibly resulting in rupture. An isotonic solution, which has the same osmotic pressure as the cells, wouldn’t cause any shift. A solution’s alkalinity is related to the hydrogen ion concentration, not its osmotic effect.

31. A patient with suspected renal insufficiency is scheduled for a comprehensive diagnostic work-up. After the nurse explains the diagnostic tests, the patient asks which part of the kidney “does the work.” Which answer is correct?

The glomerulus

Bowman’s capsule

The nephron

The tubular system

The nephron is the kidney’s functioning unit. The glomerulus, Bowman’s capsule, and tubular system are components of the nephron.

Explanation

The nephron is the kidney’s functioning unit. The glomerulus, Bowman’s capsule, and tubular system are components of the nephron.

32. If a patient’s GI tract is functioning but he’s unable to take foods by mouth, the preferred method of feeding is:

Total parenteral nutrition

Peripheral parenteral nutrition

Enteral nutrition

Oral liquid supplements

If the patient’s GI tract is functioning, enteral nutrition via a feeding tube is the preferred method. Peripheral and total parenteral nutrition places the patient at risk for infection. If the patient is unable to consume foods by mouth, oral liquid supplements are contraindicated.

Explanation

If the patient’s GI tract is functioning, enteral nutrition via a feeding tube is the preferred method. Peripheral and total parenteral nutrition places the patient at risk for infection. If the patient is unable to consume foods by mouth, oral liquid supplements are contraindicated.

33. Although Ms. Priestly has a spinal cord injury, she can still have sexual intercourse. Discharge teaching should make her aware that:

She must remove indwelling urinary catheter prior to intercourse.

She can no longer achieve orgasm.

Positioning may be awkward.

She can still get pregnant.

Women with spinal cord injuries who were sexually active may continue having sexual intercourse and must be reminded that they can still become pregnant. She may be fully capable of achieving orgasm. An indwelling urinary catheter may be left in place during sexual intercourse. Positioning will need to be adjusted to fit the patient’s needs.

Explanation

Women with spinal cord injuries who were sexually active may continue having sexual intercourse and must be reminded that they can still become pregnant. She may be fully capable of achieving orgasm. An indwelling urinary catheter may be left in place during sexual intercourse. Positioning will need to be adjusted to fit the patient’s needs.

34. During a shock state, the renin-angiotensin-aldosterone system exerts which of the following effects on renal function?

Decreased urine output, increased reabsorption of sodium and water

Decreased urine output, decreased reabsorption of sodium and water

Increased urine output, increased reabsorption of sodium and water

Increased urine output, decreased reabsorption of sodium and water

As a response to shock, the renin-angiotensin-aldosterone system alters renal function by decreasing urine output and increasing reabsorption of sodium and water. Reduced renal perfusion stimulates the renin-angiotensin-aldosterone system in an effort to conserve circulating volume.

Explanation

As a response to shock, the renin-angiotensin-aldosterone system alters renal function by decreasing urine output and increasing reabsorption of sodium and water. Reduced renal perfusion stimulates the renin-angiotensin-aldosterone system in an effort to conserve circulating volume.

35. Many men who suffer spinal injuries continue to be sexually active. The teaching plan for a man with a spinal cord injury should include sexually concerns. Which of the following injuries would most likely prevent erection and ejaculation?

C5

C7

T4

S4

Men with spinal cord injury should be taught that the higher the level of the lesion, the better their sexual function will be. The sacral region is the lowest area on the spinal column and injury to this area will cause more erectile dysfunction.

Explanation

Men with spinal cord injury should be taught that the higher the level of the lesion, the better their sexual function will be. The sacral region is the lowest area on the spinal column and injury to this area will cause more erectile dysfunction.

36. Which nursing intervention would most likely lead to a hypo-osmolar state?

Performing nasogastric tube irrigation with normal saline solution

Weighing the patient daily

Administering tap water enema until the return is clear

Encouraging the patient with excessive perspiration to dink broth

Administering a tap water enema until return is clear would most likely contribute to a hypo-osmolar state. Because tap water is hypotonic, it would be absorbed by the body, diluting the body fluid concentration and lowering osmolarity. Weighing the patient is the easiest, most accurate method to determine fluid changes. Therefore, it helps identify rather than contribute to fluid imbalance. Nasogastric tube irrigation with normal saline solution wouldn’t cause a shift in fluid balance. Drinking broth wouldn’t contribute to a hypo-osmolar state because it doesn’t replace sodium and water lost through excessive perspiration.

Explanation

Administering a tap water enema until return is clear would most likely contribute to a hypo-osmolar state. Because tap water is hypotonic, it would be absorbed by the body, diluting the body fluid concentration and lowering osmolarity. Weighing the patient is the easiest, most accurate method to determine fluid changes. Therefore, it helps identify rather than contribute to fluid imbalance. Nasogastric tube irrigation with normal saline solution wouldn’t cause a shift in fluid balance. Drinking broth wouldn’t contribute to a hypo-osmolar state because it doesn’t replace sodium and water lost through excessive perspiration.

