NCLEX Prep U Med Surg 1 (71
Questions and Correct Answers With
Rationale) Updated Fall 2024/2025.
Which finding requires immediate intervention when planning care for an adolescent with cystic
fibrosis (CF)?
a) large, foul-smelling, and bulky stools
b) chest pain with dyspnea
c) poor weight gain
d) delayed puberty
b) chest pain with dyspnea
Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed
puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is
common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling
stools indicate noncompliance with taking enzymes and should be addressed, but respiratory
complications are the greatest concern.
Which precautions should the health care team observe when caring for clients with hepatitis A?
a) wearing gloves when giving direct care
b) wearing a mask when providing care
c) gowning when entering a client's room
d) assigning the client to a private room
a) wearing gloves when giving direct care
Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for
direct care. A gown is not required unless substantial contact with the client is anticipated. It is not
necessary to wear a mask. The client does not need a private room unless incontinent of stool.
A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag.
Which observation by the nurse ensures that the client's urine has been measured accurately?
a) The LPN pours the urine into a graduated measuring container.
b) The LPN pours the urine into a paper cup that holds approximately 250 mL.
c) The LPN holds the Foley drainage bag up to eye level.
d) The LPN uses the measuring markings on the Foley drainage bag.
a) The LPN pours the urine into a graduated measuring container.
The only means to measure urine output accurately is to use a container that has specific markings
for measuring liquid. The other options would not provide an accurate measure of urine output.
An elderly couple who have just relocated to a long-term care facility have been unable to obtain a
shared room. A staff member at the facility states that this should not be a concern and implies that
,sexual activity between the couple likely ceased many years ago. How should the nurse best respond
to this individual's assertion?
a) "Research has shown the nature of sexual activity changes with age but that it actually becomes
more frequent."
b) "It's true that they've probably stopped having sexual activity, but it's important for them to have
companionship."
c) "That's true, but it's important for us to give them the teaching they need in order to resume this
part of their relationship."
d) "Actually it's not true that older people always stop having sexual activity when they get older."
d) "Actually it's not true that older people always stop having sexual activity when they get older."
Sexual activity need not be hindered by age. There is no evidence, however, that it becomes
increasingly frequent in late adulthood.
The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also
allergic to:
You selected: Iodine skin preparations.
Correct
Explanation:
Clients who are allergic to shellfish are allergic to iodine skin preparations (Iodophor and Betadine)
or any other products containing iodine, such as dyes. Clients who are allergic to shellfish do not
necessarily have an allergy to any other substances or seafood. (less)
Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain?
a) Clean from the center outward in a circular motion.
b) Wear sterile gloves and a mask.
c) Remove the drain before cleaning the skin.
d) Clean briskly around the site with alcohol.
a) Clean from the center outward in a circular motion.
The nurse should move from the center outward in ever-larger circles when cleaning around a
wound drain because the skin near the drain site is more contaminated than the site itself. The nurse
should never remove the drain before cleaning the skin. Alcohol should never be used to clean
around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria.
The nurse should wear sterile gloves to prevent contamination, but need not wear a mask.
After receiving information on various forms of birth control, a young couple decides to use a barrier
method because they would like to try and conceive in 1 to 2 years. Which barrier method uses a
rubber barrier to hold spermicide against the cervix?
a) A cervical cap.
b) A vaginal sponge.
c) A diaphragm.
d) A condom.
, c) A diaphragm.
A diaphragm is a dome-shaped device made from latex rubber that mechanically prevents semen
from coming in contact with the cervix. It also holds a spermicidal jelly in place against the cervix. A
condom rolls over an erect penis and collects the semen after ejaculation. A cervical cap is placed
over the cervix and may be left in place for up to 3 days. A vaginal sponge contains spermicide and is
a reservoir to hold the semen.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which
intervention is most appropriate for this problem?
a) Place the client in semi-Fowler's position while feeding.
b) Give the feedings at room temperature.
c) Change the feeding container daily.
d) Stop the feedings and check for residual volume.
d) Stop the feedings and check for residual volume.
Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings.
Stopping the feeding and checking for residual volume helps assess the reason for the client's
nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the
physician. Feedings are normally given at room temperature to minimize abdominal cramping;
however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the
head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding
containers are changed daily to prevent bacterial growth.
The nurse is caring for a client with a Jackson-Pratt drain. Which of the following would be the most
appropriate action by the nurse?
a) Attach the tube to straight drainage to monitor the output.
b) Irrigate the drain with normal saline to ensure patency.
c) Ensure that the drainage receptacles are kept compressed to maintain suction.
d) Leave the drain open to the air to ensure maximum drainage.
c) Ensure that the drainage receptacles are kept compressed to maintain suction.
Portable wound drainage systems are self-contained and can be emptied and compressed to
reestablish negative pressure, which promotes drainage. The other choices are incorrect because a
Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.
A client has a wound with a drain. When performing wound cleansing around the drain, the nurse
should cleanse in which direction?
a) From the superior portion of the wound to the inferior
b) Laterally, from one side of the wound to the opposite side
c) In a widening circle around the drain, outward from the center
d) Laterally, from the distal area to the center
c) In a widening circle around the drain, outward from the center
Questions and Correct Answers With
Rationale) Updated Fall 2024/2025.
