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

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

Q.4)

Explanation Central tissue hypoxia is commonly associated with dizziness. Recognition of cerebral hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs. Correct Which of the following nursing interventions is contraindicated in the care of a client with acute osteomyelitis?

A. Apply heat compress to the affected area (Your Answer) B. Immobilize the affected area C. Administer narcotic analgesics for pain D. Administer OTC analgesics for pain Explanation Options B, C and D are appropriate nursing interventions when caring for a client diagnosed with osteomyelitis. The application of heat can increase edema and pain in the affected area and spread bacteria through vasodilation. Correct Nurse Marian is caring for a client with haital hernia, which of the following should be included in her teaching plan regarding causes: Q.5)

Q.6)

To avoid heavy lifting (Your Answer) A. A dietary plan based on soft foods B. Its prevalence in young adults C. Its prevalence in fair-skinned individuals D. Explanation Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors involve limiting fat intake, not restricting client to soft foods. It is more prevalent in individuals who are middle-aged or older. Fair-skinned individuals are not prone to this condition. 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. away from the body (Your Answer) B. to the left of the body C. to the right of the body D. 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

the body eliminates the need to later reach across the steri9le field while opening the package. To remove equipment from the package, opening the first portion of the package toward, to the left, or to the right of the body would require reaching across a sterile field. Correct Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The nurse understands that a postoperative patient whos Q.7) maintained on bed rest is at high risk for developing:

Q.8)

Angina A. arterial bleeding B. deep vein thrombosis (DVT) (Your Answer) C. dehiscence of the wound D. Explanationa DVT, is the most probable complication for postoperative patients on bed rest. Options A, B and D arent likely complications of the post operative period. Correct What laboratory test is a common measure of the renal function?

A. CBC B. BUN/Crea (Your Answer) C. Glucose D. 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. Creatinine is produced in relatively constant amounts, according to the amount of muscle mass and is excreted entirely by the kidneys making it a good indicator of renal function. Correct A 24 year old male patient comes to the clinic after contracting genital herpes. Which of the following intervention would be most Q.9) appropriate?

A. B. C. D.

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

Explanation Herpes is a virus and is spread through direct contact. An antifungal would not be useful; bed rest and temperature measurement are usually not necessary. Correct Q.10) Hazel Murray, 32 years old complains of abrupt onset of chest and back pain and loss of radial pulses. The nurse suspects that Mrs. Murray may have: A. Acute MI B. CVA C. Dissecting abdominal aorta D. Dissecting thoracic aneurysm (Your Answer) Explanation A dissecting thoracic aneurysm may cause loss of radical pulses and severe chest and back pain. An MI typically doesnt cause loss of radial pulses or severe back pain. CVA and dissecting abdominal aneurysm are incorrect responses. Correct Q.11) A patient is admitted to the medical surgical unit following surgery. Four days after surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet, productive cough. 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 B. a nosocomial infection (Your Answer) C. an opportunistic infection D. Explanation Nosocomial, or hospital-acquired are infections acquired during hospitalization for which the patient isnt being primarily treated. Community acquired or opportunistic infections may not be acquired during hospitalization. An iatrogenic infection is caused by the doctor or by medical therapy. And an opportunistic infection affects a compromised host. Correct Q.12) A client with congestive heart failure has digoxin (Lanoxin) ordered everyday. Prior to giving the medication, the nurse checks the digoxin level which is therapeutic and ausculates an apical pulse. The apical pulse is 63 bpm for 1 full minute. The nurse should: A. B. C. Hold the Lanoxin Give the half dose now, wait an hour and give the other half Call the physician

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

A. B. C. D.

AIDS Alzheimers disease (Your Answer) Brain tumors Vascular disease

Explanation Alzheimers disease is the most common cause of dementia in the elderly population. AIDS, brain tumors and vascular disease are all less common causes of progressive loss of mental function in elderly patients. Correct Q.16) Which of the following findings would strongly indicate the possibility of cirrhosis?

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

Q.18)

Correct Q.19) Chvosteks sign is associated with which electrolyte impabalnce?

hypoclacemia (Your Answer) A. Hypokalemia B. Hyponatremia C. Hypophosphatenia D. Explanation Chvosteks sign is a spasm of the facial muscles elicited by tapping the facial nerve and is associated with hypocalcemia. Clinical signs of hypokalemia are muscle weakness, leg cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia, nausea and vomiting are clinical signs of hyponatremia. Clinical manifestations associated with hypophosphatemia include muscle pain, confusion, seizures and coma. Correct Q.20) A client was involved in a motor vehicular accident in which the seat belt was not worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of the following assessment findings would concern the nurse most?

A. Temperature of 102 degrees F and productive cough B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg C. Trachea deviating to the right (Your Answer) D. Barrel-chested appearance Explanation A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Since the individual was involved in a MVA, assessment would be targeted at acute traumatic injuries to the lungs, heart or chest wall rather than other conditions indicated in the other answers. Option A is common with pneumonia; values in option B are not alarming; and option D is typical of someone with COPD. Correct Q.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. The client complains of extreme pain in the calf. This should be documented as: A. B. C. D. positive tourniquet test positive homans sign (Your Answer) negative homans sign negative tourniquet test

Explanation Pain in the calf while pulling up on the toes is abnormal and indicates a positive test. If the client feels nothing or just feels like the calf muscle is stretching, it is considered negative. A tourniquet test is used to measure for varicose veins. Correct Q.22) Nursing management of the client with a UTI should include: A. Taking medication until feeling better B. Restricting fluids C. Decreasing caffeine drinks and alcohol (Your Answer) D. Douching daily Explanation Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increase the signs and symptoms of UTI. All antibiotics should be taken completely to prevent resistant strains of organisms. Correct Q.23) Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma. The nurse assesses the client for which of the following common presenting symptoms of the disorder? halo vision A. dull eye pain B. severe eye and face pain (Your Answer) C. impaired night vision D. Explanation Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain and is a medial emergency. Halo vision, dull eye pain and impaired night vision are symptoms associated with open-angle glaucoma. Incorrect Q.24) A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing symptoms of cerebral tissue hypoxia. Which of the following nursing interventions would be most important in providing care?

A. Providing rest periods throughout the day B. Instituting energy conservation techniques (Your Answer) C. Assisting in ambulation to the bathroom (Correct Answer) D. Checking temperature of water prior to bathing Explanation Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential risk to the client with dizziness is injury, especially

with changes in position. 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. Correct Q.25) Nurse Edward is performing discharge teaching for a newly diagnosed diabetic patient scheduled for a fasting blood glucose test. The nurse explains to the patient that hyperglycemia is defined as a blood glucose level above: A. 100 mg/dl B. 120 mg/dl (Your Answer) C. 130 mg/dl D. 150 mg/dl Explanation Hyperglycemia is defined as a blood glucose level greater than 120 mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are considered hyperglycemic. A blood glucose of 100 mg/dl is normal.