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MED-SURG REVIEW Makeba Felton, RN, MSN, FNPC Spring, 2007 NCLEX FORMAT Safe, Effective Care Environment Management of Care Safety and Infection Control Health ... – PowerPoint PPT presentation

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  • Makeba Felton, RN, MSN, FNPC
  • Spring, 2007

  • Safe, Effective Care Environment
  • Management of Care
  • Safety and Infection Control
  • Health Promotion and Maintenance
  • Growth and Development Through the Life Span
  • Prevention and Early Detection of Disease
  • Psychosocial Integrity
  • Coping and Adaptation
  • Psychosocial Adaptation
  • Physiological Integrity
  • Basic Care and Comfort
  • Pharmacological and Parenteral Therapies
  • Reduction of Risk Potential
  • Physiological Adaptation

1. During the acute phase of a cerebrovascular
accident (CVA), the nurse should maintain the
patient in which of the following positions?
  • Semi-prone with the head of the bed elevated
    60-90 degrees.
  • Lateral, with the head of the bed flat.
  • Prone, with the head of the bed flat.
  • Supine, with the head of the bed elevated 30-45
  • Kaplan, 2005

2. A client comes to the ER with c/o n/v and
abdominal pain. He has IDDM. Four days earlier,
he reduced his insulin dose when flu sxs
prevented him from eating. The nurse performs an
assessment of the pt which reveals poor skin
turgor, dry mucous membranes, and fruity breath
odor. The nurse should be alert for which of the
following problems?
  • 1. Hypoglycemia
  • 2. Viral Illness
  • 3. Ketoacidosis
  • 4. Hyperglycemic Hyperosmolar Nonketotic
    Coma Kaplan, 2005

A pt hospitalized with a gastric ulcer is
scheduled for discharge. The nurse teaches the
pt about an anti-ulcer diet. Which of the
following statements, if made by the pt, would
indicate that dietary teaching was successful?
  1. I must eat bland foods to help my stomach heal.
  2. I can eat most foods, as long as they dont
    bother my stomach.
  3. I cannot eat fruits and vegetables because they
    cause too much gas.
  4. I should eat a low-fiber diet to delay gastric
    emptying. Kaplan, 2005

4. The nurse cares for a patient receiving full
strength Ensure by tube feeding. The nurse knows
that the MOST common complication of a tube
feeding is
  • Edema
  • Diarrhea
  • Hypokalemia
  • Vomiting
  • Kaplan, 2005

5. A man is diagnosed with cancer of the larynx
and comes to the hospital for a total
laryngectomy. When admitting this patient, how
should the nurse assess laryngeal nerve function?
  • Assess the extent of neck edema.
  • Check his ability to swallow.
  • Observe for excessive drooling
  • Tap the side of his neck gently and observe for
    facial twitching.
  • Kaplan, 2005

6. The nurse cares for a pt with a possible
bowel obstruction. An NG tube is to be inserted.
Before inserting the tube, the nurse explains
the purpose to the pt. Which of the following
explanations, if made by the nurse, is MOST
  • It empties the stomach of fluids and gas.
  • It prevents spasms of the sphincter of Oddi.
  • It prevents air from forming in the small and
    large intestine.
  • It removes bile from the gall bladder.
  • Kaplan, 2005

7. The nurse evaluates the care provided to a pt
hospitalized for tx of adrenal crisis. Which of
the following changes would indicate to the nurse
that the pt is responding favorably to medical
and ng tx?
  • The pts urinary output has increased.
  • The pts blood pressure has increased.
  • The pt has lost weight.
  • The pts peripheral edema has decreased.
  • Kaplan, 2005

8. The physician orders heparin for a pt. In
order to evaluate the effectiveness of the pts
heparin therapy, the nurse should monitor which
of the following lab values?
  • Platelet count
  • Clotting time
  • Bleeding time
  • Prothrombin time
  • Kaplan, 2005

9. A pt returns to his room following a cardiac
catheterization. Which of the following
assessments, if made by the nurse, would justify
calling the physician?
  • Pain at the site of the catheter insertion.
  • Absence of a pulse distal to the catheter
    insertion site.
  • Drainage on the dressing covering the catheter
    insertion site.
  • Redness at the catheter insertion site.
  • Kaplan, 2005

The nurse is caring for a pt with a cast on the
left leg. The nurse would be MOST concerned if
which of the following were observed?
  • 1. Capillary refill time was less than 3 seconds
  • Pt complained of discomfort and itching.
  • Pt complained of tightness and pain.
  • Pts foot is elevated on a pillow.
  • Kaplan, 2005

