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NCLEX-RN Med Surg Exam 2022-
Guide
1. 1. Question
A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? o A. Sexual dysfunction related to radiation therapy o B. Anticipatory grieving related to terminal illness o C. Tissue integrity related to prolonged bed rest o D. Fatigue related to chemotherapy Correct Answer: A. Sexual dysfunction related to radiation therapy Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Know the importance of sex to individual, partner, and patient’s motivation for change. Because lymphomas often affect the relatively young who are in their productive years, these people may be affected more by these problems and may be less knowledgeable about the possibilities of change. o Option B: Grieving may not be an appropriate diagnosis since the client would be experiencing new milestones in his life despite his condition. Let the patient describe the problem in own words. Provides a more accurate picture of
• 2. Question
A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor: o A. Platelet count o B. White blood cell count o C. Potassium levels o D. Partial prothrombin time (PTT) o Option B: Often associated with the CBC is a differential, which refers to the relative amounts of white blood cell types (i.e., neutrophil, lymphocyte, eosinophil, etc.) as a percentage of the total number of WBCs. Of note, if a subtype of white blood cells seems to be elevated based on the differential, the actual value of the type of white blood cells should be Correct Answer: A. Platelet count Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. The laboratory tests will show low platelet count, usually <40× 1 0^9/L for over three months. Blood film shows large platelets and tiny platelet fragments. Bone marrow examination shows an increased number of megakaryocytes. o Option C: Option B is not applicable since the client is not on bed rest. Encourage the patient to share thoughts and concerns with his partner and to clarify values and impact of condition on relationship. Helps the couple begin to deal with issues that can strengthen or weaken the relationship. o Option D: Fatigue may occur during chemotherapy, but it is not the priority diagnosis. Identify pre-existing and current stress factors that may be affecting the relationship. The patient may be concerned about other issues, such as job, financial, and
risk patient and caregivers about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. o Option B: Thoroughly conform patient to surroundings; put call light within reach and teach how to call for assistance; respond to call light immediately; avoid use of restraints; obtain a physician’s order if restraints are needed; and eliminate or drop all possible hazards in the room such as razors, medications, and matches. o Option C: Option C is important, but platelets do not carry oxygen. Wash hands and teach patient and SO to wash hands before contact with patients and between procedures with the patient; encourage fluid intake of 2,000 to 3, mL of water per day, unless contraindicated. o Option D: Option D is of lesser priority and is in this instance. Recommend the use of soft- bristled toothbrushes and stool softeners to protect mucous membranes; and if infection occurs, teach the patient to take antibiotics as prescribed; instruct the patient to take the full course of antibiotics even if symptoms improve or disappear.
• 4. Question
A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client? o A. Place the client in Trendelenburg position for postural drainage o B. Encourage coughing and deep breathing every 2 hours o C. Elevate the head of the bed 30° o D. Encourage the Valsalva maneuver for bowel movements Correct Answer: C. Elevate the head of the bed 30°
Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. A, B, and D are. In the immediate postoperative period, patients are monitored in an intensive care unit with monitoring for neurological deterioration, epistaxis, visual dysfunction, diabetes insipidus (DI), and hypotension secondary to acute hypocortisolism. o Option A: Placing the patient in Trendelenburg will increase the intracranial pressure. The most common complications are CSF leak, sinusitis, and meningitis. CSF leaks, occurring in 6 in every 100 cases, is usually prevented by a multilayer closure at the end of surgery. In the occurrence of a leak in the postoperative period, the patient is advised bed rest, and a lumbar drain is placed. If the leak does not improve in 24 hours, exploration and closure of the defect are to be done. o Option B: Coughing and deep breathing causes increase in intracranial pressure. Worsening of vision as a result of bleeding or manipulation and arterial hemorrhage are other immediate complications. A detailed study of preoperative imaging is essential to avoid catastrophes like optic nerve and carotid artery injury. o Option D: Valsalva maneuver increases the intracranial pressure. The first follow up visit is 1 week after the procedure, where postoperative day 7 serum sodium levels are reviewed to rule out occult hyponatremia. Serial nasal endoscopies are done for debridement and to assess healing. The frequency of follow-up visits is determined by nasal crusting and maintenance of nasal hygiene with irrigation. Routine early postoperative imaging is not done in most patients.