Which finding requires immediate intervention when planning care for an adolescent with cystic
fibrosis (CF)?
a) large, foul-smelling, and bulky stools
b) chest pain with dyspnea
c) poor weight gain
d) delayed puberty
b) chest pain with dyspnea
Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed
puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is
common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling
stools indicate noncompliance with taking enzymes and should be addressed, but respiratory
complications are the greatest concern.
Which precautions should the health care team observe when caring for clients with hepatitis A?
a) wearing gloves when giving direct care
b) wearing a mask when providing care
c) gowning when entering a client's room
d) assigning the client to a private room
a) wearing gloves when giving direct care
Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for
direct care. A gown is not required unless substantial contact with the client is anticipated. It is not
necessary to wear a mask. The client does not need a private room unless incontinent of stool.
A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag.
Which observation by the nurse ensures that the client's urine has been measured accurately?
a) The LPN pours the urine into a graduated measuring container.
b) The LPN pours the urine into a paper cup that holds approximately 250 mL.
c) The LPN holds the Foley drainage bag up to eye level.
d) The LPN uses the measuring markings on the Foley drainage bag.
a) The LPN pours the urine into a graduated measuring container.
The only means to measure urine output accurately is to use a container that has specific markings
for measuring liquid. The other options would not provide an accurate measure of urine output.
An elderly couple who have just relocated to a long-term care facility have been unable to obtain a
shared room. A staff member at the facility states that this should not be a concern and implies that
,sexual activity between the couple likely ceased many years ago. How should the nurse best respond
to this individual's assertion?
a) "Research has shown the nature of sexual activity changes with age but that it actually becomes
more frequent."
b) "It's true that they've probably stopped having sexual activity, but it's important for them to have
companionship."
c) "That's true, but it's important for us to give them the teaching they need in order to resume this
part of their relationship."
d) "Actually it's not true that older people always stop having sexual activity when they get older."
d) "Actually it's not true that older people always stop having sexual activity when they get older."
Sexual activity need not be hindered by age. There is no evidence, however, that it becomes
increasingly frequent in late adulthood.
The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also
allergic to:
You selected: Iodine skin preparations.
Correct
Explanation:
Clients who are allergic to shellfish are allergic to iodine skin preparations (Iodophor and Betadine)
or any other products containing iodine, such as dyes. Clients who are allergic to shellfish do not
necessarily have an allergy to any other substances or seafood. (less)
Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain?
a) Clean from the center outward in a circular motion.
b) Wear sterile gloves and a mask.
c) Remove the drain before cleaning the skin.
d) Clean briskly around the site with alcohol.
a) Clean from the center outward in a circular motion.
The nurse should move from the center outward in ever-larger circles when cleaning around a
wound drain because the skin near the drain site is more contaminated than the site itself. The nurse
should never remove the drain before cleaning the skin. Alcohol should never be used to clean
around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria.
The nurse should wear sterile gloves to prevent contamination, but need not wear a mask.
After receiving information on various forms of birth control, a young couple decides to use a barrier
method because they would like to try and conceive in 1 to 2 years. Which barrier method uses a
rubber barrier to hold spermicide against the cervix?
a) A cervical cap.
b) A vaginal sponge.
c) A diaphragm.
d) A condom.
, c) A diaphragm.
A diaphragm is a dome-shaped device made from latex rubber that mechanically prevents semen
from coming in contact with the cervix. It also holds a spermicidal jelly in place against the cervix. A
condom rolls over an erect penis and collects the semen after ejaculation. A cervical cap is placed
over the cervix and may be left in place for up to 3 days. A vaginal sponge contains spermicide and is
a reservoir to hold the semen.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which
intervention is most appropriate for this problem?
a) Place the client in semi-Fowler's position while feeding.
b) Give the feedings at room temperature.
c) Change the feeding container daily.
d) Stop the feedings and check for residual volume.
d) Stop the feedings and check for residual volume.
Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings.
Stopping the feeding and checking for residual volume helps assess the reason for the client's
nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the
physician. Feedings are normally given at room temperature to minimize abdominal cramping;
however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the
head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding
containers are changed daily to prevent bacterial growth.
The nurse is caring for a client with a Jackson-Pratt drain. Which of the following would be the most
appropriate action by the nurse?
a) Attach the tube to straight drainage to monitor the output.
b) Irrigate the drain with normal saline to ensure patency.
c) Ensure that the drainage receptacles are kept compressed to maintain suction.
d) Leave the drain open to the air to ensure maximum drainage.
c) Ensure that the drainage receptacles are kept compressed to maintain suction.
Portable wound drainage systems are self-contained and can be emptied and compressed to
reestablish negative pressure, which promotes drainage. The other choices are incorrect because a
Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.
A client has a wound with a drain. When performing wound cleansing around the drain, the nurse
should cleanse in which direction?
a) From the superior portion of the wound to the inferior
b) Laterally, from one side of the wound to the opposite side
c) In a widening circle around the drain, outward from the center
d) Laterally, from the distal area to the center
c) In a widening circle around the drain, outward from the center
