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Test bank for Chapter 5 NCLEX - Medical-Surgical Nursing questions with verified answers
Test bank for Chapter 5 NCLEX - Medical-Surgical Nursing questions with verified answers
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Test bank for Chapter 5 NCLEX -Medical-Surgical Nursing questions with
verified answers
1.
2. A 42 yo patient is recovering from cranial surgery. It is important to plan nursing
interventions to prevent an increase in intracranial pressure (ICP). Which action best
helps to decrease the possibility of increased intracranial pressure?
3.
4. 1. Encourage her to deep breath and cough.
5. 2. Doing endotracheal suctioning every 4 hours or as needed.
6. 3. Maintaining her bed in a high fowler (90 - degree) position.
7. 4. Spreading interventions evenly throughout the day. - ANS-4. Spreading interventions
evenly throughout the day.
8.
9. Allowing the patient to rest between nursing activities helps to keep the ICP between 5
and 15 mm Hg.
10. A newly admitted patient has asthma and uses inhalers. He takes Metaproterenol
(Alupent), Albuterol (Proventil), and Beclomethasone (Vanceril). He complains that he
does not like the side effects that these inhaled medications cause. The nurse instructs
him that he:
11.
12. 1. Must sit down when using inhalers.
13. 2. Is overdosing himself if he uses all three inhalers within 1 hour.
14. 3. Needs to use the Metaproterenol and Albuterol inhalers before the Beclomethasone.
15. 4. Needs to stop using the inhalers until his next scheduled clinic appointment. - ANS-3.
Needs to use the Metaproterenol and Albuterol inhalers before the Beclomethasone.
16.
17. Proper technique. Corticosteroid inhalers should be used last because they require
gargling after use to prevent oral candidiasis.
18. A nurse is assisting a patient with an above the knee amputation into a prone position.
Which statement made by the patient would indicate that he or she understands the
need for this positioning?
19.
20. 1. "Lying prone will alleviate my phantom limb pain."
21. 2. "I have to lie this way to make sure that I have good circulation to my residual limb."
22. 3. "This position will allow me greater comfort than lying on my back."
23. 4. "I have to do this to make sure that my hip doesn't get a flexion contracture." - ANS-4.
"I have to do this to make sure that my hip doesn't get a flexion contracture."
,24.
25. Correct rationale behind positioning.
26. A nurse is bathing a patient 1 day after total hip replacement. Which statement made by
the patient would indicate understanding of the positioning required after this surgery?
27.
28. 1. "I know I shouldn't point my toes."
29. 2. "I need to have lowered chairs."
30. 3. "It will hard for me to cross my legs."
31. 4. "I will have trouble not walking for a long time." - ANS-3. "It will hard for me to cross
my legs."
32.
33. Crossing the legs may result in displacement of the new femoral head.
34. A nurse is caring for a female patient who has had a conization. Which nursing
intervention should the nurse expect to carry out for this patient?
35.
36. 1. Insert her to replace tampon every 3 hours.
37. 2. Maintain vaginal packing for the first 12 to 24 hours.
38. 3. Assist her in using a site bath twice per day.
39. 4. Provide her with instructions on the use of a medicated, vaginal douche. - ANS-2.
Maintain vaginal packing for the first 12 to 24 hours.
40.
41. This needs to be maintained and anticipate monitoring for bleeding.
42. A nurse is caring for a patient 2 days after an appendectomy. The patient experiences
incisional pain on ambulation. The nurse suggests splinting the wound with a pillow
based on the understanding that:
43.
44. 1. Splinting allows for deeper respirations and coughing.
45. 2. Persons with abdominal incisions are hesitant to ambulate.
46. 3. An abdominal binder would restrict the patient's movements.
47. 4. Sustained stress disrupts wound layers and may impede tissue repair. - ANS-4.
Sustained stress disrupts wound layers and may impede tissue repair.
48.
49. Additional stress placed on the tissues by movement may disrupt the healing tissue.
Splinting lessens the chance for this to occur.
50. A nurse is caring for a patient with a suspected diagnosis of osteoarthritis. What are
common characteristics of osteoarthritis?
51.
52. 1. Tenderness and crepitus.
53. 2. Bilateral inflammation and immobility.
54. 3. Pain resulting from destruction of supportive structures.
55. 4. Fluid within the joint along with inflammatory tissue changes. - ANS-1. Tenderness
and crepitus.
56.
57. Are common characteristics of joints involved in osteoarthritis.
, 58. A nurse is carrying for a patient with cirrhosis. Which snack would help to prevent the
development of hepatic coma?
59.
60. 1. Banana and mayonnaise sandwich.
61. 2. Cheese and crackers.
62. 3. Peanut butter and jelly sandwich.
63. 4. Milk and cookies. - ANS-1. Banana and mayonnaise sandwich.
64.
65. Protein is converted to ammonia, and a build up of ammonia affects brain tissue. Protein
should be restricted if ammonia levels rise. This snack is lowest in protein.
66. A nurse is discharging a patient who has hyperparathyroidism. The nurse advises the
patient to contact the physician if she develops flank pain because:
67.
68. 1. Flank pain can signal a worsening of her condition.
69. 2. Low calcium levels might be causing the pain.
70. 3. Kidney stones are a frequent complication of her disorder.
71. 4. Pain requires immediate surgical interventions. - ANS-3. Kidney stones are a frequent
complication of her disorder.
72.
73. Flank pain would signal the presence of kidney stones.
74. A nurse is educating a group of women on premenstrual tension. The nurse has the
participants complete a survey of favorite foods. Which favorite food of the participants
can aggravate premenstrual syndrome (PMS)?
75.
76. 1. Pizza.
77. 2. Mineral water.
78. 3. Pasta and sauce.
79. 4. Raw fruits and vegetables. - ANS-1. Pizza.
80.
81. Pizza is high in sodium and would aggravate PMS symptoms.
82. A nurse is obtaining a history from a patient who has been admitted with a diagnosis of
probable mitral insufficiency. Which fact in the patient's history would be most
significant?
83.
84. 1. Appendectomy 1 year ago.
85. 2. One pack a day smoker for 20 years.
86. 3. History of rheumatic fever as a child.
87. 4. History of pacemaker insertion 5 years ago. - ANS-3. History of rheumatic fever as a
child.
88.
89. Rheumatic fever and subsequent heart disease are the prominent causes of valvular
insufficiency.
90. A nurse is preparing a patient for an upcoming panhysterectomy. What should the nurse
caution the patient to expect after the surgery?
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