Prepare for NCLEX with this comprehensive Med-Surg review and practice questions. This guide covers all medical-surgical nursing content areas and clinical scenarios.
Q: The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder?
Answer: A sense of a curtain falling across the field of vision
Q: The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?
Answer: A red, dull, thick, and immobile tympanic membraneOtoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.
Q: A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?
Answer: TinnitusTinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s thinking process and attention span.
Q: The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?
Answer: Blurred visionA gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.
Q: The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply.
Answer: avoid activities that require bending over.Take acetaminophen for minor eye discomfort.Place an eye shield on the surgical eye at bedtime.Contact the surgeon if a decrease in visual acuity occurs.Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.
Q: Tonometry is a method of measuring intraocular fluid pressure.
Answer: Pressures between 10 and 21 mm Hg are considered within the normal range.However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed.
Q: The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?
Answer: Cranial nerve VII, facial nerven acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.
Q: The nurse places an eye patch over the client’s affected eye to reduce eye movement w/ GLAUCOMA. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Therefore, reading and watching television are not allowed. The client’s position is prescribed by the health care provider; normally, the .
Answer: prescription is to lie flat.
Q: open angle glaucoma
Answer: tunnel vision,cupping of optic disc.Tx- timolol drops,maybe laser trabeculoplasty, maybe surgical trabeculectomy
Q: The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply.
Answer: Position the client with the affected side down after the irrigation.Warm the irrigating solution to a temperature that is close to body temperature.Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal.
Q: A _________is a surgical procedure that will allow fluid to drain from the middle ear and may be necessary to treat acute otitis media. Strict bed rest is not necessary, although activity may be restricted. Additionally, bed rest would not assist in reducing pressure or allowing fluid to drain. In some recurrent and persistent cases, the mastoid bone is removed or partially removed for chronic otitis media. Benadryl is an antihistamine with antiemetic properties.
Answer: myringotomy
Q: the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation.
Answer: Microalbuminuria is
Q: associated with end-stage renal disease caused by diabetic nephropathy.
Answer: Hyperkalemia, is
Q: Straining all urine is the most important nursing action for ppl w/ kideny stones. Encouraging fluid intake is important for any client who may have a kidney stone, but it is even more important to strain all urine.
Answer: Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery.
Q: The nurse should call the provider for a different medication because morphine is a _____________and should be avoided when the client has asthma.
Answer: histamine release drug
Q: Suctioning Tips
Answer: Insert the catheter until resistance or coughing occurs.Suction pressure should be between 80 and 120 mm HgThe catheter should be withdrawn 1 to 2 cm at a time with intermittent, not suction.
Q: Trigeminal neuralgia is characterized by
Answer: paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V).
Q: Tinnitus, vertigo, and hearing difficulties
Answer: characteristic of Ménière syndrome (cranial nerve VIII).
Q: characteristic of Bell palsy (cranial nerve VII).
Answer: Unilateral facial weakness and paralysis
Q: characteristic of disorders of the hypoglossal (cranial nerve XII).
Answer: .Difficulty in chewing, talking, and swallowing
Q: Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by
Answer: an increased oral temperature, because the fracture leaves the meninges open to bacterial invasion.
Q: The blood urea nitrogen (BUN) level indicates the
Answer: effectiveness of the kidneys in filtering waste from the blood.Dehydration, which could be caused by vomiting, would cause an increased BUN level.
Q: may indicate pacer failure.
Answer: Changes in pulse rate and/or rhythm
Q: Increasing the oxygen flow rate provides more oxygen to the client’s myocardium and may
Answer: decrease myocardial irritability as manifested by the frequent PVCs.
Q: In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury
Answer: moved into the hallways, away from windows, to prevent flying debris from causing injury.
Q: A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority?
Answer: Place the client on NPO status
Q: A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?
Answer: Support the client to a sitting position.
Q: A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide, 0.04 mg/kg every 12 hours IV, is prescribed. What is the priority nursing diagnosis for this client?
Answer: Impaired communication related to paralysis of skeletal muscles
Q: Clients with primary aldosteronism exhibit
Answer: a profound decline in serum levels of potassium; hypokalemia; hypertension is the most prominent and universal sign.
Q: The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention?
Answer: The presence of crepitus in the right elbowCompartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise.
Q: Hypocalcemia develops in CKD because of
Answer: chronic hyperphosphatemia,
Q: 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 intervention should the nurse implement first?
Answer: Auscultate the client’s breath sounds.The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.
Q: whose skin is cool, pale, and moist.
Answer: Hypovolemic shock
Q: Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing.
Answer: This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall.
Q: Chest Tube stuff
Answer: Vigorous bubbling in the suction control chamberDrainage system maintained below the client’s chest50 mL of drainage in the drainage collection chamberOcclusive dressing in place over the chest tube insertion siteFluctation of water in the tube in the water seal chamber during inhalation and exhalation
Q: Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus.
Answer: Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.
Q: A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply.
Answer: HypotensionHyperkalemia
Q: Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as
Answer: nervousness,irritability, andtremors.Hunger –> HYPOglycemia
Q: The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?
Answer: A heart rate that is 90 beats/minute and irregularPheochromocytoma is a catecholamine-producing tumor usually found in the adrenal medulla, but extraadrenal locations include the chest, bladder, abdomen, and brain; it is typically a benign tumor but can be malignant. Excessive amounts of epinephrine and norepinephrine are secreted. The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hour is an adequate output. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) is a normal finding.
Q: Acromegaly results from excess secretion of growth hormone, usually caused by
Answer: a benign tumor on the anterior pituitary gland.Treatment is surgical removal of the tumor, usually with a sublingual transsphenoidal complete or partial hypophysectomy.The sublingual transsphenoidal approach is often through an incision in the inner upper lip at the gum line.Transsphenoidal surgery is a type of brain surgery and infection is a primary concern.Leukocytosis, or an elevated white count, may indicate infection.Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy.In diabetes insipidus there is decreased secretion of antidiuretic hormone and clients excrete large amounts of dilute urine.Following transsphenoidal surgery, the nasal passages are packed and a dripper pad is secured under the nares.Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid leak.The surgeon should be notified and the drainage should be tested for glucose.A cerebrospinal fluid leak increases the postoperative risk of meningitis.Anxiety is a nonspecific finding that is common to many disorders.
Q: Chvostek’s sign is a test of _________________associated with hypocalcemia and is seen as grimacing in response to tapping on the facial nerve.
Answer: nerve hyperexcitability
Q: The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include afasting blood glucose level of 120 mg/dL (6.8 mmol/L),temperature of 101°F (38.3°C),pulse of 102 beats/minute,respirations of 22 breaths/minute, andblood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse?
Answer: Temperature
Q: During an acute episode of cholecystitis, the client may complain of
Answer: severe RUQ pain that radiates to the right scapula or shoulderepigastric pain after a fatty or high-volume meal.Fever and signs of dehydration would also be expected, as well ascomplaints of indigestion, belching, flatulence, nausea, and vomiting.
Q: Hepatitis causes gastrointestinal symptoms such as
Answer: anorexianausearight upper quadrant discomfortweight loss.Fatigue and malaise are common.Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
Q: The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form.
Answer: Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.
Q: B12 rich
Answer: nuts,organ meats,dried beans,citrus fruits,green leafy vegetables, andyeast.
Q: The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.
Answer: Maintain NPO (nothing by mouth) status.Encourage coughing and deep breathing.Give hydromorphone intravenously as prescribed for pain.
Q: A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
Answer: Lying recumbent following meals
Q: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include
Answer: vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.