11. The home care nurse is visiting a client
with a dx of hepatitis of unknown etiology. The
nurse knows that teaching has been successful if
the pt makes which one of the following
  • I am so sad that I am not able to hold my baby.
  • I will eat after my family eats.
  • I will make sure that my children dont eat or
    drink after me.
  • Im glad that I dont have to get help taking
    care of my children. Kaplan, 2005

12. The nurse is caring for a pt four hours
after intracranial surgery. Which of the
following actions should the nurse take
  • Turn, cough and deep breathe the pt.
  • Place the pt with the neck flexed and head turned
    to the side.
  • Perform passive range of motion exercises.
  • Move client to the head of the be using a turning
  • Kaplan, 2005

13. The nurse is caring for a pt with an acute
myocardial infarction. Which of the following
laboratory findings would MOST concern the nurse?
  • Erythrocyte sedimentation rate (ESR) 10mm/h
  • Hematocrit (Hct) 42
  • Creatine Kinase (CK) 150U/mL
  • Serum Glucose 100mg/ dL
  • Kaplan, 2005

14. The nurse is supervising care of a pt
receiving TPN through a single-lumen percutaneous
central catheter. The nurse would be MOST
concerned if which of the following was observed?
  • The pt receives insulin through the single-lumen
  • A mask is worn when changing the pts dressing.
  • The pts dressing is changed daily using sterile
  • The pt is weighed two or three times per week.
  • Kaplan, 2005

15. The nurse assists the physician with the
removal of a chest tube. Before the physician
removes the chest tube, which instruction should
the nurse give to the pt?
  • Exhale and bear down.
  • Hold your breath for five seconds.
  • Inhale and exhale rapidly.
  • Cough as hard as you can.
  • Kaplan, 2005

A man is admitted to the Telemetry Unit for
evaluation of c/o chest pain. Eight hours after
admission, the pt goes into ventricular
fibrillation. The physician defibrillates the
pt. The nurse understands that the purpose of
defibrillation is to
  • Increase cardiac contractility and cardiac
  • Cause asystole so the normal pacemaker can
  • Reduce cardiac ischemia and acidosis.
  • Provide energy for depleted myocardial cells.
  • Kaplan, 2005

17. A pt newly diagnosed with Alzheimers
disease is admitted to the unit. Which action,
if taken by the nurse, is BEST?
  • Place the pt in a private room away from the
    nurses station.
  • Ask the family to wait in the waiting room while
    the nurse admits the pt.
  • Assign a different nurse daily to care for the
  • Ask the pt to state todays date.
  • Kaplan, 2005

18. The client is instructed regarding foods
that are low in fat and cholesterol. Which diet
selection is lowest in saturated fats?
  • Macaroni and cheese
  • Shrimp with rice
  • Turkey breast
  • Spaghetti
  • http//

19. The client with Alzheimer's disease is being
assisted with activities of daily living when the
nurse notes that the client uses her toothbrush
to brush her hair. The nurse is aware that the
client is exhibiting
  • Agnosia
  • Apraxia
  • Anomia
  • Aphasia
  • http//

The nurse knows that a positive diagnosis for
HIV infection is made based on
  • Positive ELISA and Western blot tests.
  • A history of high-risk sexual behaviors
  • Evidence of extreme wt loss and high fever.
  • Identification of an associated opportunistic
  • Mosby, 2004

21. A client with a family hx of atherosclerosis
is advised to follow a diet based on the US Dept
of Ag. Food Guide Pyramid. The nurse should
teach the client to eat
  • 4-6 servings of fruit daily
  • 5-7 servings of vegetables daily
  • 3-5 servings of meat, poultry, or fish daily
  • 6-11 servings of bread, rice or pasta daily.
  • Mosby, 2004

The (NEW) Food Pyramid
22. The teaching plan for a client receiving
digoxin for left ventricular failure should
include having the client
  • Sleep flat in bed
  • Rest during the day
  • Follow a low potassium diet
  • Take the pulse three times daily
  • Mosby, 2004

23. During a routine physical exam, an abdominal
aortic aneurysm is diagnosed. The client is
immediately admitted to the hospital, and surgery
is scheduled for the next morning. When
performing the admission assessment, the nurse
should expect
  • Severe radiating abdominal pain
  • Cyanosis and symptoms of shock
  • A pattern of visible peristaltic waves
  • A palpable pulsating abdominal mass
  • Mosby, 2004

