NCLEX Practice Exam for Medical Surgical Nursing 4

1. The nurse is performing her admission assessment of a patient. When grading arterial pulses, a 1+ pulse indicates:

1. Above normal perfusion.
2. Absent perfusion.
3. Normal perfusion.
4. Diminished perfusion.

2. Murmurs that indicate heart disease are often accompanied by other symptoms such as:

1. Dyspnea on exertion.
2. Subcutaneous emphysema.
3. Thoracic petechiae.
4. Periorbital edema.

3. Which pregnancy-related physiologic change would place the patient with a history of cardiac disease at the greatest risk of developing severe cardiac problems?

1. Decrease heart rate
2. Decreased cardiac output
3. Increased plasma volume
4. Increased blood pressure

4. The priority nursing diagnosis for the patient with cardiomyopathy is:

1. Anxiety related to risk of declining health status.
2. Ineffective individual coping related to fear of debilitating illness
3. Fluid volume excess related to altered compensatory mechanisms.
4. Decreased cardiac output related to reduced myocardial contractility.

5. A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg appears pink and warm. Her pedal pulse is palpable and there is no edema present. Which step in the nursing process is described above?

1. Planning
2. Implementation
3. Analysis
4. Evaluation

6. An elderly patient may have sustained a basilar skull fracture after slipping and falling on an icy sidewalk. The nurse knows that basilar skull factures:

1. Are the least significant type of skull fracture.
2. May have cause cerebrospinal fluid (CSF) leaks from the nose or ears.
3. Have no characteristic findings.
4. Are always surgically repaired.

7. Which of the following types of drugs might be given to control increased intracranial pressure (ICP)?

1. Barbiturates
2. Carbonic anhydrase inhibitors
3. Anticholinergics
4. Histamine receptor blockers

8. The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP?

1. Decreased systolic blood pressure
2. Headache and vomiting
3. Inability to wake the patient with noxious stimuli
4. Dilated pupils that don’t react to light

9. Jessie James is diagnosed with retinal detachment. Which intervention is the most important for this patient?

1. Admitting him to the hospital on strict bed rest
2. Patching both of his eyes
3. Referring him to an ophthalmologist
4. Preparing him for surgery

10. Dr. Bruce Owen, a chemist, sustained a chemical burn to one eye. Which intervention takes priority for a patient with a chemical burn of the eye?

1. Patch the affected eye and call the ophthalmologist.
2. Administer a cycloplegic agent to reduce ciliary spasm.
3. Immediately instill a tropical anesthetic, then irrigate the eye with saline solution.
4. Administer antibiotics to reduce the risk of infection

11. The nurse is assessing a patient and notes a Brudzinski’s sign and Kernig’s sign. These are two classic signs of which of the following disorders?

1. Cerebrovascular accident (CVA)
2. Meningitis
3. Seizure disorder
4. Parkinson’s disease

12. A patient is admitted to the hospital for a brain biopsy. The nurse knows that the most common type of primary brain tumor is:

1. Meningioma.
2. Angioma.
3. Hemangioblastoma.
4. Glioma.

13. The nurse should instruct the patient with Parkinson’s disease to avoid which of the following?

1. Walking in an indoor shopping mall
2. Sitting on the deck on a cool summer evening
3. Walking to the car on a cold winter day
4. Sitting on the beach in the sun on a summer day

14. Gary Jordan suffered a cerebrovascular accident that left her unable to comprehend speech and unable to speak. This type of aphasia is known as:

1. Receptive aphasia
2. Expressive aphasia
3. Global aphasia
4. Conduction aphasia

15. Kelly Smith complains that her headaches are occurring more frequently despite medications. Patients with a history of headaches should be taught to avoid:

1. Freshly prepared meats.
2. Citrus fruits.
3. Skim milk
4. Chocolate

16. Immediately following cerebral aneurysm rupture, the patient usually complains of:

1. Photophobia
2. Explosive headache
3. Seizures
4. Hemiparesis

17. Which of the following is a cause of embolic brain injury?

1. Persistent hypertension
2. Subarachnoid hemorrhage
3. Atrial fibrillation
4. Skull fracture

18. Although Ms. Priestly has a spinal cord injury, she can still have sexual intercourse. Discharge teaching should make her aware that:

1. She must remove indwelling urinary catheter prior to intercourse.
2. She can no longer achieve orgasm.
3. Positioning may be awkward.
4. She can still get pregnant.

19.Ivy Hopkins, age 25, suffered a cervical fracture requiring immobilization with halo traction. When caring for the patient in halo traction, the nurse must:

1. Keep a wrench taped to the halo vest for quick removal if cardiopulmonary resuscitation is necessary.
2. Remove the brace once a day to allow the patient to rest.
3. Encourage the patient to use a pillow under the ring.
4. Remove the brace so that the patient can shower.

20. The nurse asks a patient’s husband if he understands why his wife is receiving nimodipine (Nimotop), since she suffered a cerebral aneurysm rupture. Which response by the husband indicates that he understands the drug’s use?

1. “Nimodipine replaces calcium.”
2. “Nimodipine promotes growth of blood vessels in the brain.”
3. “Nimodipine reduces the brain’s demand for oxygen.”
4.  “Nimodipine reduces vasospasm in the brain.”

21. Many men who suffer spinal injuries continue to be sexually active. The teaching plan for a man with a spinal cord injury should include sexually concerns. Which of the following injuries would most likely prevent erection and ejaculation?

1. C5
2. C7
3. T4
4. S4

22. Cathy Bates, age 36, is a homemaker who frequently forgets to take her carbamazepine (Tegretol). As a result, she has been experiencing seizures. How can the nurse best help the patient remember to take her medication?

1. Tell her take her medication at bedtime.
2. Instruct her to take her medication after one of her favorite television shows.
3. Explain that she should take her medication with breakfast.
4. Tell her to buy an alarm watch to remind her.

23. Richard Barnes was diagnosed with pneumococcal meningitis. What response by the patient indicates that he understands the precautions necessary with this diagnosis?

1. “I’m so depressed because I can’t have any visitors for a week.”
2. “Thank goodness, I’ll only be in isolation for 24 hours.”
3. “The nurse told me that my urine and stool are also sources of meningitis bacteria.”
4. “The doctor is a good friend of mine and won’t keep me in isolation.”

24. An early symptom associated with amyotrophic lateral sclerosis (ALS) includes:

1. Fatigue while talking
2. Change in mental status
3. Numbness of the hands and feet
4. Spontaneous fractures

25. When caring for a patient with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:

1. Esophageal perforation
2. Pulmonary hypertension
3. Portal hypertension
4. Peptic ulcers

26. Tiffany Black is diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this patient?

1. Put on a mask and gown before entering the patient’s room.
2. Wear gloves and a gown when removing the patient’s bedpan.
3. Prevent the droplet spread of the organism.
4. Use caution when bringing food to the patient.

27. Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states he’ll contact the doctor if:

1. He experiences abdominal cramping while the irrigant is infusing
2. He has difficulty inserting the irrigation tube into the stoma
3. He expels flatus while the return is running out
4. He’s unable to complete the procedure in 1 hour

28. The nurse explains to the patient who has an abdominal perineal resection that an indwelling urinary catheter must be kept in place for several days afterward because:

1. It prevents urinary tract infection following surgery
2. It prevents urine retention and resulting pressure on the perineal wound
3. It minimizes the risk of wound contamination by the urine
4. It determines whether the surgery caused bladder trauma

29. The first day after, surgery the nurse finds no measurable fecal drainage from a patient’s colostomy stoma. What is the most appropriate nursing intervention?

1. Call the doctor immediately.
2. Obtain an order to irrigate the stoma.
3. Place the patient on bed rest and call the doctor.
4. Continue the current plan of care.

30. If a patient’s GI tract is functioning but he’s unable to take foods by mouth, the preferred method of feeding is:

1. Total parenteral nutrition
2. Peripheral parenteral nutrition
3. Enteral nutrition
4. Oral liquid supplements

31. Which type of solution causes water to shift from the cells into the plasma?

1. Hypertonic
2. Hypotonic
3. Isotonic
4. Alkaline

32. Particles move from an area of greater osmelarity to one of lesser osmolarity through:

1. Active transport
2. Osmosis
3. Diffusion
4. Filtration

33. Which assessment finding indicates dehydration?

1. Tenting of chest skin when pinched
2. Rapid filling of hand veins
3. A pulse that isn’t easily obliterated
4. Neck vein distention

34. Which nursing intervention would most likely lead to a hypo-osmolar state?

1. Performing nasogastric tube irrigation with normal saline solution
2. Weighing the patient daily
3. Administering tap water enema until the return is clear
4. Encouraging the patient with excessive perspiration to dink broth

35. Which assessment finding would indicate an extracellular fluid volume deficit?

1. Bradycardia
2. A central venous pressure of 6 mm Hg
3. Pitting edema
4. An orthostatic blood pressure change

36. A patient with metabolic acidosis has a preexisting problem with the kidneys. Which other organ helps regulate blood pH?

1. Liver
2. Pancreas
3. Lungs
4. heart

37. The nurse considers the patient anuric if the patient;

1. Voids during the nighttime hours
2. Has a urine output of less than 100 ml in 24 hours
3. Has a urine output of at least 100 ml in 2 hours
4. Has pain and burning on urination

38. Which nursing action is appropriate to prevent infection when obtaining a sterile urine specimen from an indwelling urinary catheter?

1. Aspirate urine from the tubing port using a sterile syringe and needle
2. Disconnect the catheter from the tubing and obtain urine
3. Open the drainage bag and pour out some urine
4. Wear sterile gloves when obtaining urine

39. After undergoing a transurethral resection of the prostate to treat benign prostatic hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place. One day later, the patient reports bladder pain. What should the nurse do first?

1. Increase the I.V. flow rate
2. Notify the doctor immediately
3. Assess the irrigation catheter for patency and drainage
4. Administer meperidine (Demerol) as prescribed

40. A patient comes to the hospital complaining of sudden onset of sharp, severe pain originating in the lumbar region and radiating around the side and toward the bladder. The patient also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The doctor tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?

1. Kidney
2. Ureter
3. Bladder
4. Urethra

41. A patient comes to the hospital complaining of severe pain in the right flank, nausea, and vomiting. The doctor tentatively diagnoses right ureter-olithiasis (renal calculi). When planning this patient’s care, the nurse should assign highest priority to which nursing diagnosis?

1. Pain
2. Risk of infection
3. Altered urinary elimination
4. Altered nutrition: less than body requirements

42. The nurse is reviewing the report of a patient’s routine urinalysis. Which of the following values should the nurse consider abnormal?

1. Specific gravity of 1.002
2. Urine pH of 3
3. Absence of protein
4. Absence of glucose

43. A patient with suspected renal insufficiency is scheduled for a comprehensive diagnostic work-up. After the nurse explains the diagnostic tests, the patient asks which part of the kidney “does the work.” Which answer is correct?

1. The glomerulus
2. Bowman’s capsule
3. The nephron
4. The tubular system

44. During a shock state, the renin-angiotensin-aldosterone system exerts which of the following effects on renal function?

1. Decreased urine output, increased reabsorption of sodium and water
2. Decreased urine output, decreased reabsorption of sodium and water
3. Increased urine output, increased reabsorption of sodium and water
4. Increased urine output, decreased reabsorption of sodium and water

45. While assessing a patient who complained of lower abdominal pressure, the nurse notes a firm mass extending above the symphysis pubis. The nurse suspects:

1. A urinary tract infection
2. Renal calculi
3. An enlarged kidney
4. A distended bladder

46. Gregg Lohan, age 75, is admitted to the medical-surgical floor with weakness and left-sided chest pain. The symptoms have been present for several weeks after a viral illness. Which assessment finding is most symptomatic of pericarditis?

1. Pericardial friction rub
2. Bilateral crackles auscultated at the lung bases
3. Pain unrelieved by a change in position
4. Third heart sound (S3)

47. James King is admitted to the hospital with right-side-heart failure. When assessing him for jugular vein distention, the nurse should position him:

1. Lying on his side with the head of the bed flat.
2. Sitting upright.
3. Flat on his back.
4. Lying on his back with the head of the bed elevated 30 to 45 degrees.

48. The nurse is interviewing a slightly overweight 43-year-old man with mild emphysema and borderline hypertension. He admits to smoking a pack of cigarettes per day. When developing a teaching plan, which of the following should receive highest priority to help decrease respiratory complications?

1. Weight reduction
2. Decreasing salt intake
3. Smoking cessation
4. Decreasing caffeine intake

49. What is the ratio of chest compressions to ventilations when one rescuer performs cardiopulmonary resuscitation (CPR) on an adult?

1. 15:1
2. 15:2
3. 12:1
4. 12:2

50. When assessing a patient for fluid and electrolyte balance, the nurse is aware that the organs most important in maintaining this balance are the:

1. Pituitary gland and pancreas
2. Liver and gallbladder.
3. Brain stem and heart.
4.  Lungs and kidneys.

Answers and Rationales