Nclex Questions Med/surg Chapters 12-17

Front 1

A patient one day postoperative after abdominal surgery has incisional pain, 99.5 temp, slight erythema at the incision margins, and 30 ml serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make?
incision shows signs of an infection
normal inflammatory response
shows signs of impending dehiscence
physician needs to be notified about her condition

Back 1

normal inflammatory response

Front 2

A patient in the unit has a 103.7 temp. Which intervention would be most effective in restoring normal body temp?

cooling blanket
antipyretics on an around the clock schedule
increased fluids and have the UAP give sponge bath
prescribed antibiotics and warm blankets

Back 2

antipyretics on an around the clock schedule

Front 3

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur?

tertiary intention
secondary intention
regeneration of cells
remodeling of tissues

Back 3

secondary intention

Front 4

A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left greater toe. The patient's WBC count is 15.0 X 10/6/UL and he has coolness of the lower extremities, weighs 75 pounds more than his ideal weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal?

Imbalanced nutrition due to high fat foods
impaired tissue integrity related to decreased blood flow from diabetes and smoking
ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking
ineffective coping dealing with indifference and denial of long term effects of diabetes and smoking

Back 4

impaired tissue integrity related to decreased blood flow from diabetes and smoking

Front 5

Which one of the orders should a nurse question in the plan of care for a patient with a stage III pressure ulcer?

pack the ulcer with foam dressing
turn and position every 2 hours
clean the ulcer every shift with Dakins solution
assess for pain and medicate before dressing change

Back 5

clean the ulcer every shift with Dakin's solution

Front 6

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response?

serum protein analysis
WBC count and differential
punch biopsy of center of wound
culture and sensitivity of the wound

Back 6

WBC count an differential

Front 7

An 85 year old patient is assessed to have a score of 16 on the Braden scale. based on this info, how should the nurse plan for this patient's care?

implement a q2hr turning schedule with skin assess
place Duoderm on the patient's sacrum
elevate the head of the bed 90 degrees
continue with weekly skin assessments with no special precautions

Back 7

implement a q2hr turning schedule with skin assess

Front 8

A 65 year old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnosis is/are most appropriate (select all that apply)?

acute pain related to tissue damage and inflammation
impaired skin integrity related to immobility and decreased sensitivity
impaired tissue integrity related to inadequate circulation secondary to pressure
risk for infection related to loss of tissue integrity and undernutrition secondary to stroke

Back 8

impaired skin integrity related to immobility and decreased sensitivity
impaired tissue integrity related to inadequate circulation secondary to pressure

Front 9

An 82 year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 x 2 x 0.8 cm in depth and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form?

I
II
III
IV

Back 9

III

Front 10

When assessing a patient who is receiving cefazolin (Ancef) for the treatment of a bacterial infection, which data suggest that treatment has been effective?
White blood cell (WBC) count 8000/μL, temperature 101○ F
White blood cell (WBC) count 4000/μL, temperature 100○ F
White blood cell (WBC) count 8500/μL, temperature 98.4○ F
White blood cell (WBC) count 16,500/μL, temperature 98.8○ F

Back 10

White blood cell (WBC) count 8500/μL, temperature 98.4○ F

Front 11

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication?

Pain level
Intake and output
Oxygen saturation
Level of consciousness

Back 11

Intake and output

Front 12

The nurse determines that the patient may be suffering from an acute bacterial infection based upon which laboratory test result?
Increased platelet count
Increased blood urea nitrogen
Increased number of band neutrophils
Increased number of segmented myelocytes

Back 12

Increased number of band neutrophils

Front 13

Which strategy by the nurse would be most helpful in treating a patient who is experiencing chills because of an infection

Provide a light blanket.
Encourage a hot shower.
Monitor temperature every hour.
Turn up the thermostat in the patient's room.

Back 13

Provide a light blanket.

Front 14

A patient with pneumonia has a fever of over 103o F. What should the nurse do to manage the patient's fever?
Administer aspirin on a scheduled basis around the clock.
Provide acetaminophen every 4 hours to maintain consistent blood levels.
Administer acetaminophen when the patient's oral temperature exceeds 103.5° F.
Provide drug interventions if complementary and alternative therapies have failed.

Back 14

Provide acetaminophen every 4 hours to maintain consistent blood levels.

Front 15

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment?
Frequent examination of the character and quantity of exudate
Monitoring for signs and symptoms of local or systemic infections
Assessment of the patient's circulation distal to the location of the dressing
Assessment of the range of motion of the ankle and the patient's activity tolerance

Back 15

Assessment of the patient's circulation distal to the location of the dressing

Front 16

A patient had abdominal surgery last week. The patient calls the office and says the wound is now draining thick white material and it smells funny. How should the nurse document this drainage?
Serous
Purulent
Fibrinous
Catarrhal

Back 16

purulent

Front 17

The patient has inflammation and is complaining of malaise, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way?
Local response
Systemic response
Infectious response
Acute inflammatory response

Back 17

Systemic response

Front 18

An older patient is transferred from the nursing home with a black wound on her heel. What should the nurse expect to be the first treatment of this wound?
Dress it with an absorbent dressing for exudate.
Handle the wound gently and let it dry out to heal.
Debride the nonviable, eschar tissue to allow healing
Use negative-pressure wound (vacuum) therapy to facilitate

Back 18

Debride the nonviable, eschar tissue to allow healing

Front 19

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing?
Apple Incorrect
Custard
Popsicle
Potato chips

Back 19

Custard

Front 20

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply)?
Take the antibiotic until the wound feels better.
Take the analgesic every day to promote adequate rest for healing.
Be sure to wash hands after changing the dressing to avoid infection.
Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.
Notify the health care provider of redness, swelling, and increased drainage.

