RN- General information- NCLEX STYLE QUESTIONS- MED SURG
A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to cover the staffing shortages. One of the staff nurses hasn't volunteered and states, "Forty hours a week of nursing is all I can manage to do. I won't volunteer for overtime." The nurse-manager says to an attending physician on the unit, "I'll adjust her schedule to make her wish she'd volunteered." The physician to whom she commented should: 1. choose to ignore the comment because it isn't the physician's domain. 2. report the nurse-manager to the labor relations board. 3. ensure that the nurse-manager receives counseling about her comment. 4. tell the staff nurse what the manager said about her.
3. ensure that the nurse-manager receives counseling about her comment. RATIONALES: It's discriminatory and punitive for the nurse-manager to alter the staff nurse's schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the nurse-manager to the labor relations board should be avoided. Institutional documentation should exist for such matters. It's inappropriate for the physician to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.
A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide (Tolinase). Which of the following is the most important laboratory test for confirming this disorder?
Serum osmolarity RATIONALES: Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren't as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.
With primary hyperthyroidism:
T4 and T3 levels are elevated and TSH is subnormal
With Hashimoto's thyroiditis:
T4 and T3 levels are typically subnormal and TSH is elevated.
With hypothyroidism:
T4 is subnormal and T3 and TSH levels are elevated
Group (skin integrity/pressure ulcers) The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1? × 1? (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a) stage I pressure ulcer b) stage II pressure ulcer c) stage IV pressure ulcer d) stage III pressure ulcer
b) stage II pressure ulcer Explanation: Stage I pressure ulcers appear as nonblanching macules that are red in color. Stage II ulcers have breakdown of the dermis. Stage III ulcers have full-thickness skin breakdown. Stage IV ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.
The ELISA test
is diagnostic for human immunodeficiency virus (HIV) and isn't indicated in this case.
During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to order:
stool for Clostridium difficile test. Immunosuppressed clients — for example, clients receiving chemotherapy, — are at risk for infection with C. difficile, which causes "horse barn" smelling diarrhea. Successful treatment begins with an accurate diagnosis, which includes a stool test.
Group (comfort) A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? 1. Acute pain related to biliary spasms 2. Deficient knowledge related to prevention of disease recurrence 3. Anxiety related to unknown outcome of hospitalization 4. Imbalanced nutrition: Less than body requirements related to biliary inflammation
1. Acute pain related to biliary spasms RATIONALES: The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.
The best way for the nurse to assess pain in an 18-month-old child is to: 1. check the child's pupils. 2. observe for behavioral changes. 3. ask the child, "Are you feeling any pain?" 4. tell the parents to call if the child has pain.
2. observe for behavioral changes. RATIONALES: Behavioral changes are common signs of pain and are especially valuable indicators in an 18-month-old child, who has limited verbal skills. Evaluating pupillary response isn't an appropriate technique for assessing pain. Requesting a parental report of a child's pain isn't a reliable assessment technique.
The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development? 1. Has perceptions based on reality 2. Assumes responsibility for actions 3. Generates new levels of awareness 4. Has maximum ability to solve problems and learn new skills
3. Generates new levels of awareness RATIONALES: Adults ages 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30.
A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which of the following interventions should the nurse implement? 1. Discuss the client's concern with the husband. 2. Refer the client to a psychiatrist. 3. Invite a client with a similar experience to speak with the client. 4. Refer the client to a sex therapist.
3. Invite a client with a similar experience to speak with the client. RATIONALES: Having someone who has had a similar surgery and concerns speak to the client would be beneficial. The client is coping normally and doesn't need professional help. Discussing the concerns with the client's husband doesn't address the client's needs. In fact, the client may feel that the nurse violated confidentiality.
group (comfort) When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find? 1. Painful skin that is swollen and pale in color 2. Cold, red skin 3. Small, localized blackened area of skin 4. Red, swollen skin with inflammation spreading to surrounding tissues
4. Red, swollen skin with inflammation spreading to surrounding tissues RATIONALES: Cellulitis is an inflammation of soft tissues that can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.
The nurse suspects that her client is in cardiac arrest. According to the American Heart Association, the nurse should perform the actions listed below. Order these actions in the sequence that the nurse should perform them. 1. Activate the emergency medical system. 2. Assess responsiveness. 3. Call for a defibrillator. 4. Provide two slow breaths. 5. Assess pulse. 6. Assess breathing.
Correct Answer: 213645 RATIONALES: According to the American Heart Association, the nurse should first assess responsiveness. If the client is unresponsive, the nurse should activate the emergency medical system, and then call for a defibrillator. Next, the nurse should assess breathing by opening the airway and then looking, listening, and feeling for respirations. If respirations aren't present, the nurse should administer two slow breaths, then assess the pulse. If no pulse is present, the nurse should start chest compressions.
