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NCLEX Questions - MEDICAL SURGICAL NURSING-1 PDF
NCLEX Questions - MEDICAL SURGICAL NURSING-1 PDF
RESPIRATORY SYSTEM:
3. What symptoms of pneumonia might the nurse expect to see in an older client?
- Confusion, lethargy, anorexia, rapid respiratory rate.
4. What should the O2 flow rate be for the client with COPD?
- 1-2 liters per nasal cannula, too much O2 may eliminate the COPD client’s stimulus
to breathe, a COPD client has hypoxic drive to breathe.
7. When examining a client with emphysema, what physical findings is the nurse
likely to see?
- Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in
lung fields.
8. What is the most common risk factor associated with lung cancer?
- Smoking
13. What precautions are required for clients with TB when placed on respiratory
isolation?
- Mask for anyone entering room; private room; client must wear mask if leaving room.
RENAL SYSTEM:
2. During the oliguric phase of renal failure, protein should be severely restricted.
What is the rationale for this restriction?
- Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly
from protein catabolism.
4. What is the highest priority nursing diagnosis for clients in any type of renal
failure?
- Alteration in fluid and electrolyte balance.
5. A client in renal failure asks why he is being given antacids. How should the
nurse reply?
- Calcium and aluminum antacids bind phosphates and help to keep phosphates from
being absorbed into blood stream thereby preventing rising phosphate levels, and
must be taken with meals.
6. List 4 essential elements of a teaching plan for clients with frequent urinary tract
infections.
- Fluid intake 3 liters/day; good handwashing; void every 2-3 hours during waking
hours; take all prescribed medications; wear cotton undergarments.
7. What are the most important nursing interventions for clients with possible
renal calculi?
- Strain all urine is the MOST IMPORTANT intervention. Other interventions include
accurate intake and output documentation and administer analgesics as needed.
8. What discharge instructions should be given to a client who has had urinary
calculi?
- Maintain high fluid intake 3-4 liters per day. Follow-up care (stones tend to recur).
Follow prescribed diet based in calculi content. Avoid supine position.
10. After the urinary catheter is removed in the TURP client, what are 3 priority
nursing actions?
- Continued strict I&O; continued observations for hematuria; inform client burning
and frequency may last for a week.
11. After kidney surgery, what are the primary assessments the nurse should make?
- Respiratory status (breathing is guarded because of pain); circulatory status (the
kidney is very vascular and excess bleeding can occur); pain assessment; urinary
assessment most importantly, assessment of urinary output.
CARDIOVASCULAR SYSTEM:
9. What lab values should be monitored daily for the client with thrombophlebitis
who is undergoing anticoagulant therapy?
- PTT, PT, Hgb, and Hct, platelets.
11. Differentiate between the symptoms of left-sided cardiac failure and right-sided
cardiac failure.
- Left-sided failure results in pulmonary congestion due to back-up of circulation in the
left ventricle. Right-sided failure results in peripheral congestion due to back-up of
circulation in the right ventricle.
14. What life style changes can the client who is at risk for hypertension initiate to
reduce the likelihood of becoming hypertensive?
- Cease cigarette smoking if applicable, control weight, exercise regularly, and
maintain a low-fat/low-cholesterol diet.
15. What immediate actions should the nurse implement when a client is having a
myocardial infarction?
- Place the client on immediate strict bedrest to lower oxygen demands of heart,
administer oxygen by nasal cannula at 2-5 L/min., take measures to alleviate pain and
anxiety (administer prn pain medications and anti-anxiety medications).
16. What symptoms should the nurse expect to find in the client with hypokalemia?
- Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and
tachycardia.
17. Bradycardia is defined as a heart rate below ___ BPM. Tachycardia is defined
as a heart rate above ___ BPM.
- bradycardia 60 bpm; tachycardia 100 bpm
18. What precautions should clients with valve disease take prior to invasive
procedures or dental work?
- Take prophylactic antibiotics.
GASTROINTESTINAL SYSTEM:
5. List 4 nursing interventions for post-op care of the client with a colostomy.
- Irrigate daily at same time; use warm water for irrigations; wash around stoma with
mild soap/water after each colostomy bag change; pouch opening should extend at
least 1/8 inch around the stoma.
7. What are the common food intolerances for clients with cholelithiasis?
- Fried/spicy or fatty foods.
8. List 5 symptoms indicative of colon cancer.
- Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal
pain with nausea, weight loss.