• 5. Question
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: o A. Measure the urinary output
o B. Pack the nares tightly with gauze to apply pressure to the source of bleeding o C. Pinch the soft lower part of the nose for a minimum of 5 minutes o D. Apply ice packs to the forehead and back of the neck Correct Answer: C. Pinch the soft lower part of the nose for a minimum of 5 minutes The client should be positioned upright and leaning forward, to prevent aspiration of blood. Usual sites of external bleeding may include the bleeding in the mouth from a cut, bite, or from cutting or losing a tooth; nosebleeds for no obvious reasons; heavy bleeding from a minor cut, or bleeding from a cut that resumes after stopping for a short time. Hemophiliacs do not bleed faster or more frequently. Instead, they bleed longer due to a deficiency of clotting factor. Clients are often aware of bleeding before clinical manifestation. Bleeding can be life- threatening to these clients.
o Option A: Direct pressure to the nose stops the bleeding. Apply manual or mechanical pressure if active bleeding is noted. If spontaneous or traumatic bleeding is evident, monitor vital signs. o Option B: If a pack is necessary, the nares are loosely packed. Controlling bleeding is a nursing priority. Nasal packing should be avoided, because the subsequent removal of the packing may precipitate further bleeding. o Option D: Ice packs should be applied directly to the nose as well. Assess for any signs of bruising and bleeding (note the extent of bleeding). Assess for prolonged bleeding after minor injuries.
Question
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is:
o A. Blood pressure
adrenal surgeon (>/=6 adrenalectomies/year).
• 8. Question
A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? o A. Daily weights o B. Intake/output measurements o C. Sodium and potassium levels monitored o D. Glucometer readings as ordered Correct Answer: D. Glucometer readings as ordered IV glucocorticoids raise the glucose levels and often require coverage with insulin. Cortisone and prednisone replace cortisol deficits, which will promote sodium reabsorption. Fludrocortisone is a mineralocorticoid for patients who require aldosterone replacement to promote sodium and water replacement. Acute adrenal insufficiency is a medical emergency requiring immediate fluid and corticosteroid administration. If treated for adrenal crisis, the patient requires IV hydrocortisone initially; usually by the second day, administration can be converted to an oral form of replacement. o Option A: Daily weights are unnecessary. Monitor trends in weight. This provides documentation of weight loss trends. Weight loss is a common manifestation of adrenal insufficiency. o Option B: Intake/output measurements are not necessary at this time. Assess vital signs, especially noting BP and HR for orthostatic changes. A BP drop of more than 15 mm Hg when changing from supine to sitting position, with a concurrent elevation of 15 beats per min in HR, indicates reduced circulating fluids. o Option C: Sodium and potassium levels would be monitored when the client is receiving mineralocorticoids. Abnormal laboratory findings include hyperkalemia (related to aldosterone
• 10. Question
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? o A. Impaired physical mobility related to decreased endurance o B. Hypothermia r/t decreased metabolic rate o C. Disturbed thought processes r/t interstitial edema o D. Decreased cardiac output r/t bradycardia Correct Answer: D. Decreased cardiac output r/t bradycardia The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices. Protect against coldness. Provide extra layers of clothing or extra blankets. Discourage and avoid the use of external heat sources. Monitor patient’s body temperature. o Option A: Impaired physical mobility is not applicable to a client with hypothyroidism. Promote rest. Space activities to promote rest and exercise as tolerated. Assess the client’s ability to perform activities of daily living (ADLs). The client may experience fatigue with minimal exertion due to a slow metabolic rate. This symptom hinder the client’s ability to perform daily activities (e.g., self-care, eating) o Option B: Hypothermia is correct but not a priority. Teach the expected benefits and possible side effects. The client should report symptoms such as chest pain/palpitations; these happen due to the increased metabolic and thyroidectomy may result in increased hormone release, causing thyroid storm.
