Nursing Board Review: Medical Surgical Nursing Practice Test Part 2 (Practice Mode

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Correct Mang Edison is on bed rest has developed an ulcer that is full thickness and is penetrating the subcutaneous tissue. The nurse documents Q.1) that this ulcer is in which of the following stages? Stage 1 A. Stage 2 B. Stage 3 (Your Answer) C. Stage 4 D. Explanation A stage 3 ulcer is full thickness involving the subcutaneous tissue. A stage 1 ulcer has a defined area of persistent redness in lightly pigmented skin. A stage 2 ulcer involves partial thickness skin loss. Stage 4 ulcers extend through the skin and exhibit tissue necrosis and muscle or bone involvement. Correct Joseph has been diagnosed with hepatic encephalopathy. The nurse observes flapping tremors. The nurse understands that flapping tremors associated with hepatic encephalopathy are also known as:

Q.2)

A. Aphasia B. Ascites C. Astacia D. asterixis (Your Answer) Explanation Flapping tremors associated with hepatic encephalophaty are asterixis. Aphasia is the inability to speak. Ascites is an accumulation of fluid in the peritoneal cavity. Astacia is the inability to stand or sit still. Incorrect A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL. Which of the following complaints would be indicative of tissue Q.3) hypoxia related to anemia? A. B. C. D. dizziness (Correct Answer) fatigue relieved by rest (Your Answer) skin that is warm and dry to the touch Apathy

C and D are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. Administer OTC analgesics for pain Explanation Options B. Explanation Heavy lifting is one factor that leads to development of a hiatal hernia. away from the body (Your Answer) B. Fair-skinned individuals are not prone to this condition. Administer narcotic analgesics for pain D.5) Q. Correct Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis? A. A dietary plan based on soft foods B. Dietary factors involve limiting fat intake. Correct Nurse Marian is caring for a client with haital hernia. to the right of the body D. Apply heat compress to the affected area (Your Answer) B. Correct The proper way to open an envelop-wrapped sterile package after removing the outer package or tape is to open the first position of the wrapper: A. not restricting client to soft foods. which of the following should be included in her teaching plan regarding causes: Q. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilation. Its prevalence in young adults C. to the left of the body C. It is more prevalent in individuals who are middle-aged or older.6) To avoid heavy lifting (Your Answer) A. Immobilize the affected area C. Recognition of cerebral hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs. toward the body Explanation When opening an envelop-wrapped sterile package. reaching across the package and using the first motion to open the top cover away from . Its prevalence in fair-skinned individuals D.Q.4) Explanation Central tissue hypoxia is commonly associated with dizziness.

Correct Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. deep vein thrombosis (DVT) (Your Answer) C. Glucose D. B.9) appropriate? A. Options A. to the left. opening the first portion of the package toward. Which of the following intervention would be most Q. C. B and D aren’t likely complications of the post operative period. Explanationa DVT. or to the right of the body would require reaching across a sterile field. BUN/Crea (Your Answer) C. D. To remove equipment from the package. Encourage him to maintain bed rest for several days Monitor temperature every 4 hours Instruct him to avoid sexual contact during acute phases of illness (Your Answer) Encourage him to use antifungal agents regularly . Alanine amino transferase (ALT) Explanation The BUN is primarily used as indicator of kidney function because most renal diseases interfere with its excretion and cause blood vessels to rise. is the most probable complication for postoperative patients on bed rest. arterial bleeding B. The nurse understands that a postoperative patient who’s Q. Correct A 24 year old male patient comes to the clinic after contracting genital herpes.7) maintained on bed rest is at high risk for developing: Q. Correct What laboratory test is a common measure of the renal function? A.the body eliminates the need to later reach across the steri9le field while opening the package. according to the amount of muscle mass and is excreted entirely by the kidneys making it a good indicator of renal function.8) Angina A. dehiscence of the wound D. Creatinine is produced in relatively constant amounts. CBC B.

