MED-SURG REVIEW Makeba Felton, RN, MSN, FNPC Spring, 2007.

MED-SURG REVIEWMED-SURG REVIEW

Makeba Felton, RN, MSN, Makeba Felton, RN, MSN, FNPCFNPC

Spring, 2007Spring, 2007

NCLEX FORMATNCLEX FORMAT Safe, Effective Care Environment Safe, Effective Care Environment

Management of Care Management of Care Safety and Infection Control Safety and Infection Control

Health Promotion and Maintenance Health Promotion and Maintenance Growth and Development Through the Life Span Growth and Development Through the Life Span Prevention and Early Detection of Disease Prevention and Early Detection of Disease

Psychosocial Integrity Psychosocial Integrity Coping and Adaptation Coping and Adaptation Psychosocial Adaptation Psychosocial Adaptation

Physiological Integrity Physiological Integrity Basic Care and Comfort Basic Care and Comfort Pharmacological and Parenteral Therapies Pharmacological and Parenteral Therapies Reduction of Risk Potential Reduction of Risk Potential Physiological AdaptationPhysiological Adaptation

1. During the acute phase of a 1. During the acute phase of a cerebrovascular accident cerebrovascular accident (CVA), the nurse should (CVA), the nurse should maintain the patient in which maintain the patient in which of the following positions?of the following positions?

1.1. Semi-prone with the head of the bed Semi-prone with the head of the bed elevated 60-90 degrees.elevated 60-90 degrees.

2.2. Lateral, with the head of the bed flat.Lateral, with the head of the bed flat.

3.3. Prone, with the head of the bed flat.Prone, with the head of the bed flat.

4.4. Supine, with the head of the bed Supine, with the head of the bed elevated 30-45 degrees.elevated 30-45 degrees.

Kaplan, 2005Kaplan, 2005

2. A client comes to the ER with c/o n/v and 2. A client comes to the ER with c/o n/v and abdominal pain. He has IDDM. Four days abdominal pain. He has IDDM. Four days earlier, he reduced his insulin dose when flu earlier, he reduced his insulin dose when flu sxs prevented him from eating. The nurse sxs prevented him from eating. The nurse performs an assessment of the pt which performs an assessment of the pt which reveals poor skin turgor, dry mucous reveals poor skin turgor, dry mucous membranes, and fruity breath odor. The membranes, and fruity breath odor. The nurse should be alert for which of the nurse should be alert for which of the following problems?following problems?

1. Hypoglycemia1. Hypoglycemia

2. Viral Illness2. Viral Illness

3. Ketoacidosis3. Ketoacidosis4. Hyperglycemic Hyperosmolar 4. Hyperglycemic Hyperosmolar

Nonketotic ComaNonketotic Coma Kaplan, 2005Kaplan, 2005

3.3. A pt hospitalized with a gastric A pt hospitalized with a gastric ulcer is scheduled for discharge. ulcer is scheduled for discharge. The nurse teaches the pt about an The nurse teaches the pt about an anti-ulcer diet. Which of the anti-ulcer diet. Which of the following statements, if made by following statements, if made by the pt, would indicate that dietary the pt, would indicate that dietary teaching was successful?teaching was successful?

1.1. ““I must eat bland foods to help my I must eat bland foods to help my stomach heal.”stomach heal.”

2.2. ““I can eat most foods, as long as they I can eat most foods, as long as they don’t bother my stomach.”don’t bother my stomach.”

3.3. ““I cannot eat fruits and vegetables I cannot eat fruits and vegetables because they cause too much gas.”because they cause too much gas.”

4.4. ““I should eat a low-fiber diet to delay I should eat a low-fiber diet to delay gastric emptying.”gastric emptying.” Kaplan, 2005Kaplan, 2005

4. The nurse cares for a patient 4. The nurse cares for a patient receiving full strength Ensure by receiving full strength Ensure by tube feeding. The nurse knows tube feeding. The nurse knows that the MOST common that the MOST common complication of a tube feeding is:complication of a tube feeding is:

1.1. EdemaEdema

2.2. DiarrheaDiarrhea

3.3. HypokalemiaHypokalemia

4.4. VomitingVomiting Kaplan, Kaplan,

20052005

55. A man is diagnosed with cancer . A man is diagnosed with cancer of the larynx and comes to the of the larynx and comes to the hospital for a total laryngectomy. hospital for a total laryngectomy. When admitting this patient, how When admitting this patient, how should the nurse assess laryngeal should the nurse assess laryngeal nerve function?nerve function?

