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MED SURG NCLEX PREP U
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Question 1: A client with acquired immunodeficiency syndrome (AIDS)
(see full question) develops Pneumocystis carinii pneumonia. Which nursing
diagnosis has the highest priority?
You selected: Impaired oral mucous membranes
Incorrect
Correct response: Impaired gas exchange
Explanation: Although all of these nursing diagnoses are appropriate for a
client with AIDS, Impaired gas exchange is the priority
nursing diagnosis for a client with P. carinii pneumonia.
Airw ... (more)
Remediation: Pneumocystis jiroveci (carinii) pneumonia
Pneumocystis carinii pneumonia
Question 2: Adolescents and adults who were sexually abused as children
(see full question) commonly mutilate themselves. The nurse interprets this
behavior as:
You selected: use of physical pain to avoid dealing with emotional pain.
Correct
Explanation: Dealing with the physical pain associated with mutilation is
viewed as easier than dealing with the intense anger and
emotional pain. The client fears an aggressive outburst when
a ... (more)
Remediation: Self-mutilation
Question 3: A client with diabetes mellitus asks the nurse to recommend
(see full question) something to remove corns from his toes. The nurse should
advise the client to:
You selected: consult a health care provider (HCP) about removing the
corns.
Correct
Explanation: A client with diabetes should be advised to consult a HCP or
podiatrist for corn removal because of the danger of
traumatizing the foot tissue and potential development of
ulcers. ... (more)
Remediation: Foot care
Diabetes
Question 4: A nurse is developing a care plan for a client recovering from a
(see full question) serious thermal burn. What does the nurse determine is the
priority goal of therapy?
You selected: Maintaining the client's fluid and electrolyte balance
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Correct
Explanation: After maintaining respirations, the most important and
immediate goal of therapy for a client with a serious thermal
burn is to maintain fluid, electrolyte, and acid-base balance t ...
(more)
Remediation: Fluid assessment
Burn wound care
Question 5: A distraught father is waiting for his son to come out of
(see full question) surgery. He accidentally backed the car into his son, causing
multiple fractures and a serious head injury. Which statement
by the father would most alert the nurse to the need for a
psychiatric consultation?
You selected: "If he dies, there will be nothing for me to do but join him."
Correct
Explanation: The statement about joining the son if he dies indicates
potential for self-harm and subsequent suicide, always a risk
during crisis. Although the father may be charged with
reckle ... (more)
Remediation: Suicide precautions
Question 6: A nurse is completing discharge teaching for the client who
(see full question) has left-sided hemiparesis following a stroke. When
investigating the client's home environment, the nurse should
focus on which nursing diagnosis?
You selected: Risk for injury
Correct
Explanation: Because of decreased physical mobility, a client with recent
left-sided hemiparesis is at risk for falls in the home setting.
His ability to cope with the stroke is important, but ... (more)
Remediation: Stroke
Question 7: At which time should the nurse instruct the client to take
(see full question) ibuprofen, prescribed for left hip pain secondary to
osteoarthritis, to minimize gastric mucosal irritation?
You selected: immediately after a meal
Correct
Explanation: Drugs that cause gastric irritation, such as ibuprofen, are best
taken after or with a meal, when stomach contents help
minimize the local irritation. Taking the medication on an e ...
(more)
Remediation: Ibuprofen
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Question 8: Which nursing measure would be most effective in helping the
(see full question) client cough and deep breathe after a cholecystectomy?
You selected: Teach the client to use a folded blanket or pillow to splint the
incision.
Correct
Explanation: A folded bath blanket or pillow placed over the incision will
be most effective in helping the client cough and deep breathe
after a cholecystectomy.
Taking rapid, shallow breaths
... (more)
Remediation: Cholecystectomy
Teaching Coughing and Splinting
Question 9: A child requires IV fluids to infuse at 27 ml/hr. The tubing
(see full question) delivers 60 gtts/ml. How many gtts/min should the nurse count
to ensure that the fluid is safely infusing?
You selected: 27 gtts/min
Correct
Explanation: The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60
min/h = 27 gtts/min
Remediation: IV infusion, dose and flow rate calculations
Question 10: Before administering the evening dose of an ordered
(see full question) medication, a nurse on the evening shift finds an unlabeled,
filled syringe in a client's medication drawer. What should the
nurse do?
You selected: Discard the syringe to avoid a medication error.
Correct
Explanation: As a safety precaution, the nurse should discard an unlabeled
syringe that contains medication. The other options are
considered unsafe practices because they promote error.
Remediation: Safe medication administration practices
Question 11: A 13-year-old child has seen the school nurse several times
(see full question) with headache, vomiting, and difficulty walking. When calling
the adolescent's mother about these symptoms, what should
the nurse suggest the mother do first?
You selected: Make an appointment with the adolescent's health care
provider (HCP).