9 degrees C oral temperature and exhibits a wet. Dissecting thoracic aneurysm (Your Answer) Explanation A dissecting thoracic aneurysm may cause loss of radical pulses and severe chest and back pain. CVA C. An MI typically doesn’t cause loss of radial pulses or severe back pain. C. An antifungal would not be useful. wait an hour and give the other half Call the physician . Murray may have: A. Prior to giving the medication. a nosocomial infection (Your Answer) C. the nurse checks the digoxin level which is therapeutic and ausculates an apical pulse. Acute MI B. The nurse should: A. B. And an opportunistic infection affects a compromised host. The apical pulse is 63 bpm for 1 full minute. Dissecting abdominal aorta D. The nurse assesses the patient with understanding that an infection that is acquired during hospitalization is known as: a community acquired infection A. An iatrogenic infection is caused by the doctor or by medical therapy. CVA and dissecting abdominal aneurysm are incorrect responses. Four days after surgery. 32 years old complains of abrupt onset of chest and back pain and loss of radial pulses. bed rest and temperature measurement are usually not necessary.10) Hazel Murray.11) A patient is admitted to the medical surgical unit following surgery. Correct Q. The nurse suspects that Mrs. Hold the Lanoxin Give the half dose now. Community acquired or opportunistic infections may not be acquired during hospitalization.Explanation Herpes is a virus and is spread through direct contact. productive cough. or hospital-acquired are infections acquired during hospitalization for which the patient isn’t being primarily treated. Correct Q. an iatrogenic infection B.12) A client with congestive heart failure has digoxin (Lanoxin) ordered everyday. the patient spikes a 38. an opportunistic infection D. Correct Q. Explanation Nosocomial.

breathing and circulation. The nurse understands that the most common cause of dementia in this population is: A. Nurses cannot arbitrarily give half of a dose without a physician’s order. Fluid volume excess (Your Answer) C. Correct Q. C. Give the Lanoxin as ordered (Your Answer) Explanation The Lanoxin should be held for a pulse of 60 bpm. Correct Q. The nurse will also assess options B and D. The doctor orders a series of laboratory tests to determine whether Mr. Risk for injury D. Anxiety related to disease process B. Correction is aimed at restoring fluid and electrolyte balance. Elison’s dementia is treatable.13) Nurse Alexandra is establishing a plan of care for a client newly admitted with SIADH. Priority assessment would include which of the following? A. most resources identify 60 as the reference pulse. AIDS Alzheimer’s disease (Your Answer) Brain tumors Vascular disease .15) Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia. Patency of airway (Your Answer) D. Airway always comes first. even before pain. but these are not the highest priority assessments. Anxiety and risk for injury should be addressed following fluid volume excess. Unless specific parameters are given concerning pulse rate. Skin integrity B. BP and pulse C. D. B. Amount of pain Explanation A burn face. Correct Q.14) An 8 year old boy is brought to the trauma unit with a chemical burn to the face. neck or chest may cause airway closure because of the edema that occurs within hours.D. Remember the ABC’s: airway. Explanation SIADH results in fluid retention and hyponatremia. The priority diagnosis for this client would be which of the following? Fluid volume deficit A.

fluid accumulations is usually in the form of ascites in the abdomen. Which of the following findings would strongly indicate the possibility of cirrhosis? dry skin B. Hepatomegaly is an enlarged liver. Explanation Typically. gradual loss of vision. hepatomegaly (Your Answer) C. The dextrose doesn’t directly cause potassium excretion or any movement of potassium.Explanation Alzheimer’s disease is the most common cause of dementia in the elderly population. gradual blurring (Your Answer) B. causes potassium to be excreted B. causes potassium to move into the serum D. Correct Which of the following statement is true regarding the visual changes associated with cataracts? Q. The loss of vision is experienced as a painless.16) Which of the following findings would strongly indicate the possibility of cirrhosis? A. Insulin drives the potassium into the cell. The patient is typically experiences a painful. Correct Hyperkalemia can be treated with administration of 50% dextrose and insulin. AIDS. sudden blurring of vision. The 50% dextrose: A. thereby lowering the serum potassium levels. D. The spleen may also be enlarged. a patient with cataracts experiences painless.17) Both eyes typically cataracts at the same time A. The patient is suddenly blind C. counteracts the effects of insulin (Your Answer) Explanation The 50% dextrose is given to counteract the effects of insulin. Pruritus Explanation Although option D is correct. which is correct. brain tumors and vascular disease are all less common causes of progressive loss of mental function in elderly patients. causes potassium to move into the cell C.18) . Correct Q. peripheral edema D. it is not a strong indicator of cirrhosis. Q. Options A and C are incorrect. Although both eyes may develop at different rates. Pruritus can occur for many reasons.

