NCLEX style questions from M2 lectures

Of the following patients scheduled for surgery, which is at greatest risk for a poor surgical outcome? a. 19-year old athlete b. 30-year old obese housewife c. 45-year old height- and weight-appropriate office manager d. 50-year old running coach

b. 30-year old obese housewife

The nurse is monitoring the status of a postoperative patient. The nurse would be most concerned with which sign that could indicate an evolving complication? a. Increasing restlessness b. Heart rate of 86 bpm c. Blood pressure of 110/70 d. Hypoactive bowel sounds in all four quadrants

a. Increasing restlessness

TB is an 88 you female with AD who speaks in single words without full sentences. You ask if she would like to go to the activity room, but she is not answering you. Which technique would best facilitate this communication? a. Keep voice pitch low, volume firm, use single words and gestures. b. Hold pt's head between your hands to direct attention to your face and lips. c. Rephrase the question, and allow time for her to respond. d. Repeat the question, a little louder.

a. Keep voice pitch low, volume firm, use single words and gestures.

A patient with Alzheimer's has become frustrated with you for not understanding and is agitated, pacing, and waving her arms. Your priority is to: a. Provide safety for this and other clients, and for staff. b. Move the patient to a less stimulating area. c. Distract the patient with TV or radio. d. Assure the other patients that you have things under control.

a. Provide safety for this and other clients, and for staff.

A nurse just reassessed a postoperative patient who was admitted 1 hour ago to the medical-surgical unit from PACU. The nurse plans to monitor which parameter most closely during the next hour? a. Urinary output of 20 ml/hour b. Temperature of 37.6˙C c. Blood pressure of 100/68 mm Hg d. Scant serosanguinous drainage on the surgical dressing

a. Urinary output of 20 ml/hour

The nurse correctly identifies which symptoms as a possible anaphylactic reaction. a. Urticaria and wheezing b. Nausea and vomiting c. Abdominal pain and diarrhea d. Hypertension and poor skin turgor

a. Urticaria and wheezing

A patient underwent abdominal surgery and complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. a. Contact the surgeon b.Instruct the patient to remain quiet and lying in bed c. Prepare the patient for wound closure d. Gently place the bowel loop back into the abdominal cavity e. Place a sterile saline dressing and ice packs over the wound f. Document the findings and actions taken

a. Contact the surgeon b.Instruct the patient to remain quiet and lying in bed c. Prepare the patient for wound closure f. Document the findings and actions taken

A patient experiences abdominal distension following surgery. Which nursing actions are appropriate? Select all that apply. a. Encouraging ambulation b. Giving sips of ginger ale c. Auscultating bowel sounds d. Providing a straw for drinking e. Offering the prescribed opioid analgesic

a. Encouraging ambulation c. Auscultating bowel sounds

Which of the following would most likely help a patient with Parkinson's bradykinesia to avoid falling? a. A four point cane. b. A 4 wheel walker. c. A thoracic-lumbar corset. d. Ear plugs.

b. A 4 wheel walker "A 4 wheel walker is easier to get walking started than a FWW or a pickup walker. A cane would provide less balance. A corset might help posture but would not prevent falls. Sound is not a factor in the balance problem."

Which of the following patients are most likely to require special preoperative assessment and treatment prior to surgery? a. A male who regularly treats his rheumatoid arthritis with over-the-counter ibuprofen b. A female who takes daily anticoagulants to treat atrial fibrillation c. A female who takes daily thyroid supplement to treat her long-standing hypothyroidism d. A male who takes an angiotensin converting enzyme inhibitor to treat his hypertension

b. A female who takes daily anticoagulants to treat atrial fibrillation

A 57-year old female patient was just transferred from the post-anesthesia care unit to the medical- surgical floor following an abdominal surgery. She has a urinary catheter and epidural in place. The patient is complaining of feeling the need to void. What is the nurse's first action? a. Notify the physician b. Assess whether the urinary catheter is draining and remove dependent loops c. Calmly tell the patient not to worry because the urinary catheter is draining her bladder d. Bladder scan the patient and document the results

b. Assess whether the urinary catheter is draining and remove dependent loops

The patient who will be having surgery in the morning tells the nurse which medications he took that day. Of the following medications, which should the nurse report to the surgeon? a. Tylenol b. Plavix c. Benadryl d. Lipitor

b. Plavix

Which technique would most likely reduce hand tremor in Parkinson's? a. Keep hands warm with gloves. b. Use hand to do something. c. Relaxation exercises. d. Range of motion every day.

b. Use hand to do something. "The tremor in Parkinson's is an essential resting tremor. It may be reduced with voluntary movement like grasping the arm rest of a chair or rolling coins together."