1.1. Assess the extent of neck edema.Assess the extent of neck edema.

2.2. Check his ability to swallow.Check his ability to swallow.

3.3. Observe for excessive droolingObserve for excessive drooling

4.4. Tap the side of his neck gently and Tap the side of his neck gently and observe for facial twitching.observe for facial twitching.

Kaplan, Kaplan, 20052005

6. The nurse cares for a pt with a 6. The nurse cares for a pt with a possible bowel obstruction. An NG possible bowel obstruction. An NG tube is to be inserted. Before inserting tube is to be inserted. Before inserting the tube, the nurse explains the the tube, the nurse explains the purpose to the pt. Which of the purpose to the pt. Which of the following explanations, if made by the following explanations, if made by the nurse, is MOST accurate?nurse, is MOST accurate?

1.1. ““It empties the stomach of fluids and It empties the stomach of fluids and gas.”gas.”

2.2. ““It prevents spasms of the sphincter of It prevents spasms of the sphincter of Oddi.”Oddi.”

3.3. ““It prevents air from forming in the small It prevents air from forming in the small and large intestine.”and large intestine.”

4.4. ““It removes bile from the gall bladder.”It removes bile from the gall bladder.” Kaplan, Kaplan,

20052005

7. The nurse evaluates the care 7. The nurse evaluates the care provided to a pt hospitalized for tx provided to a pt hospitalized for tx of adrenal crisis. Which of the of adrenal crisis. Which of the following changes would indicate following changes would indicate to the nurse that the pt is to the nurse that the pt is responding favorably to medical responding favorably to medical and ng tx?and ng tx?1.1. The pt’s urinary output has increased.The pt’s urinary output has increased.

2.2. The pt’s blood pressure has increased.The pt’s blood pressure has increased.

3.3. The pt has lost weight.The pt has lost weight.

4.4. The pt’s peripheral edema has The pt’s peripheral edema has decreased.decreased.


8. The physician orders heparin for 8. The physician orders heparin for a pt. In order to evaluate the a pt. In order to evaluate the effectiveness of the pt’s heparin effectiveness of the pt’s heparin therapy, the nurse should monitor therapy, the nurse should monitor which of the following lab values?which of the following lab values?

1.1. Platelet countPlatelet count

2.2. Clotting timeClotting time

3.3. Bleeding timeBleeding time

4.4. Prothrombin timeProthrombin time Kaplan, Kaplan,

20052005

9. A pt returns to his room following a 9. A pt returns to his room following a cardiac catheterization. Which of the cardiac catheterization. Which of the following assessments, if made by the following assessments, if made by the nurse, would justify calling the nurse, would justify calling the physician?physician?

1.1. Pain at the site of the catheter Pain at the site of the catheter insertion.insertion.

2.2. Absence of a pulse distal to the Absence of a pulse distal to the catheter insertion site.catheter insertion site.

3.3. Drainage on the dressing covering Drainage on the dressing covering the catheter insertion site.the catheter insertion site.

4.4. Redness at the catheter insertion site.Redness at the catheter insertion site. Kaplan, 2005Kaplan, 2005

10.10. The nurse is caring for a pt The nurse is caring for a pt with a cast on the left leg. The with a cast on the left leg. The nurse would be MOST nurse would be MOST concerned if which of the concerned if which of the following were observed?following were observed?

1. Capillary refill time was less than 3 1. Capillary refill time was less than 3 secondsseconds

2.2. Pt complained of discomfort and Pt complained of discomfort and itching.itching.

3.3. Pt complained of tightness and Pt complained of tightness and pain.pain.

4.4. Pt’s foot is elevated on a pillow.Pt’s foot is elevated on a pillow. Kaplan, Kaplan,

20052005

1111. The home care nurse is visiting . The home care nurse is visiting a client with a dx of hepatitis of a client with a dx of hepatitis of unknown etiology. The nurse knows unknown etiology. The nurse knows that teaching has been successful if that teaching has been successful if the pt makes which one of the the pt makes which one of the following statements?following statements?1.1. ““I am so sad that I am not able to hold I am so sad that I am not able to hold

my baby.”my baby.”