Explanation Chvostek’s sign is a spasm of the facial muscles elicited by tapping the facial nerve and is associated with hypocalcemia. The client complains of extreme pain in the calf. and option D is typical of someone with COPD. C. D. Correct Q. Hypokalemia B. and has a respiratory rate of 34 breaths per minute. Temperature of 102 degrees F and productive cough B. leg cramps. values in option B are not alarming. nausea and vomiting. confusion. assessment would be targeted at acute traumatic injuries to the lungs.Correct Q. Barrel-chested appearance Explanation A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. positive tourniquet test positive homan’s sign (Your Answer) negative homan’s sign negative tourniquet test . Correct Q. Clinical signs of hypokalemia are muscle weakness. Muscle cramps.21) Assessment of a client with possible thrombophlebitis to the left leg and a deep vein thrombosis is done by pulling up on the toes while gently holding down on the knee. Hyponatremia C. seizures and coma. Since the individual was involved in a MVA. Clinical manifestations associated with hypophosphatemia include muscle pain. Which of the following assessment findings would concern the nurse most? A. anorexia. decrease breath sounds on the left. B. nausea and vomiting are clinical signs of hyponatremia. ABG with PaO2 of 92 and PaCO2 of 40 mmHg C. The client is exhibiting crepitus. Trachea deviating to the right (Your Answer) D. heart or chest wall rather than other conditions indicated in the other answers. complains of shortness of breath. Option A is common with pneumonia.20) A client was involved in a motor vehicular accident in which the seat belt was not worn. Hypophosphatenia D. fatigue.19) Chvostek’s sign is associated with which electrolyte impabalnce? hypoclacemia (Your Answer) A. This should be documented as: A.

Correct Q.5 g/dL. thus increase the signs and symptoms of UTI. Douching daily Explanation Caffeine and alcohol can increase bladder spasms and mucosal irritation. it is considered negative. Assisting in ambulation to the bathroom (Correct Answer) D. Halo vision. The nurse assesses the client for which of the following common presenting symptoms of the disorder? halo vision A. Decreasing caffeine drinks and alcohol (Your Answer) D. dull eye pain B. All antibiotics should be taken completely to prevent resistant strains of organisms. dull eye pain and impaired night vision are symptoms associated with open-angle glaucoma. The greatest potential risk to the client with dizziness is injury.22) Nursing management of the client with a UTI should include: A. Restricting fluids C. Taking medication until feeling better B. Providing rest periods throughout the day B.Explanation Pain in the calf while pulling up on the toes is abnormal and indicates a positive test. Explanation Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medial emergency. If the client feels nothing or just feels like the calf muscle is stretching. impaired night vision D. especially . Which of the following nursing interventions would be most important in providing care? A. Correct Q. Instituting energy conservation techniques (Your Answer) C.23) Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma. Incorrect Q. The client is experiencing symptoms of cerebral tissue hypoxia.24) A client with anemia has a hemoglobin of 6. A tourniquet test is used to measure for varicose veins. severe eye and face pain (Your Answer) C. Checking temperature of water prior to bathing Explanation Cerebral tissue hypoxia is commonly associated with dizziness.

150 mg/dl Explanation Hyperglycemia is defined as a blood glucose level greater than 120 mg/dl. . 130 mg/dl D. 120 mg/dl (Your Answer) C. Correct Q. 100 mg/dl B.25) Nurse Edward is performing discharge teaching for a newly diagnosed diabetic patient scheduled for a fasting blood glucose test. 130 mg/dl and 150 mg/dl are considered hyperglycemic. Planning for periods of rest and conserving energy are important with someone with anemia because of his or her fatigue level but most important is safety.with changes in position. Blood glucose levels of 120 mg/dl. The nurse explains to the patient that hyperglycemia is defined as a blood glucose level above: A. A blood glucose of 100 mg/dl is normal.

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