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MED SURG 206 Comprehensive Foundation NCLEX Questions and Answers with Rationale: Jersey College, School of Nursing

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Comprehensive Foundation NCLEX Question 1 100 / 100 pts The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin? Staphylococcus epidermidis Correct! Escherichia coli Candida albicans Staphylococcus aureus Rationale: E. coli is normally found in the intestines and is a common source of infection of wounds and the urinary system. C. albicans, S. aureus, and S. epidermis are part of the normal flora of the skin. Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal microorganisms that inhabit the skin. Note that the question asks for the organism that is not part of normal flora. Remember that E. coli is normally found in the intestines. Review basic skin structures if you had difficulty with this question. Question 2 100 / 100 pts The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the: Pilosebaceous glands Correct! Nails Hair follicles Epithelial layer of skin Rationale: Paronychia is a fungal infection that is most often caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The area is generally tender to touch, with purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a variety of disorders involving the epithelial skin.

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Comprehensive Foundation NCLEX

Question 1
pts
The client with cellulitis of the lower leg has had cultures done on the affected area. The
nurse reviewing the results of the culture report interprets that which of the following
organisms is not part of the normal flora of the skin?


Staphylococcus epidermidis
Correct!

Escherichia coli


Candida albicans


Staphylococcus aureus
Rationale: E. coli is normally found in the intestines and is a common source of
infection of wounds and the urinary system. C. albicans, S. aureus,
and S. epidermis are part of the normal flora of the skin.

Test-Taking Strategy: To answer this question correctly, you must be familiar with the
normal microorganisms that inhabit the skin. Note that the question asks for the
organism that is not part of normal flora. Remember that E. coli is normally found in the
intestines. Review basic skin structures if you had difficulty with this question.


Question 2
pts
The client has been diagnosed with paronychia. The nurse understands that this is a
disorder of the:


Pilosebaceous glands

Correct!

Nails

,Hair follicles



Epithelial layer of skin

Rationale: Paronychia is a fungal infection that is most often caused by Candida
albicans. This results in inflammation of the nail fold, with separation of the fold from the
nail plate. The area is generally tender to touch, with purulent drainage. Disorders of the
hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the
pilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a
variety of disorders involving the epithelial skin.

Test-Taking Strategy: To answer this question accurately, you must be familiar with a
variety of skin disorders and their causes. Remember that paronychia is a nail disorder.
If this question was difficult, review the characteristics of paronychia.


Question 3
pts
The nurse is assigned to the care of a client scheduled for surgery for a right colon
tumor. Which of the following is the most characteristic manifestation of cancer at this
site?
Correct!

Dull abdominal pain exacerbated by walking



Flat, ribbon-like stools



Crampy gas pains



Frequent diarrhea

Rationale: Characteristic symptoms of right colon tumors include vague, dull,
abdominal pain exacerbated by walking, and dark red- or mahogany-colored blood
mixed in the stool. The symptoms described in the other options are associated with left
colon tumors.

Test-Taking Strategy: Knowledge regarding the signs of right and left colon tumors is

,required to answer this question. Note, however, that “crampy gas pains” and “dull
abdominal pain exacerbated by walking” describe different patterns of pain. This may
suggest to you that one of the two is correct. If you are not familiar with the differences
between right and left colon tumors, review this content.


Question 4
pts
The client with an endocrine disorder complains of weight loss and diarrhea, and says
that he can “feel his heart beating in his chest.” The nurse interprets that which of the
following glands is most likely responsible for these symptoms?


Parathyroid



Pituitary

Correct!

Thyroid



Adrenal cortex

Rationale: The thyroid gland is responsible for a number of metabolic functions in the
body, including metabolism of nutrients (such as fats and carbohydrates). Increased
metabolic function places a demand on the cardiovascular system for a higher cardiac
output. Thus, a client with increased activity of the thyroid gland exhibits weight loss
from higher metabolic rate and increased pulse rate.

Test-Taking Strategy: Use knowledge of the function of the thyroid gland to answer
this question. Remember that the thyroid gland is responsible for metabolic function.
This will assist in directing you to “thyroid.” If you had difficulty answering this question,
review the function of the thyroid gland.


Question 5
pts
The client with diabetes mellitus is being tested to determine long-term diabetic control.
Which of the following results would the nurse expect to see if the client’s long-term
control is within acceptable limits?

, Fasting blood glucose level of 150 mg/dL

Correct!

Glycosylated hemoglobin of 6%



Presence of albumin in the urine



Presence of ketones in the urine

Rationale: This measurement of glycosylated hemoglobin (Hb A 1c) detects glucose
binding on the red blood cell (RBC) membrane and is expressed as a percentage. It
measures glucose for the life of the RBC, which is 120 days. The fasting blood glucose
level should be lower than 130 mg/dL. The urine should be free of both ketones and
urine.

Test-Taking Strategy: Specific knowledge of the effects of an increased blood glucose
level in the body is necessary to answer this question. Noting the words “long-term” will
direct you to “glycosylated hemoglobin of 6%.” Review the alterations in normal
physiology that occur with diabetes mellitus if you had difficulty with this question.


Question 6
pts
Discharge teaching for a client recovering from an attack of chronic pancreatitis should
include which of the following instructions?


Diet should be high in carbohydrates, fats, and proteins.



Frothy fatty stools indicate that enzyme replacement is working.



Alcohol should be consumed in moderation.

Correct!

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