10. What is the main side effect of lactulose, which is used to reduce ammonia levels
in clients with cirrhosis?
- Diarrhea.
ENDOCRINE SYSTEM:
4. List 5 important teaching aspects for clients who are beginning corticosteroid
therapy.
- Continue medication until weaning plan is begun by physician, monitor serum
potassium, glucose, and sodium frequently; weigh daily, and report gain of >5lbs./wk;
monitor BP and pulse closely; teach symptoms of Cushing’s syndrome
10. Name the necessary elements to include in teaching the new diabetic.
- Teach the underlying pathophysiology of the disease, its management/treatment
regime, meal planning, exercise program, insulin administration, sick-day
management, symptoms of hyperglycemia (not enough insulin)
11. In less than ten steps, describe the method for drawing up a mixed dose of
insulin (regular with NPH).
- Identify the prescribed dose/type of insulin per physician order; store unopened
insulin in refrigerator. If opened, may be kept at room temperature for up to 3 months.
Draw up regular insulin FIRST. Rotate injection sites. May reuse syringe by
recapping and storing in refrigerator.
12. Identify the peak action time of the following types of insulin: rapid-acting
regular insulin, intermediate-acting, long-acting.
- Rapid-acting regular insulin: 2-4 hrs. Immediate-acting: 6-12 hrs. Long-acting: 14-
20 hrs.
13. When preparing the diabetic for discharge, the nurse teaches the client the
relationship between stress, exercise, bedtime snacking, and glucose balance.
State the relationship between each of these.
- Stress and stress hormones usually increase glucose production and increase insulin
need; exercise can increase the chance for an insulin reaction, therefore, the client
should always have a sugar snack available when exercising (to treat hypoglycemia);
bedtime snacking can prevent insulin reactions while waiting for long-acting insulin
to peak.
14. When making rounds at night, the nurse notes that an insulin-dependent client is
complaining of a headache, slight nausea, and minimal trembling. The client’s
hand is cool and moist. What is the client most likely experiencing?
- Hypoglycemia/insulin reaction.
15. Identify 5 foot-care interventions that should be taught to the diabetic client.
- Check feet daily & report any breaks, sores, or blisters to health care provider, wear
well-fitting shoes; never go barefoot or wear sandals, never personally remove corns
or calluses, cut or file nails straight across; wash daily with mild soap & warm water.
MUSCULOSKELETAL SYSTEM:
1. Differentiate between rheumatoid arthritis and degenerative joint disease in
terms of joint involvement.
- Rheumatoid arthritis occurs bilaterally. Degenerative joint disease occurs
asymmetrically.
4. What measures should the nurse encourage female clients to take to prevent
osteoporosis?
- Estrogen replacement after menopause, high calcium and vitamin D intake beginning
in early adulthood, calcium supplements after menopause, and weight-bearing
exercise.
6. What is the priority nursing intervention used with clients taking NSAIDs?
- Administer or teach client to take drugs with food or milk.
8. Describe post-op stump care (after amputation) for the 1st 48 hours.
- Elevate stump first 24 hours. Do not elevate stump after 48 hours. Keep stump in
extended position and turn prone three times a day to prevent flexion contracture.
9. Describe nursing care for the client who is experiencing phantom pain after
amputation.
- Be aware that phantom pain is real and will eventually disappear. Administer pain
medication; phantom pain responds to medication.
10. A nurse discovers that a client who is in traction for a long bone fracture has a
slight fever, is short of breath, and is restless. What does the client most likely
have?
- Fat embolism, which is characterized by hypoxemia, respiratory distress, irritability,
restlessness, fever and petechiae.
11. What are the immediate nursing actions if fat embolization is suspected in a
fracture/orthopedic client?
- Notify physician STAT, draw blood gas results, assist with endotracheal intubation
and treatment of respiratory failure.
1. What are the classifications of the commonly prescribed eye drops for
glaucoma?
- Parasympathominetics for pupillary constriction. Beta-adrenergic receptor-blocking
agents to inhibit formation of aqueous humor. Carbonic anhydrase inhibitors to
reduce aqueous humor production, and prostaglandin agonists to increase aqueous
humor outflow.
3. Write 4 nursing interventions for the care of the blind person and 4 nursing
interventions for the care of the deaf person.
- Care of the blind: announce presence clearly, call by name, orient carefully to
surroundings, guide by walking in front of client with his/her hand in your elbow.
Care of deaf: reduce distraction before beginning conversation, look and listen to
client, give client full attention if they are a lip reader, face client directly.