A client has recently been diagnosed with Type I
diabetes. A glucose tolerance test is ordered.
The order reads, Administer glucose 1.0 g/kg.
The client weighs 240 pounds. The nurse should
administer ( ___ pounds 1 kg)
  • Answer ________________
  • Mosby, 2004

25. A female client has a tentative diagnosis of
Cushings syndrome. The nurses physical
assessment of this client will probably include
the findings of
  • Fever and tachycardia
  • Lethargy and constipation
  • Hypertension and moon-face
  • Hyperactivity and exopthalmos
  • Mosby, 2004

26. The lab findings of a 40 yo man with burns
are BUN, 30mg/dL serum potassium, 6.3mEq/L
pH, 7.1 PO2, 90mm Hg and Hgb, 7.4 g/dL. The
nurse is aware that these findings indicate
  • Azotemia
  • Hypokalemia
  • Metabolic Alkalosis
  • Respiratory Alkalosis
  • Mosby, 2004

Normal Lab Values
  • BUN 5-20
  • K 3.5-5.5
  • Hgb 12-15
  • Na 135-145
  • pH 7.35-7.45
  • PO2 80-100

27. When teaching a client how to avoid dumping
syndrome following a gastrectomy, the nurse
should emphasize
  1. Increasing activity after eating
  2. Avoiding excess fluids with meals
  3. Eating heavy meals to delay emptying
  4. Providing carbohydrates with each meal
    Mosby, 2004

28. The nurse is preparing to change a clients
dressing. The statement that best explains the
basis of surgical asepsis that the nurse will
perform in this procedure is
  • Keep the area free of microorganisms
  • Protect self from microorganisms to the surgical
  • Confine the microorganisms to the surgical site
  • Keep the number of opportunistic microorganisms
    to a minimum
  • Mosby, 2004

29. A 30 yo female dancer notices a mole on her
ankle has turned dark brown and seeks medical
attention. A diagnosis of malignant melanoma is
made. This client has increased her chance of
survival by early tx, b/c melanoma spreads
quickly. The nurse recognizes that melanoma
  • By seeding across membranes of body tissues
  • By runner-like chains of cells to satellite
  • Through invasion of the lymphatic system and
  • Through direct extension into subcutaneous tissue
    to bone
  • Mosby, 2004

Melanoma Normal Nevi
30. A client with burns develops a wound
infection. The nurse knows that local wound
infections are primarily treated with
  • Oral antibiotics
  • Topical antibiotics
  • IV antibiotics
  • IM antibiotics
  • Mosby, 2004

A client is admitted to the hospital after
sustaining a head injury. The most reliable sign
that this is client is experiencing an increase
in intracranial pressure would be a slowly
  • Rising RR
  • Narrowing pulse pressure
  • Decrease in level of conscious
  • Increasing diastolic blood pressure
  • Mosby, 2004

32. A client has been admitted to the emergency
department with multiple injuries including
fractured ribs. Because of the clients
fractured ribs, the nurse should assess for signs
  • Pneumonitis
  • Hematemesis
  • Pulmonary Edema
  • Respiratory acidosis
  • Mosby, 2004

33. A client is placed on a ventilator. Because
hyperventilation can occur when mechanical
ventilation is used, the nurse should monitor the
client for signs of
  • Hypoxia
  • Hypercapnia
  • Metabolic Acidosis
  • Respiratory Alkalosis
  • Mosby, 2004

34. A 21yo client comes to the ED with chief
complaint of left sided chest pain following
racquetball game. A chest x-ray reveals a left
pneumothorax. When assessing the left side of
the clients chest, the nurse would expect to
  • A dull sound on percussion
  • Vocal fremitus on palpation
  • Rales and rhonchi on auscultation
  • An absence of breath sounds on auscultation
  • Mosby, 2004

35. A client with end-stage renal dz is
receiving continous ambulatory peritoneal
dialysis. The nurse is preparing to teach the
client to monitor for signs of complications
associated with peritoneal dialysis. Check all
the complications that should be included in this
teaching plan.
  • ____Pruritus
  • ____Oliguria
  • __x__Tachycardia
  • __x__Cloudy Outflow
  • __x_Abdominal Pain
  • Mosby, 2004

36. A client with a distal femoral fracture is
placed in skeletal traction. The nurse is aware
that the weights would only be removed if
  • There is a life-threatening situation
  • The client complains of intense pain
  • There is evidence of external rotation
  • The cords have become twisted during turning
  • Mosby, 2004