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MED SURG NCLEX PREP U
Downloaded by: Ariah |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
Question 1: A client with acquired immunodeficiency syndrome (AIDS)
(see full question) develops Pneumocystis carinii pneumonia. Which nursing
diagnosis has the highest priority?
You selected: Impaired oral mucous membranes
Incorrect
Correct response: Impaired gas exchange
Explanation: Although all of these nursing diagnoses are appropriate for a
client with AIDS, Impaired gas exchange is the priority
nursing diagnosis for a client with P. carinii pneumonia.
Airw ... (more)
Remediation: Pneumocystis jiroveci (carinii) pneumonia
Pneumocystis carinii pneumonia
Question 2: Adolescents and adults who were sexually abused as children
(see full question) commonly mutilate themselves. The nurse interprets this
behavior as:
You selected: use of physical pain to avoid dealing with emotional pain.
Correct
Explanation: Dealing with the physical pain associated with mutilation is
viewed as easier than dealing with the intense anger and
emotional pain. The client fears an aggressive outburst when
a ... (more)
Remediation: Self-mutilation
Question 3: A client with diabetes mellitus asks the nurse to recommend
(see full question) something to remove corns from his toes. The nurse should
advise the client to:
You selected: consult a health care provider (HCP) about removing the
corns.
Correct
Explanation: A client with diabetes should be advised to consult a HCP or
podiatrist for corn removal because of the danger of
traumatizing the foot tissue and potential development of
ulcers. ... (more)
Remediation: Foot care
Diabetes
Question 4: A nurse is developing a care plan for a client recovering from a
(see full question) serious thermal burn. What does the nurse determine is the
priority goal of therapy?
You selected: Maintaining the client's fluid and electrolyte balance
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, Stuvia.com - The Marketplace to Buy and Sell your Study Material
Correct
Explanation: After maintaining respirations, the most important and
immediate goal of therapy for a client with a serious thermal
burn is to maintain fluid, electrolyte, and acid-base balance t ...
(more)
Remediation: Fluid assessment
Burn wound care
Question 5: A distraught father is waiting for his son to come out of
(see full question) surgery. He accidentally backed the car into his son, causing
multiple fractures and a serious head injury. Which statement
by the father would most alert the nurse to the need for a
psychiatric consultation?
You selected: "If he dies, there will be nothing for me to do but join him."
Correct
Explanation: The statement about joining the son if he dies indicates
potential for self-harm and subsequent suicide, always a risk
during crisis. Although the father may be charged with
reckle ... (more)
Remediation: Suicide precautions
Question 6: A nurse is completing discharge teaching for the client who
(see full question) has left-sided hemiparesis following a stroke. When
investigating the client's home environment, the nurse should
focus on which nursing diagnosis?
You selected: Risk for injury
Correct
Explanation: Because of decreased physical mobility, a client with recent
left-sided hemiparesis is at risk for falls in the home setting.
His ability to cope with the stroke is important, but ... (more)
Remediation: Stroke
Question 7: At which time should the nurse instruct the client to take
(see full question) ibuprofen, prescribed for left hip pain secondary to
osteoarthritis, to minimize gastric mucosal irritation?
You selected: immediately after a meal
Correct
Explanation: Drugs that cause gastric irritation, such as ibuprofen, are best
taken after or with a meal, when stomach contents help
minimize the local irritation. Taking the medication on an e ...
(more)
Remediation: Ibuprofen
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Question 8: Which nursing measure would be most effective in helping the
(see full question) client cough and deep breathe after a cholecystectomy?
You selected: Teach the client to use a folded blanket or pillow to splint the
incision.
Correct
Explanation: A folded bath blanket or pillow placed over the incision will
be most effective in helping the client cough and deep breathe
after a cholecystectomy.
Taking rapid, shallow breaths
... (more)
Remediation: Cholecystectomy
Teaching Coughing and Splinting
Question 9: A child requires IV fluids to infuse at 27 ml/hr. The tubing
(see full question) delivers 60 gtts/ml. How many gtts/min should the nurse count
to ensure that the fluid is safely infusing?
You selected: 27 gtts/min
Correct
Explanation: The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60
min/h = 27 gtts/min
Remediation: IV infusion, dose and flow rate calculations
Question 10: Before administering the evening dose of an ordered
(see full question) medication, a nurse on the evening shift finds an unlabeled,
filled syringe in a client's medication drawer. What should the
nurse do?
You selected: Discard the syringe to avoid a medication error.
Correct
Explanation: As a safety precaution, the nurse should discard an unlabeled
syringe that contains medication. The other options are
considered unsafe practices because they promote error.
Remediation: Safe medication administration practices
Question 11: A 13-year-old child has seen the school nurse several times
(see full question) with headache, vomiting, and difficulty walking. When calling
the adolescent's mother about these symptoms, what should
the nurse suggest the mother do first?
You selected: Make an appointment with the adolescent's health care
provider (HCP).
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