Group (comfort) The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. a) Elevate the head of the bed to 50 degrees. b) Obtain daily cultures. c) Reposition the client every 2 hours. d) Request an alternating-pressure mattress. e) Cover with protective dressing.
c) • Reposition the client every 2 hours. d) • Request an alternating-pressure mattress. e) • Cover with protective dressing. Explanation: The client has a stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria, and obtaining frequent cultures (unless prescribed otherwise) is not necessary.
Group (skin integrity/pressure ulcers) A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to: a) complete and document a Braden skin breakdown risk score for the client. b) apply a moist-to-moist dressing, being careful to pack just the wound bed. c) consult with a wound-ostomy-continence nurse specialist. d) reposition the client off the reddened skin and reassess in a few hours.
d) reposition the client off the reddened skin and reassess in a few hours. A stage I ulcer presents as an area of intact, nonblanchable redness, usually over a bony prominence, caused by pressure. If a reddened area blanches and refills with fingertip pressure, it indicates that there is still some blood flow to the injured area, and the redness may be reversible. It may be appropriate to complete and document a Braden score or consult a wound nurse specialist, but it is imperative to reposition the client off the reddened skin area first. Since there is no break in the skin, it is not appropriate to apply a moist to moist dressing.
An electrolyte panel and hemogram
may be useful in the overall evaluation of a client but aren't diagnostic for specific causes of diarrhea.
A flat plate of the abdomen
may provide useful information about bowel function but isn't indicated in the case of "horse barn" smelling diarrhea
When percussing a client's chest, the nurse should identify which sound as a normal finding? 1. Hyperresonance 2. Tympany 3. Resonance 4. Dullness
3. Resonance RATIONALES: Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in emphysema. The nurse may assess tympany when percussing over the abdomen, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.
Which of the following laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto's thyroiditis?
T4, 2 μg/dl; T3, 35 ng/dl; TSH 45 μIU/ml
Normal thyroid function tests are as follows:
T4, 5 to 12 μg/dl; T3, 65 to 195 ng/dl; TSH 0.3 to 5.4 μIU/ml.
Group (skin integrity) Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized? a) The client's skin is intact with non-blanchable redness of a localized area over a bony prominence. b) The client's subcutaneous tissue is visible with a blood blistered wound bed. c) The client's skin is a shiny, dry ulceration with bruising noted. d) The client's skin has partial loss of dermis presenting as a shallow open ulcer with a red pink wound bed.
a) The client's skin is intact with non-blanchable redness of a localized area over a bony prominence. Explanation: Clients who are immobilized and are in stationary positions without regular position changes are more likely to develop pressure ulcers because of pressure on the skin for extended periods. This is the definition of a stage 1 ulcer. b is stage II c is a deep tissue injury d is stage III
Group (comfort and skin integrity) A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity? a) Turn him regularly. b) Perform passive range-of-motion (ROM) exercises. c) Encourage fluid intake. d) Message bony prominences.
a) Turn him regularly. The most important intervention for maintaining skin integrity is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure is not relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and pressure ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area, but does not prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. Message of bony prominences will restore circulation to that area.
Group (comfort and skin integrity) The nurse is providing an education seminar on skin care to clients and home care families. When discussing interventions, which areas have provided effective outcomes in preventing pressure ulcers? Select all that apply. a) Avoid raising the head of the bed more than 90°. b) Turn and reposition the client every 1 to 2 hours unless contraindicated. c) Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer. d) If the client uses a wheelchair, sit on a rubber or plastic doughnut. e) When turning the client, slide and avoid lifting. f) Use positioning devices to position the client and increase comfort.
b) • Turn and reposition the client every 1 to 2 hours unless contraindicated. c) • Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer. f) • Use positioning devices to position the client and increase comfort. Explanation: Nursing interventions that are effective in preventing pressure ulcers include cleaning the skin with warm water and a mild cleaning agent, and then applying a moisturizer; lifting—rather than sliding—the client when turning to reduce friction and shear; avoiding raising the head of the bed more than 30°, except for brief periods; repositioning and turning the client every 1 to 2 hours unless contraindicated; and using positioning devices or pillows to position the client and increase comfort. If the client uses a wheelchair, the nurse would offer a pressure-relieving cushion as appropriate. The nurse would not sit the client on a rubber or plastic doughnut because these devices can increase localized pressure at vulnerable points.
Group (skin integrity) A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? (Select all that apply.) a) atrial fibrillation b) type 2 diabetes mellitus c) smoking d) advancing age e) hypertension
b) • type 2 diabetes mellitus c) • smoking d) • advancing age Explanation: type 2 diabetes mellitus, smoking, and advancing age are risk factors for delayed healing. Type 2 diabetes mellitus reduces supply of oxygen and nutrients secondary to vascular complications. Nicotine is a potent vasoconstrictor and impedes blood flow, which reduces the supply of oxygen and nutrients necessary for healing. Advanced age slows collagen synthesis by fibroblasts, impairs circulation, and requires a longer time for epithelialization of skin. Atrial fibrillation causes venous stasis in the atria, but does not have an effect on wound healing. Hypertension does not have an effect on healing.
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the:
mucous membranes. RATIONALES: Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color.