37. The nurse should instruct the patient with Parkinson’s disease to avoid which of the following?

Walking in an indoor shopping mall

Sitting on the deck on a cool summer evening

Walking to the car on a cold winter day

Sitting on the beach in the sun on a summer day

The patient with Parkinson’s disease may be hypersensitive to heat, which increases the risk of hyperthermia, and he should be instructed to avoid sun exposure during hot weather.

Explanation

The patient with Parkinson’s disease may be hypersensitive to heat, which increases the risk of hyperthermia, and he should be instructed to avoid sun exposure during hot weather.

38. When caring for a patient with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:

Esophageal perforation

Pulmonary hypertension

Portal hypertension

Peptic ulcers

Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesn’t stem from esophageal perforation, pulmonary hypertension, or peptic ulcers.

Explanation

Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesn’t stem from esophageal perforation, pulmonary hypertension, or peptic ulcers.

39. Particles move from an area of greater osmelarity to one of lesser osmolarity through:

Active transport

Osmosis

Diffusion

Filtration

Particles move from an area of greater osmolarity to one of lesser osmolarity through diffusion. Active transport is the movement of particles though energy expenditure from other sources such as enzymes. Osmosis is the movement of a pure solvent through a semipermeable membrane from an area of greater osmolarity to one of lesser osmolarity until equalization occurs. The membrane is impermeable to the solute but permeable to the solvent. Filtration is the process by which fluid is forced through a membrane by a difference in pressure; small molecules pass through, but large ones don’t.

Explanation

Particles move from an area of greater osmolarity to one of lesser osmolarity through diffusion. Active transport is the movement of particles though energy expenditure from other sources such as enzymes. Osmosis is the movement of a pure solvent through a semipermeable membrane from an area of greater osmolarity to one of lesser osmolarity until equalization occurs. The membrane is impermeable to the solute but permeable to the solvent. Filtration is the process by which fluid is forced through a membrane by a difference in pressure; small molecules pass through, but large ones don’t.

40. Cathy Bates, age 36, is a homemaker who frequently forgets to take her carbamazepine (Tegretol). As a result, she has been experiencing seizures. How can the nurse best help the patient remember to take her medication?

Tell her take her medication at bedtime.

Instruct her to take her medication after one of her favorite television shows.

Explain that she should take her medication with breakfast.

Tell her to buy an alarm watch to remind her.

Tegretol should be taken with food to minimize GI distress. Taking it at meals will also establish a regular routine, which should help compliance.

Explanation

Tegretol should be taken with food to minimize GI distress. Taking it at meals will also establish a regular routine, which should help compliance.

41. The nurse is performing her admission assessment of a patient. When grading arterial pulses, a 1+ pulse indicates:

Above normal perfusion.

Absent perfusion.

Normal perfusion.

Diminished perfusion.

A 1+ pulse indicates weak pulses and is associated with diminished perfusion. A 4+ is bounding perfusion, a 3+ is increased perfusion, a 2+ is normal perfusion, and 0 is absent perfusion.

Explanation

A 1+ pulse indicates weak pulses and is associated with diminished perfusion. A 4+ is bounding perfusion, a 3+ is increased perfusion, a 2+ is normal perfusion, and 0 is absent perfusion.

42. Gary Jordan suffered a cerebrovascular accident that left her unable to comprehend speech and unable to speak. This type of aphasia is known as:

Receptive aphasia

Expressive aphasia

Global aphasia

Conduction aphasia

Global aphasia occurs when all language functions are affected. Receptive aphasia, also known as Wernicke’s aphasia, affects the ability to comprehend written or spoken words. Expressive aphasia, also known as Broca’s aphasia, affected the patient’s ability to form language and express thoughts. Conduction aphasia refers to abnormalities in speech repetition.

Explanation

Global aphasia occurs when all language functions are affected. Receptive aphasia, also known as Wernicke’s aphasia, affects the ability to comprehend written or spoken words. Expressive aphasia, also known as Broca’s aphasia, affected the patient’s ability to form language and express thoughts. Conduction aphasia refers to abnormalities in speech repetition.

43. Which assessment finding would indicate an extracellular fluid volume deficit?

Bradycardia

A central venous pressure of 6 mm Hg

Pitting edema

An orthostatic blood pressure change

An orthostatic blood pressure indicates an extracellular fluid volume deficit. (The extracellular compartment consists of both the intravascular compartment and interstitial space.) A fluid volume deficit within the intravascular compartment would cause tachycardia, not bradycardia or orthostatic blood pressure change. A central venous pressure of 6 mm Hg is in the high normal range, indicating adequate hydration. Pitting edema indicates fluid volume overload.