2.2. ““I will eat after my family eats.”I will eat after my family eats.”

3.3. ““I will make sure that my children don’t I will make sure that my children don’t eat or drink after me.”eat or drink after me.”

4.4. ““I’m glad that I don’t have to get help I’m glad that I don’t have to get help taking care of my children.”taking care of my children.” Kaplan, 2005Kaplan, 2005

12. The nurse is caring for a pt 12. The nurse is caring for a pt four hours after intracranial four hours after intracranial surgery. Which of the following surgery. Which of the following actions should the nurse take actions should the nurse take immediately?immediately?

1.1. Turn, cough and deep breathe the pt.Turn, cough and deep breathe the pt.

2.2. Place the pt with the neck flexed and Place the pt with the neck flexed and head turned to the side.head turned to the side.

3.3. Perform passive range of motion Perform passive range of motion exercises.exercises.

4.4. Move client to the head of the be using a Move client to the head of the be using a turning sheet.turning sheet.


13. The nurse is caring for a pt 13. The nurse is caring for a pt with an acute myocardial with an acute myocardial infarction. Which of the following infarction. Which of the following laboratory findings would MOST laboratory findings would MOST concern the nurse?concern the nurse?1.1. Erythrocyte sedimentation rate (ESR): Erythrocyte sedimentation rate (ESR):

10mm/h10mm/h

2.2. Hematocrit (Hct): 42%Hematocrit (Hct): 42%

3.3. Creatine Kinase (CK): 150U/mLCreatine Kinase (CK): 150U/mL

4.4. Serum Glucose: 100mg/ dLSerum Glucose: 100mg/ dL Kaplan, Kaplan,

20052005

14. The nurse is supervising care of a pt 14. The nurse is supervising care of a pt receiving TPN through a single-lumen receiving TPN through a single-lumen percutaneous central catheter. The nurse percutaneous central catheter. The nurse would be MOST concerned if which of the would be MOST concerned if which of the following was observed?following was observed?1.1. The pt receives insulin through the The pt receives insulin through the

single-lumensingle-lumen

2.2. A mask is worn when changing the pt’s A mask is worn when changing the pt’s dressing.dressing.

3.3. The pt’s dressing is changed daily using The pt’s dressing is changed daily using sterile technique.sterile technique.

4.4. The pt is weighed two or three times per The pt is weighed two or three times per week.week.


15. The nurse assists the 15. The nurse assists the physician with the removal of a physician with the removal of a chest tube. Before the physician chest tube. Before the physician removes the chest tube, which removes the chest tube, which instruction should the nurse give instruction should the nurse give to the pt?to the pt?

1.1. ““Exhale and bear down.”Exhale and bear down.”

2.2. ““Hold your breath for five seconds.”Hold your breath for five seconds.”

3.3. ““Inhale and exhale rapidly.”Inhale and exhale rapidly.”

4.4. ““Cough as hard as you can.”Cough as hard as you can.” Kaplan, Kaplan,

20052005

16.16. A man is admitted to the Telemetry Unit A man is admitted to the Telemetry Unit for evaluation of c/o chest pain. Eight for evaluation of c/o chest pain. Eight hours after admission, the pt goes into hours after admission, the pt goes into ventricular fibrillation. The physician ventricular fibrillation. The physician defibrillates the pt. The nurse defibrillates the pt. The nurse understands that the purpose of understands that the purpose of defibrillation is to:defibrillation is to:

1.1. Increase cardiac contractility and cardiac Increase cardiac contractility and cardiac output.output.

2.2. Cause asystole so the normal pacemaker Cause asystole so the normal pacemaker can recapture.can recapture.

3.3. Reduce cardiac ischemia and acidosis.Reduce cardiac ischemia and acidosis.

4.4. Provide energy for depleted myocardial Provide energy for depleted myocardial cells.cells.


17. A pt newly diagnosed with 17. A pt newly diagnosed with Alzheimer’s disease is admitted to Alzheimer’s disease is admitted to the unit. Which action, if taken by the unit. Which action, if taken by the nurse, is BEST?the nurse, is BEST?