A preoperative patient expresses anxiety to the nurse about an upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the patient and the nurse? a. "If it's any help, everyone is nervous before surgery." b. "I will be happy to explain the entire surgical procedure to you." c. "Can you share with me what you've been told about your surgery?" d. "Let me tell you about the type of postoperative care and amount of pain you can anticipate."

c. "Can you share with me what you've been told about your surgery?"

The operating room nurse is aware that which of the following patients are at a greater risk related to surgery. a. 8-year old boy b. 48-year old man c. 83-year old woman d. 34-year old woman

c. 83-year old woman

The nurse notes that an advance directive is in the patient's record. Which of the following statements best represents the descriptions of guidelines the nurse would follow? a. A durable power of attorney is invoked only when the patient has a terminal condition or is in a persistent vegetative state b. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state c. A living will is invoked when the patient is in a persistent vegetative state. d. The patient cannot make changes in the advance directive once admitted into the hospital

c. A living will is invoked when the patient is in a persistent vegetative state.

The nurse is reviewing lab results of a patient who is scheduled for surgery later that day. The nurse notes that the patient has a serum potassium level of 6.5. The nurse informs the physician of this result because the nurse recognizes this increases the patient's risk for which of the following? a. Infection b. Bleeding and anemia c. Dysrhythmias d. Fluid imbalances

c. Dysrhythmias

An adult man is in the post anesthesia care unit following a hemicolectomy. While in the PACU, the nurse will monitor his vital signs: a. Continuously b. Every 5 minutes c. Every 15 minutes d. On a PRN basis

c. Every 15 minutes

What is the priority nursing intervention for a patient during the immediate postoperative period? a. Monitoring vital signs b. Observing for hemorrhage c. Maintaining a patent airway d. Recording the intake and output

c. Maintaining a patent airway

What is the best strategy for preventing aspiration in a patient with Parkinson's? a. Take sip of water or clear liquids before each bit of food. b. Lay on left side for 30 minutes after eating. c. Sit up and swallow twice with each bite. d. Tip the head back before swallowing.

c. Sit up and swallow twice with each bite. "Thick liquids are easier to swallow than thin. Sitting up, concentrating, double swallowing and neck flexion also can help. Bites should be small, food pureed or chopped small."

Which of the following methods for getting out of bed should the nurse teach a patient having abdominal surgery to minimize pain and discomfort? a. Raise the HOB to 90 degrees and swing legs to the side of the bed. b. From a flat supine position, sit up in bed and swing legs to the side of the bed c. Turn on side, use arms to push self into an upright position. d. Raise HOB to 45 degrees and swing legs to the side of the bed.

c. Turn on side, use arms to push self into an upright position.

Which of the following is part of the breathing assessment in the PACU? a. Pulse oximeter b. Wound status c. Respiratory assistance devices d. Breath sounds

d. Breath sounds

Five minutes after receiving a preoperative sedative medication by IV injection a male patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? a. Assist the patient to the bathroom and stay next to the door to assist the patient back to bed when done b. Allow the patient to go to the bathroom since the medication onset will be more than 5 minutes c. Ask patient to hold the urine for a short period since a urinary catheter will be placed in the operating room d. Offer a urinal for the patient to use after explaining the need to maintain safety

d. Offer a urinal for the patient to use after explaining the need to maintain safety

Which of the following should the nurse teach the patient about postoperative pain control? a. Pain medication will be provided and the patient should ask for medication when the pain is becoming unbearable b. Pain medication will be provided sparingly due to a high risk for addiction. c. Pain medication will be given when the patient is participating in postoperative ambulation exercises. d. Pain medication will be available and the patient should ask for medication when he or she begins to feel uncomfortable

d. Pain medication will be available and the patient should ask for medication when he or she begins to feel uncomfortable

The PACU nurse notes a patient has snoring respirations and decreasing oxygen saturation. What is the nurse's first intervention? a. Suctioning b. Use of an oral airway c. Use of a nasal airway d. Positioning of the head

d. Positioning of the head