Explanation

An orthostatic blood pressure indicates an extracellular fluid volume deficit. (The extracellular compartment consists of both the intravascular compartment and interstitial space.) A fluid volume deficit within the intravascular compartment would cause tachycardia, not bradycardia or orthostatic blood pressure change. A central venous pressure of 6 mm Hg is in the high normal range, indicating adequate hydration. Pitting edema indicates fluid volume overload.

44. Which of the following types of drugs might be given to control increased intracranial pressure (ICP)?

Barbiturates

Carbonic anhydrase inhibitors

Anticholinergics

Histamine receptor blockers

Barbiturates may be used to induce a coma in a patient with increased ICP. This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brain’s need for glucose and oxygen. Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease the serum pH in a patient with metabolic alkalosis. Anticholinergics have many uses including reducing GI spasms. Histamine receptor blockers are used to decrease stomach acidity.

Explanation

Barbiturates may be used to induce a coma in a patient with increased ICP. This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brain’s need for glucose and oxygen. Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease the serum pH in a patient with metabolic alkalosis. Anticholinergics have many uses including reducing GI spasms. Histamine receptor blockers are used to decrease stomach acidity.

45. Richard Barnes was diagnosed with pneumococcal meningitis. What response by the patient indicates that he understands the precautions necessary with this diagnosis?

“I’m so depressed because I can’t have any visitors for a week.”

“Thank goodness, I’ll only be in isolation for 24 hours.”

“The nurse told me that my urine and stool are also sources of meningitis bacteria.”

“The doctor is a good friend of mine and won’t keep me in isolation.”

Patient with pneumococcal meningitis require respiratory isolation for the first 24 hours after treatment is initiated.

Explanation

Patient with pneumococcal meningitis require respiratory isolation for the first 24 hours after treatment is initiated.

46. A patient is admitted to the hospital for a brain biopsy. The nurse knows that the most common type of primary brain tumor is:

Meningioma

Angioma

Hemangioblastoma

Glioma

Gliomas account for approximately 45% of all brain tumors. Meningiomas are the second most common, with 15%. Angiomas and hemangioblastomas are types of cerebral vascular tumors that account for 3% of brain tumors.

Explanation

Gliomas account for approximately 45% of all brain tumors. Meningiomas are the second most common, with 15%. Angiomas and hemangioblastomas are types of cerebral vascular tumors that account for 3% of brain tumors.

47. In early symptom associated with amyotrophic lateral sclerosis (ALS) includes:

Fatigue while talking

Change in mental status

Numbness of the hands and feet

Spontaneous fractures

Early symptoms of ALS include fatigue while talking, dysphagia, and weakness of the hands and arms. ALS doesn’t cause a change in mental status, paresthesia, or fractures.

Explanation

Early symptoms of ALS include fatigue while talking, dysphagia, and weakness of the hands and arms. ALS doesn’t cause a change in mental status, paresthesia, or fractures.

48. Jessie James is diagnosed with retinal detachment. Which intervention is the most important for this patient?

Admitting him to the hospital on strict bed rest

Patching both of his eyes

Referring him to an ophthalmologist

Preparing him for surgery

Immediate bed rest is necessary to prevent further injury. Both eyes should be patched to avoid consensual eye movement and the patient should receive early referral to an ophthalmologist should treat the condition immediately. Retinal reattachment can be accomplished by surgery only. If the macula is detached or threatened, surgery is urgent; prolonged detachment of the macula results in permanent loss of central vision.

Explanation

Immediate bed rest is necessary to prevent further injury. Both eyes should be patched to avoid consensual eye movement and the patient should receive early referral to an ophthalmologist should treat the condition immediately. Retinal reattachment can be accomplished by surgery only. If the macula is detached or threatened, surgery is urgent; prolonged detachment of the macula results in permanent loss of central vision.

49. Which of the following is a cause of embolic brain injury?

Persistent hypertension

Subarachnoid hemorrhage

Atrial fibrillation

Skull fracture

An embolic injury, caused by a traveling clot, may result from atrial fibrillation. Blood may pool in the fibrillating atrium and be released to travel up the cerebral artery to the brain. Persistent hypertension may place the patient at risk for a thrombotic injury to the brain. Subarachnoid hemorrhage and skull fractures aren’t associated with emboli.

Explanation

An embolic injury, caused by a traveling clot, may result from atrial fibrillation. Blood may pool in the fibrillating atrium and be released to travel up the cerebral artery to the brain. Persistent hypertension may place the patient at risk for a thrombotic injury to the brain. Subarachnoid hemorrhage and skull fractures aren’t associated with emboli.

50. Which pregnancy-related physiologic change would place the patient with a history of cardiac disease at the greatest risk of developing severe cardiac problems?

Decrease heart rate

Decreased cardiac output

Increased plasma volume

Increased blood pressure

Pregnancy increase plasma volume and expands the uterine vascular bed, possibly increasing both the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels.

Explanation

Pregnancy increase plasma volume and expands the uterine vascular bed, possibly increasing both the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels.