nclex questions for final med-surg exam
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| 1. A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurs provides what instruction to the client? | show 🗑
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| 4. The clinic nurse is conducting health screenings. Which of the following client assessment findings indicates that client teaching is needed about the risk for stroke? Select all that apply | show 🗑
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| 8 The nurse places highest priority on taking which of the following actions to reduce the spread of microoganisms when caring for a client at risk for infection? | show 🗑
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| show | White blood cell count 12,260/mm3, Blood urea nitrogen 38 mg/dL
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| show | Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility
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| 17. The nurse is assigned to a client diagnosed with head & neck cancer who is receiving enteral feedings via gastrostomy tube. When the nurse is called away to care for another client, which task for this client could be appropriately delegated to a UAP | show 🗑
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| show | pH 7.2; serum potassium 6.2 mEq/L
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| 19. A client has a BUN of 68 mg/dL and a creatinine level of 6.0 mg/dL. The IV fluid is 5% dextrose in 0.9% sodium chloride with 40 mEq KCL @ 100 mL/hr. Which action would be most appropriate for the nurse to take? | show 🗑
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| show | anxiety or anger
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| show | Increased drowsiness, mild confusion, and concentrated urine
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| show | hourly coughing and deep breathing
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| show | Client has a normal laboratory value and has not nutritional risk
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| show | Ensure the client's safety, cover the field with a sterile towel, and respond to another client.
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| 39. When giving directions to a 24-year-old female with abdominal pain who is about to undergo a pelvic sonogram, which statement should the nurse make to the client? | show 🗑
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| 43. When a female client preparing for surgery suddenly bursts into tears, the preoperative holding unit nurse should take which of the following actions? | show 🗑
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| 44. After reviewing the client's health history, the nurse concludes that which of the following is the most significant factor related to the development of bronchogenic carcinoma for this client? | show 🗑
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| 48. Which of the following actions would the nurse institute that is specific to the care of the assigned client who has tuberculosis | show 🗑
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| 49. A client has a potassium level of 6.8 mEq/L. Which sign or symptom would the nurse expect to find when assessing this client? | show 🗑
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| 52. The nurse is assigned to the care of an obese client who has GERD. Which of the following activities could the nurse appropriately delegate to a UAP? | show 🗑
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| 53. The nurse is admitting a client with thermal burns to both arms and anterior trunk. The client asks for a drink of water. What is the most appropriate response for the nurse to make? | show 🗑
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| 55 A client who has pancreatitis is experiencing pain. After administering an analgesic, the nurse should place the client in which of the following positions to promote comfort? | show 🗑
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| 58 The nurse believes a client has slight one-sided weakness. Tests muscle strength by asking the client to hold the arms up with supinated hands- as if holding a tray, eyes closed. The clients right hand moves down slightly and turns. The nurse documents | show 🗑
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| 61. A client who is receiving IV heparin by protocol orders has an activated partial thromboplastin time (aPTT) level of 140 seconds (control time is 36 seconds) What is the priority action that the nurse should institute? | show 🗑
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| 62. The nurse has admitted to the intermediate care unit a client who sustained a SCI at T1 in a motor vehicle accident. Which of the following nursing care activities can the nurse delegate to the UAP when working with this client?Select all that apply | show 🗑
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| 63 The nurse has been instructed to have a surgical consent form signed by a client who will be undergoing a surgical procedure. What is the most essential information to include in the discussion prior to the client signing the permission? | show 🗑
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| show | the correct stoma is on the transverse part of colon
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| 67 The nursing unit is understaffed and a nurse from the surgical intermediate care unit has been floated to the unit for the day shift. Which of the following two clients should the nurse assign to this RN float nures? | show 🗑
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| 68 The nurse would conclude that hypomagnesemia has not resolved if which of the following neuromuscular signs is still present after treatment. | show 🗑
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| show | troponin
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| 74 A client has a strong family tendency toward HTN. He denies that he will get HTN because he watches what he eats, gets plenty of exercise, and keeps his weight within a normal range. When implementing the plan of care, the nurse should do which: | show 🗑
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| 78 A client presents to the ED with a stab wound to the abdominal RUQ. Vitals are bp 85/60, pulse 125, RR 28. The nurse should immediately suspect damage to what organ? | show 🗑
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| 82 As part of the ongoing assessment of a client who has an electrical burn, a CBC, electrolyte panel, and renal panel were ordered. The nurse would expect to find which of the following results? | show 🗑
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| 83 A client with CHF has been advised to follow a low sodium diet. Which statement by the client indicates to the nurse that diet teaching has been effective? | show 🗑
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| show | refocus the conversation on a less threatening topic.
