Green NCLEX-Med Surg Exam Complete Questions and Answers Rated A+ 2024

For the client undergoing hemodialysis, the nurse suspects the client has an air embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.) a) Dyspnea b) BP 168/92 mm Hg c) Chest pain d) Anxiety e) O2 saturation of 98% f) Blue nail beds - a, c, d, f During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the best immediate action for the charge nurse to take? - Continue with the shift report and talk to the nurse about the incident at a later time. Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? - infection When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? - glucose A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately? - Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? - Pedal pulses will be weak or absent in the left foot. The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function? - Change in level of consciousness The nurse is assessing a client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? - The client has a carpal spasm when taking a blood pressure. A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? - perform synchronized cardioversion. A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? - Flush the line with normal saline. The nurse on a medical-surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? - If the client's wound is infected A 77-year-old client is admitted to the hospital with confusion and anorexia of several days' duration. Additional symptoms reported are nausea and vomiting, and current complaints of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? - digoxin An older client comes to the outpatient clinic complaining of left calf pain. The nurse notices a reddened area on the calf of the right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? - Auscultate the client's breath sounds. The clinic nurse is providing post-operative teaching for a client scheduled for a myringoplasty. Which client statements indicate to the nurse that the teaching has been effective? (Select all that apply.) a) "I can wash my hair in the shower when I get home." b) "I will avoid forceful and deep coughing until my post-op checkup." c) "I must lay flat on my non-operative side for the first 12 hours after surgery." d) "My hearing may be less or muffled until the packing comes out." e) "I need to only take the first two doses of antibiotics and save the rest for another time." - b, c, d The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately? (Select all that apply.) a) Reactivity of deep tendon reflexes b) Heart rate and respiratory rate c) Memory of recent events d) Ability to open the eyes spontaneously e) Dizziness f) Ringing in the ears - b-f The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? - Prevent infection. The nurse is observing an unlicensed assistive personnel (UAP) performing care for a bedridden client with advanced Huntington disease. Which care measures are most important for the nurse to supervise? (Select all that apply.) a) Oral care b) Bathing c) Foot care d) Catheter care e) Enteral feeding - a, e The nurse hears the presence of secretions in the lungs and determines the client, post thoracotomy, needs to be suctioned. What steps will the nurse include in the suctioning procedure? (Select all that apply.) a) Perform hand hygiene. b) Position in no less than a semi-Fowler's position. c) Lubricate the suction catheter with a petroleum-based product. d) Insert the catheter with the suction on. e) Listen for breath sounds. f) Hyperoxygenate the client. - a, b, e, f The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food items chosen by the client indicate understanding of the teaching? (Select all that apply.) a) White bread b) Salmon c) Broccoli d) Whole milk e) Banana - b, c, e Which instruction is best for the nurse to provide to a client with emphysema and chronic fatigue? - Pace your activities and schedule rest periods A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take with the staff caring for this client? - Determine if all employees have had the hepatitis B vaccine series. While at a home game, the mother of a 6-year-old is heard screaming, "My child is having an asthma attack! Can anyone help?" The nurse arrives and finds the child gasping for breath with circumoral cyanosis. What are the nurse's next actions? (Select all that apply.) a) Yell, "Call 911." b) Ask the mother if she has the child's bronchodilator. c) Start cardiopulmonary respirations. d) Ask the mother if the child is allergic to bee stings. e) Stay with the child and mother until the ambulance arrives. f) Sit the child straight up in Fowler's position. - a, b, e, f The clinic nurse is teaching a client newly diagnosed with Raynaud's Syndrome. What instructions will the nurse include in the client's teaching plan? (Select all that apply.) a) Place your hands in 130°F/54.4°C water until warmed through. b) Wear warm clothing and socks when you are cold. c) Use finger guards when using a knife to avoid cutting your hands. d) Take your medication only when you feel the tingling in your fingers. e) Avoid stressful situations at work and in your home life. - b, c, e An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to take for this client? - Initiate airborne infection precautions. Which foods will the nurse recommend for the client with tuberculosis being discharged to home? (Select all that apply.) a) Bean soup b) Spinach c) Apples d) Bananas e) Dark chocolate f) Shellfish - bean soup, spinach, dark chocolate, shellfish The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing in place to the mid abdomen. The nurse notes a spot of red staining centrally on the dressing. What is the nurse's next action? - Circle the stain with an ink pen. The nurse observes the chest tube drainage has exceeded 300 mL of bright red bloody fluid for the past 30 minutes in the client after a coronary artery bypass graft. What is the nurse's next action? - notify the HCP A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? - Just prior to tube feeding A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine. Which statement given by the nurse would offer the client accurate information about this vaccine? - The immunization is