1.1. Place the pt in a private room away from Place the pt in a private room away from the nurses’ station.the nurses’ station.

2.2. Ask the family to wait in the waiting Ask the family to wait in the waiting room while the nurse admits the pt.room while the nurse admits the pt.

3.3. Assign a different nurse daily to care for Assign a different nurse daily to care for the pt.the pt.

4.4. Ask the pt to state today’s date.Ask the pt to state today’s date. Kaplan, Kaplan,

20052005

18. The client is instructed 18. The client is instructed regarding foods that are low in regarding foods that are low in fat and cholesterol. Which diet fat and cholesterol. Which diet selection is lowest in saturated selection is lowest in saturated fats?fats?

1.1. Macaroni and cheeseMacaroni and cheese

2.2. Shrimp with riceShrimp with rice

3.3. Turkey breastTurkey breast

4.4. SpaghettiSpaghettihttp://www.examcram2.com/articles/article.asp?http://www.examcram2.com/articles/article.asp?

p=402459&rl=1p=402459&rl=1

19. The client with Alzheimer's 19. The client with Alzheimer's disease is being assisted with activities disease is being assisted with activities of daily living when the nurse notes of daily living when the nurse notes that the client uses her toothbrush to that the client uses her toothbrush to brush her hair. The nurse is aware that brush her hair. The nurse is aware that the client is exhibiting:the client is exhibiting:

1.1. AgnosiaAgnosia

2.2. ApraxiaApraxia

3.3. AnomiaAnomia

4.4. AphasiaAphasiahttp://www.examcram2.com/articles/article.asp?http://www.examcram2.com/articles/article.asp?

p=402459&rl=1p=402459&rl=1

20.20. The nurse knows that a The nurse knows that a positive diagnosis for HIV positive diagnosis for HIV infection is made based on:infection is made based on:

1.1. Positive ELISA and Western blot Positive ELISA and Western blot tests.tests.

2.2. A history of high-risk sexual A history of high-risk sexual behaviorsbehaviors

3.3. Evidence of extreme wt loss and Evidence of extreme wt loss and high fever.high fever.

4.4. Identification of an associated Identification of an associated opportunistic infection.opportunistic infection.

Mosby, 2004Mosby, 2004

21. A client with a family hx of 21. A client with a family hx of atherosclerosis is advised to follow atherosclerosis is advised to follow a diet based on the US Dept of Ag. a diet based on the US Dept of Ag. Food Guide Pyramid. The nurse Food Guide Pyramid. The nurse should teach the client to eat:should teach the client to eat:

1.1. 4-6 servings of fruit daily4-6 servings of fruit daily

2.2. 5-7 servings of vegetables daily5-7 servings of vegetables daily

3.3. 3-5 servings of meat, poultry, or 3-5 servings of meat, poultry, or fish dailyfish daily

4.4. 6-11 servings of bread, rice or pasta 6-11 servings of bread, rice or pasta daily.daily.

Mosby, Mosby, 20042004

The The (NEW)(NEW) Food Pyramid Food Pyramid

22. The teaching plan for a client 22. The teaching plan for a client receiving digoxin for left receiving digoxin for left ventricular failure should include ventricular failure should include having the client:having the client:

1.1. Sleep flat in bedSleep flat in bed

2.2. Rest during the dayRest during the day

3.3. Follow a low potassium dietFollow a low potassium diet

4.4. Take the pulse three times dailyTake the pulse three times daily Mosby, Mosby,

20042004

23. During a routine physical exam, an 23. During a routine physical exam, an abdominal aortic aneurysm is diagnosed. abdominal aortic aneurysm is diagnosed. The client is immediately admitted to the The client is immediately admitted to the hospital, and surgery is scheduled for the hospital, and surgery is scheduled for the next morning. When performing the next morning. When performing the admission assessment, the nurse should admission assessment, the nurse should expect:expect:

1.1. Severe radiating abdominal painSevere radiating abdominal pain

2.2. Cyanosis and symptoms of shockCyanosis and symptoms of shock

3.3. A pattern of visible peristaltic wavesA pattern of visible peristaltic waves

4.4. A palpable pulsating abdominal A palpable pulsating abdominal massmass

Mosby, Mosby,

20042004

24.24.A client has recently been A client has recently been diagnosed with Type I diagnosed with Type I diabetes. A glucose diabetes. A glucose tolerance test is ordered. tolerance test is ordered. The order reads, The order reads, “Administer glucose 1.0 “Administer glucose 1.0 g/kg.” The client weighs g/kg.” The client weighs 240 pounds. The nurse 240 pounds. The nurse should administer:should administer:( ___ pounds= 1 kg)( ___ pounds= 1 kg)Answer: ________________Answer: ________________


25. A female client has a 25. A female client has a tentative diagnosis of tentative diagnosis of Cushing’s syndrome. The Cushing’s syndrome. The nurse’s physical assessment of nurse’s physical assessment of this client will probably include this client will probably include the findings of:the findings of:

1.1. Fever and tachycardiaFever and tachycardia

2.2. Lethargy and constipationLethargy and constipation

3.3. Hypertension and moon-faceHypertension and moon-face

4.4. Hyperactivity and exopthalmosHyperactivity and exopthalmos Mosby, Mosby,

20042004

26. The lab findings of a 40 yo 26. The lab findings of a 40 yo man with burns are: BUN, man with burns are: BUN, 30mg/dL; serum potassium, 30mg/dL; serum potassium, 6.3mEq/L; pH, 7.1; PO2, 90mm Hg; 6.3mEq/L; pH, 7.1; PO2, 90mm Hg; and Hgb, 7.4 g/dL. The nurse is and Hgb, 7.4 g/dL. The nurse is aware that these findings indicate:aware that these findings indicate:

1.1. AzotemiaAzotemia

2.2. HypokalemiaHypokalemia

3.3. Metabolic AlkalosisMetabolic Alkalosis

4.4. Respiratory AlkalosisRespiratory Alkalosis Mosby, Mosby,

20042004

Normal Lab ValuesNormal Lab Values

BUN = 5-20BUN = 5-20 K+= 3.5-5.5K+= 3.5-5.5 Hgb= 12-15Hgb= 12-15 Na+= 135-145Na+= 135-145 pH = 7.35-7.45pH = 7.35-7.45 PO2= 80-100PO2= 80-100

27. When teaching a client 27. When teaching a client how to avoid dumping how to avoid dumping syndrome following a syndrome following a gastrectomy, the nurse should gastrectomy, the nurse should emphasize:emphasize:

1.1. Increasing activity after eatingIncreasing activity after eating

2.2. Avoiding excess fluids with mealsAvoiding excess fluids with meals

3.3. Eating heavy meals to delay Eating heavy meals to delay emptyingemptying

4.4. Providing carbohydrates with each Providing carbohydrates with each mealmeal Mosby, 2004Mosby, 2004

28. The nurse is preparing to 28. The nurse is preparing to change a client’s dressing. The change a client’s dressing. The statement that best explains the statement that best explains the basis of surgical asepsis that the basis of surgical asepsis that the nurse will perform in this nurse will perform in this procedure is:procedure is:1.1. Keep the area free of microorganismsKeep the area free of microorganisms2.2. Protect self from microorganisms to the Protect self from microorganisms to the

surgical sitesurgical site3.3. Confine the microorganisms to the surgical Confine the microorganisms to the surgical

sitesite4.4. Keep the number of opportunistic Keep the number of opportunistic

microorganisms to a minimummicroorganisms to a minimum Mosby, 2004Mosby, 2004

29. A 30 yo female dancer notices a mole 29. A 30 yo female dancer notices a mole on her ankle has turned dark brown and on her ankle has turned dark brown and seeks medical attention. A diagnosis of seeks medical attention. A diagnosis of malignant melanoma is made. This client malignant melanoma is made. This client has increased her chance of survival by has increased her chance of survival by early tx, b/c melanoma spreads quickly. The early tx, b/c melanoma spreads quickly. The nurse recognizes that melanoma spreads:nurse recognizes that melanoma spreads:

1.1. By seeding across membranes of body By seeding across membranes of body tissuestissues

2.2. By runner-like chains of cells to satellite By runner-like chains of cells to satellite tumorstumors

3.3. Through invasion of the lymphatic Through invasion of the lymphatic system and bloodstreamsystem and bloodstream

4.4. Through direct extension into Through direct extension into subcutaneous tissue to bonesubcutaneous tissue to bone

Mosby, Mosby, 20042004

Melanoma Normal Melanoma Normal NeviNevi

30. A client with burns 30. A client with burns develops a wound infection. develops a wound infection. The nurse knows that local The nurse knows that local wound infections are primarily wound infections are primarily treated with:treated with:

1.1. Oral antibioticsOral antibiotics

2.2. Topical antibioticsTopical antibiotics

3.3. IV antibioticsIV antibiotics

4.4. IM antibioticsIM antibiotics Mosby, Mosby,

20042004

31.31.A client is admitted to the A client is admitted to the hospital after sustaining a head hospital after sustaining a head injury. The most reliable sign injury. The most reliable sign that this is client is that this is client is experiencing an increase in experiencing an increase in intracranial pressure would be intracranial pressure would be a slowly:a slowly:

1.1. Rising RRRising RR2.2. Narrowing pulse pressureNarrowing pulse pressure3.3. Decrease in level of consciousDecrease in level of conscious4.4. Increasing diastolic blood pressureIncreasing diastolic blood pressure


32. A client has been admitted to 32. A client has been admitted to the emergency department with the emergency department with multiple injuries including multiple injuries including fractured ribs. Because of the fractured ribs. Because of the client’s fractured ribs, the nurse client’s fractured ribs, the nurse should assess for signs of:should assess for signs of:

1.1. PneumonitisPneumonitis2.2. HematemesisHematemesis3.3. Pulmonary EdemaPulmonary Edema4.4. Respiratory acidosisRespiratory acidosis


33. A client is placed on a 33. A client is placed on a ventilator. Because ventilator. Because hyperventilation can occur when hyperventilation can occur when mechanical ventilation is used, the mechanical ventilation is used, the nurse should monitor the client for nurse should monitor the client for signs of:signs of:

1.1. HypoxiaHypoxia2.2. HypercapniaHypercapnia3.3. Metabolic AcidosisMetabolic Acidosis4.4. Respiratory AlkalosisRespiratory Alkalosis


34. A 21yo client comes to the ED 34. A 21yo client comes to the ED with chief complaint of left sided with chief complaint of left sided chest pain following racquetball chest pain following racquetball game. A chest x-ray reveals a left game. A chest x-ray reveals a left pneumothorax. When assessing pneumothorax. When assessing the left side of the client’s chest, the left side of the client’s chest, the nurse would expect to find:the nurse would expect to find:

1.1. A dull sound on percussionA dull sound on percussion2.2. Vocal fremitus on palpationVocal fremitus on palpation3.3. Rales and rhonchi on auscultationRales and rhonchi on auscultation4.4. An absence of breath sounds on auscultationAn absence of breath sounds on auscultation


35. A client with end-stage renal dz is 35. A client with end-stage renal dz is receiving continous ambulatory receiving continous ambulatory peritoneal dialysis. The nurse is peritoneal dialysis. The nurse is preparing to teach the client to monitor preparing to teach the client to monitor for signs of complications associated with for signs of complications associated with peritoneal dialysis. Check all the peritoneal dialysis. Check all the complications that should be included in complications that should be included in this teaching plan.this teaching plan.____Pruritus____Pruritus

____Oliguria____Oliguria

__x__Tachycardia__x__Tachycardia

__x__Cloudy Outflow__x__Cloudy Outflow

__x_Abdominal Pain__x_Abdominal Pain Mosby, 2004Mosby, 2004

36. A client with a distal femoral 36. A client with a distal femoral fracture is placed in skeletal fracture is placed in skeletal traction. The nurse is aware that traction. The nurse is aware that the weights would only be the weights would only be removed if:removed if:

1.1. There is a life-threatening situationThere is a life-threatening situation

2.2. The client complains of intense painThe client complains of intense pain

3.3. There is evidence of external rotationThere is evidence of external rotation

4.4. The cords have become twisted during The cords have become twisted during turningturning


MED-SURG REVIEW Makeba Felton, RN, MSN, FNPC Spring, 2007.

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Transcript of MED-SURG REVIEW Makeba Felton, RN, MSN, FNPC Spring, 2007.