oxygen consumption. o Option C: Disturbed thought processes is not a related diagnosis. Assess the client’s appetite. Clients
• 12. Question
The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching? o A. The nursing assistant wears gloves while giving the client a bath. o B. The nurse wears goggles while drawing blood from the client. o C. The doctor washes his hands before examining the client. o D. The nurse wears gloves to take the client’s vital signs. Correct Answer: D. The nurse wears gloves to take the client’s vital signs. It is not necessary to wear gloves to take the vital signs of the client. If the client has an active infection with methicillin- resistant Staphylococcus aureus, gloves should be worn. Wash hands or perform hand hygiene before having contact with the a balloon angioplasty or stent placement may be performed at the same time. When the procedure is completed, the catheter will be removed, and pressure will be held on the entry site for 10-20 minutes to stop any bleeding. The client may have a compression device applied to stop the bleeding from the angiogram site. This device may stay in place for 1- ½ hours. o Option D: This statement indicates that the nurse believes that the hot feeling is abnormal, so it is. Once the angiogram is completed the client may be on bedrest for 4-6 hours or until he has recovered from sedation. The client will be allowed to eat and will be encouraged to drink fluids to flush the contrast dye from the system. During this time, the catheter insertion site will
patient. Also impart these duties to the patient and their significant others. Know the instances when to perform hand hygiene or “5 moments for hand hygiene”. o Option A: Wear personal protective equipment (PPE) properly. Wear gloves when providing direct care; perform hand hygiene after properly disposing of gloves. Initiate specific precautions for suspected agents as determined by CDC protocol. o Option B: Use masks, goggles, face shields to protect the mucous membranes of your eyes, mouth, and nose during procedures and in direct-care activities (e.g., suctioning secretions) that may generate splashes or sprays of blood, body fluids, secretions, and excretions. o Option C: The health care workers indicate knowledge of infection control by their actions. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another. Wash hands with antiseptic soap and water for at least 15 seconds followed by an alcohol- based hand rub. If hands were not in contact with anyone or anything in the room, use an alcohol- based hand rub and rub until dry. Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based hand rubs are the best.
• 13. Question
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? o A. The client loses consciousness. o B. The client vomits. o C. The client’s ECG indicates tachycardia. o D. The client has a grand mal seizure. Correct Answer: D. The client has a grand mal
o B. Scrape the skin with a piece of cardboard and bring it to the clinic o C. Obtain a stool specimen in the afternoon o D. Bring a hair sample to the clinic for evaluation Correct Answer: A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. o Option B: Pinworms do not burrow under the skin, therefore scraping the skin for examination would not reveal pinworms. Enterobius can be diagnosed through a cellophane tape test or pinworm paddle test where an adhesive tape-like material is applied to the perianal area and then examined under a microscope. o Option C: Pinworms are not usually detected in stools. Stool examination is not helpful in the diagnosis of E. vermicularis as they are only occasionally excreted in the stool usually. Sometimes analysis of the stool specimen is recommended to rule out other causes. o Option D: Taking a hair sample is inappropriate because pinworms do not live in hair. The examination might reveal characteristic ova which are 50 by 30 microns in size and have a flattened surface on one side or may reveal the worms. Female worms are around 8 to 13 mm long while male worms are 2 to 5 mm long. The examination is usually done in the early morning for higher diagnostic yield.
• 15. Question
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication? o A. Treatment is not recommended for children less than 10 years of age. o B. The entire family should be treated. o C. Medication therapy will continue for 1 year. o D. Intravenous antibiotic therapy will be ordered. Correct Answer: B. The entire family should be treated. Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Enterobiasis can cause recurrent reinfection, so treating the entire household, whether symptomatic or not is recommended to prevent a recurrence. o Option A: Enterobiasis usually occurs in children under 10 years of age. The male-to- female infection frequency is 2 to 1. However, a female predominance of infection is seen in those between the ages of 5 and 14 years. It most commonly affects children younger than 18 years of age. It is also commonly seen in adults who take care of children and institutionalized children. o Option C: The medications used for the treatment of pinworm are either mebendazole, pyrantel pamoate, or albendazole. Any of these drugs are given in one dose initially, and then another single dose of the same drug two weeks later. o Option D: Oral antibiotics are the most recommended form of treatment for enterobiasis. Young pinworms tend to be resistant to treatment and hence two doses of medication, two weeks apart are recommended. At the same time, all members of the infected child must be