administered once to older adults or those at risk for illness. The nurse is preparing a client for discharge after a right total knee replacement. Which client statements about use of a walker indicate to the nurse the teaching was effective? (Select all that apply.) a) "I will walk in the middle of the walker." b) "I will make sure all four feet of the walker are on the floor before I use the hand pieces." c) "I will move my right foot forward into the walker, and then my left foot." d) "I will collapse the walker and put it in the chair opposite the bed at night." e) "I will use a silicone-based cleaning product to clean the hand pieces and rubber tips." - a, b, c A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? - The client smokes one to two packs of cigarettes per day Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old who is in good health overall? - Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which action should the nurse take first? - Call the anesthesia provider for a different medication for pain. The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first? - Obtain IV fluids for infusion per protocol. A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit take first? - Move clients and visitors into the hallways and close all doors to clients' rooms. Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? - Average daily census The nurse is preparing teaching for nursing students who are participating in a flu vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.) a) Health care personnel b) Those who are allergic to eggs c) Individuals who are over 50 years old d) Individuals with chronic health conditions e) Those who live in nursing homes f) infants under 6 months of age - a, c, d, e A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. The client begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? - Turn off the continuous feeding pump. A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment? (Select all that apply.) a) Nausea and vomiting b) Loss of appetite c) Abdominal cramping d) Guarding with abdominal palpation e) Low urine output f) Cool, clammy skin - a, b, c, d For the client with a prescription for enteral feeding after surgery, the nurse checks the gastric aspirate and notes the pH is 5.2. What is the next nurse's action? - Initiate the procedures for the feeding. The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? - Elevated serum amylase and lipase levels When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? - Tell the client to carry a medical alert card that explains the condition. The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed? - Tidaling of water in water seal chamber The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? - infection A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? - Nembutal sodium at bedtime for rest he nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? - Assess for kinks or dependent loops in the tubing. The nurse is providing care to a client admitted to the emergency room with a blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's next actions? (Select all that apply.) a) Place 4 sugar cubes under the tongue. b) Place 1 tablespoon of honey in the client's cheek. c) Start an IV of Normal Saline. d) Obtain a 50% dextrose solution. e) Administer glucagon as per the standing order. f) Turn the client to the side. - c, d, e, f A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? - Change the bag when the seal is broken. The nurse is providing care to a client with a central venous catheter. The health care provider orders multiple labs. Using the discard method, what steps will the nurse use to draw the blood samples? (Select all that apply.) a) Prepare the catheter hub with an antiseptic solution according to facility protocol. b) Attach a syringe to the hub containing 2 mL of normal saline and flush the line. c) Attach the vacutainer sleeve or 20 mL syringe to the catheter hub. d) Withdraw waste blood and discard it in an appropriate container. e) Draw the amount of blood needed for the laboratory samples. f) Flush the line with no more than 2 mL of normal saline to flush the line. - a, c, d, e The clinic nurse is preparing to teach a client about having a cardiac catheterization. What assessment must the nurse include in the teaching plan? - Do you take any medication for Type II diabetes What is the most important nursing priority for a client who has been admitted for a possible kidney stone? - . Straining all urine A client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if dialysis will always be needed. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? - Nephron obstruction Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia? - Risk for injury related to syncope and confusion The nurse is performing a skin assessment on a client who is transferred from a long-term care facility to an in-patient hospital unit. The client is unable to move independently while in bed. The nurse observes reddened areas to the sacrum and on the heals bilaterally. What is the next nursing action? - Document the size and shape of the reddened areas. A 43-year-old homeless, malnourished client with a history of alcoholism is transferred to the ICU. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer? - mag sulfate The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally about self-care. Which teaching points will the nurse include in the client's plan of care? (Select all that apply.) a) apply heat packs to your knees as needed for pain. b) Support your knees while you are in bed with a pillow or a rolled towel. c) Take 1000 mg of acetaminophen every 4 hours, as needed for pain. d) Walk no less than 3 miles every day. d) Get 7 to 8 hours of sleep every night. e) Eat a balanced diet, including fish with Omega-3 fatty acids. - a, b, e, f The nurse is teaching a group of elders at a senior center. Which is the most significant safety implication for this group that the nurse will include in the teaching plan? - stooped posture The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all that apply.) a) Facial muscle spasms b) Sudden facial pain c) Unilateral facial weakness d) Difficulty in chewing e) Tinnitus f) Hearing difficulties - a, b