12. What is the most important principle in a bowel management program for a
neurologic client?
- Establishment of REGULARITY
14. A client with a diagnosis of CVA presents with symptoms of aphasia, right
hemiparesis, but no memory or hearing deficit. In what hemisphere has the
client suffered a lesion?
- Left
19. A neighbor calls the neighborhood nurse stating that he was knocked hard to the
floor by his very hyperactive dog. He is wondering what symptoms would
indicate the need to visit an emergency room. What should the nurse tell him to
do?
- Call his physician now and inform him/her of the fall. Symptoms needing medical
attention would include vertigo, confusion or any subtle behavioral change, headache,
vomiting, ataxia (imbalance), or seizure.
20. What activities and situations should be avoided that increase ICP?
- Change in bed position, extreme hip flexion, endotracheal suctioning, compression of
jugular veins, coughing, vomiting, or straining of any kind.
23. Headache and vomiting are symptoms of many disorders. What characteristics
of these symptoms would alert the nurse to refer a client to a neurologist?
- Headache which is more severe upon awakening and vomiting not associated with
nausea are symptoms of a brain tumor.
24. How should the head of the bed be positioned for post-craniotomy clients with
infratentorial lesions?
- Infratentorial – FLAT; Supratentorial – elevated
27. What types of drugs are used in the treatment of myasthenia gravis?
- Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve
endings to promote the accumulation of acetylcholine at receptor sires, which should
improve neuronal transmission to muscles.
HEMATOLOGY/ONCOLOGY:
1. List 3 potential causes of anemia.
- Diet lacking in iron, folate and/or vitamin B12; use of salicylates, thiazides, diuretics;
exposure to toxic agents such as lead or insecticides.
4. What actions should the nurse take if a hemolytic transfusion reaction occurs?
- Turn off transfusion. Take temperature. Send blood being transfused to lab. Obtain
urine sample. Keep vein patent with normal saline.
11. Describe the method of collecting the trough and peak blood levels of antibiotics.
- Collection of trough: draw blood 30 minutes prior to administration of antibiotic.
Collection of peak: draw blood 30 minutes after administration of antibiotic.
13. List 4 nursing interventions for care of the client with Hodgkin’s disease.
- Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide
emotional support to client and family.
14. List 4 topics you would cover when teaching an immunosuppressed client about
infection control.
- Handwashing technique. Avoid infected persons. Avoid crowds. Maintain daily
hygiene to prevent spread of microorganisms.
REPRODUCTIVE SYSTEM:
1. What are the indications for a hysterectomy in the client who has fibromas?
- Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic
analgesics, severe uterine enlargement causing pressure on other organs, severe low
back and pelvic pain.
3. What are the most important nursing interventions for the postoperative client
who has had a hysterectomy with an A&P repair?
- Avoid rectal temps and/or rectal manipulation; manage pain; and encourage early
ambulation.
4. Describe the priority nursing care for the client who has had radiation implants.
- Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by
small children. Confine client to room. Nurse must wear radiation badge. Nurse
limits time in room. Keep supplies and equipment within client’s reach.
5. What screening tool is used to detect cervical cancer? What are the American
Cancer Society’s recommendations for women ages 30 to 70 with three
consecutive normal results?
- Pap smear. Women ages 30 to 70 with 3 consecutive normal results may have pap
smear every 2 to 3 years.
7. What are the 3 most important tools for early detection of breast cancer? How
often should these tools be used?
- Breast self-exam monthly; mammogram baseline at age 35 followed by exams every
1 to 2 years in 40s and every year after age 50; physical examination by a
professional skilled in examination of the breast.
8. Describe 3 nursing interventions to help decrease edema post mastectomy.
- Position arm on operative side on pillow. Avoid BP measurements, injections, or
venipunctures in operative arm. Encourage hand activity and use.
9. Name 3 priorities to include in a discharge plan for the client who has had a
mastectomy.
- Arrange for Reach-to-Recovery visit. Discuss the grief process with the client. Have
physician discuss with the client the reconstruction options.
13. Which STD is characterized by remissions and exacerbations in both males and
females?
- Herpes Simplex Type II
BURNS:
6. Nutritional status is a major concern when caring for a burned client. List 3
specific dietary interventions used with burned clients.
- High-calorie, high-protein, high-carbohydrate diet. Medications with juice or milk.
NO “free” water. Tube feeding at night. Maintain accurate, daily calorie counts.
Weigh client daily.