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| show | maintain cervical spine precautions
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| show | canned peaches, egg omelet, whole milk, fruited yogurt
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| 97 The nursing unit is short staffed for the shift and an RN from the pediatric unit has been floated to the nursing unit. Which of the following clients should the nurse assign to the float nurse? | show 🗑
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| 99 the nurse has just read the results of a clients TB test at a health fair. An induration is apparent. The client asks what this means. The nurse's best response would be: | show 🗑
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| 101 The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice? | show 🗑
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| show | Limiting intake of coffee drinks to 2 or few cups per day
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| 107 While assessing the chest tube drainage system of client,the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which of the following actions? | show 🗑
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| 109 A client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a need for the nurse to call the physician for treatment orders? | show 🗑
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| 112 a client with a history of heart failure suddenly exhibits shortness of breath, a respiratory rate of 30, crackles auscultated bilaterally, and frothy sputum. After telephoning the physician for medical orders, which should the nurse delegate to LPN? | show 🗑
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| 113 An 86 yo client will be undergoing a surgical procedure. Which of the following changes would the nurse make in the informed consent process for this elderly client? | show 🗑
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| show | two poached eggs, hash brown potatoes, whole milk
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| 116 A client with diabetes insipidus who has been taking vasopressin intranasally comes to the clinic. On assessment the nurse notes some disorientation and behavior changes. Significant pedal edema is present. What should be the nurses next action? | show 🗑
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| show | document intake from the meal trays, assist the client to ambulate in the hall
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| show | Abdominal ultrasound
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| 129 A female client has been successfully resuscitated after cardiac arrest. Her arterial blood gas reveals a pH of 7.6. The nurse attributes this result to which of the following | show 🗑
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| 134 The nurse would assess a 76-year-old client for which common problem that most increases the risk for major complications of heart and lung disease | show 🗑
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| 135 A client with ARDS show no improvement despite increases in the concentration of oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching? | show 🗑
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| show | ACE inhibitors
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| show | potassium 2.9 mEq/L
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| 142 During a scheduled exam, the client's glycolysated hemoglobin was found to be 9%. The client has had diabetes mellitus for 3 years. The nurse should do which of the following? | show 🗑
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| 149 The nurse examines the WBC differential for a client who experienced a severe allergic reaction. The nurse anticipates that which of the following values will be elevated? | show 🗑
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| 152 In a child with acute renal failure, the nurse would help to prevent hyperkalemia by limiting which of the following foods in the diet? | show 🗑
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| 158 While making rounds, the nurse observes a client receiving oxygen by this mode. The nurse concludes the client is using this mode of oxygen therapy because of which primary benefit? | show 🗑
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| 165 A client admitted with exacerbation of COPD has a respiratory rate 18, dry cough, abg reveals pH of 7.29, CO2 of 50 mm Hg, O2 of 72 mmHg. The nurse identifies which nursing diagnosis as the priority? | show 🗑
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| 167 The nurse has delegated to a UAP the care of a client who had a right hemisphere thrombotic stroke with hemiplagia. The nurse would give further direction to the UAP after noting that the UAP did which of the following? | show 🗑
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| 169 The nurse is reviewing the results of a male clients recent lipid profile. The nurse notes that the client is experiencing beneficial effects of a heart healthy diet and exercise after noting elevations in which laboratory value? | show 🗑
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| 179 A client with bone cancer receiving chemotherapy has developed bone marrow suppression. Which laboratory report is of highest priority for the nurse to monitor at this time? | show 🗑
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| show | start IV fluid infusion for rehydration
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| 186 The home health care nurse is visiting an elderly client who is taking a prescribed calcium channel blocker. In conducting dietary teaching, the nurse instructs the client that what food is contraindicated to take with a calcium channel blocker? | show 🗑
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| 188 The nurse must assess the temperature and blood pressure of a client on contact precautions for wound infection every shift. Which is the appropriate nursing action to minimize the spread of microorganisms | show 🗑
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| show | suggest the use of sugar free candies
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| 195 The nurse would expect to find a diminished pCO2 level in the assigned client who has which of the following physical assessment findings? | show 🗑
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| 198 An adult client arrives to the ED with complaints of chest pain and shortness of breath. The nurse concludes that which of the following points, if present in the client's history, would indicate that this pain may be related to cardiac disease? | show 🗑
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| show | stop administration and attempt to aspirate
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| show | give another dose of nitro
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| 213 The nurse anticipates which of the following regarding sodium restriction for a client diagnosed with ascites secondary to cirrhosis? | show 🗑
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| show | benign prostatic hyperplasia
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| show | palpate peripheral pulses every 2-4 hours
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| 233 A client with venous stasis ulcers is being treated with an Unna boot. The nurse should include which of the following additional interventions in the plan of care? | show 🗑
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| 237 Which of these statements if made by a client receiving dietary instruction for atherosclerosis would indicate a need for furthur discussion | show 🗑
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| show | "I should cut down on the fluids I drink so I won't have to urinate so often"
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| show | "I need to wear a particulate respiratory mask when I got to x-ray."
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Created by:
ekelley10