Back 20

Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.
Notify the health care provider of redness, swelling, and increased drainage.

Front 21

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should the nurse have the UAP do for the patient?

Reposition every 2 hours.
Measure the size of the reddened area.
Massage the area to increase blood flow.
Evaluate the area later to see if it is better.

Back 21

Reposition every 2 hours.

Front 22

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What should the nurse do about this situation?
Notify the health care provider
Document the fistula formation.
Assess the patient and vaginal drainage
Have the UAP apply a dressing to the vagina.

Back 22

Assess the patient and vaginal drainage

Front 23

The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be?
Adhesion
Contractions
Keloid formation
Excess granulation tissue

Back 23

Excess granulation tissue

Front 24

After the surgeon tells the patient that his wound will be allowed to heal by secondary intention, the patient asks the nurse what that is. How should the nurse explain this to the patient?
The wound will be stapled together until it heals.
The healing will contract the area to close the wound.
The wound will be left open and heal from the edges inward.
The wound will be sutured after the current infection is controlled.

Back 24

The wound will be left open and heal from the edges inward.

Front 25

If a person is a heterozygous for a given gene, it means that the person ?

is a carrier for a genetic disorder
is affected by the genetic disorder
has two identical alleles for the gene
has two different alleles for the gene

Back 25

has two different alleles for the gene

Front 26

Common causes of genetic mutations include (select all that apply )

dna damage from toxins
dna damage from UV radiation
inheritance of altered genes from the father
inheritance of altered genes from the mother
inheritance of somatic mutations from either parent

Back 26

dna damage from toxins
dna damage from UV radiation
inheritance of altered genes from the father
inheritance of altered genes from the mother

Front 27

A father who has an X-linked recessive disorder and a wife with a normal genotype will?

pass the carrier state to his male children
pass the carrier state to all of his children
pass the carrier state to all his female children
not pass on the genetic mutation to any of his kids

Back 27

pass the carrier state to all his female children

Front 28

What characterizes multifocal genetic disorders?

Genetic testing available for most disorders
commonly caused by single gene alterations
many family members report having the disorder
caused by complex interactions of genetic and environmental factors

Back 28

caused by complex interactions of genetic and environmental factors

Front 29

If a person tests positive for a genetic mutation, it means (select all that apply)

lab found an alteration in a gene
person is predisposed to develop a genetic disease
that the person
person will develop that disease at some point
there is no possibility that other family members may also be at risk
that the person should not have any children or any additional children

Back 29

there is no possibility that other family members may also be at risk
lab found an alteration in a gene

Front 30

What role does pharmacogentics have in health care?

it can assess individual variability to many drugs
it can be used to determine the effectiveness of a drug
it provides important assessment data for gene therapy
it can assess the variability of drug responses due to single genes

Back 30

it can assess the variability of drug responses due to single genes

Front 31

A couple who recently had a son with hemophilia A is consulting with a nurse. They want to know if their next child will have hemophilia A. The nurse can tell the parents that if their child is a

boy, he will have it
boy, he will be a carrier
girl, she will be a carrier
girl, 50% chance she will be a carrier

Back 31

girl, 50% chance she will be a carrier

Front 32

r which individual is genetic carrier screening indicated?
A patient with a history of type 1 diabetes
A patient with a family history of sickle cell disease
A patient whose mother and sister died of breast cancer
A patient who has a long-standing history of iron-deficiency anemia

Back 32

A patient with a family history of sickle cell disease

Front 33

A young mother is worried that her female baby will have hemophilia because the baby's father has it. How should the nurse explain this genetic disorder to the young mother?
Nearly all affected people are male.
Daughters of affected males will be carriers.
The daughter has a 50% chance of being affected.
If the mother is a carrier, the patient could have hemophilia.

Back 33

If the mother is a carrier, the patient could have hemophilia.

Front 34

Two sons of a father who has Huntington's disease cannot agree on whether or not to be tested for Huntington's disease because of the cost. What assistance should the nurse give when discussing presymptomatic genetic testing with these men?
"If one brother has the disease, the other brother will as well."
"A positive genetic mutation increases your risk of the disease."
"If there is a positive result, the patient will be diagnosed with the disease."
"You could use a direct-to-consumer genetic test for making future life decisions."

Back 34

"If there is a positive result, the patient will be diagnosed with the disease."

Front 35

The couple is adopting a baby girl. What health information related to the baby's biologic parents will be most useful to the parents and the baby as she grows up?
The grandmother had breast cancer.
The family has a history of Alzheimer's disease.
The family has an individual with Down syndrome.
The family has familial adenomatous polyposis (FAP).

Back 35

The family has familial adenomatous polyposis (FAP).

Front 36

The parents of a child diagnosed with cystic fibrosis ask the nurse what happened to cause this disease. What is the best response by the nurse?
It is X-linked so it was passed to the child from the mother.
It is a chromosome disorder that usually skips a generation.
It is autosomal recessive so both copies of the gene are abnormal.
It is autosomal dominant so the abnormal gene allele is expressed instead of the normal allele.

Back 36

It is autosomal recessive so both copies of the gene are abnormal.

Front 37

The patient has late stage non-small cell lung cancer. The physician is considering using crizotinib (Xalkori) for this patient. What should be done before it is prescribed for the patient?
Give chemotherapy first.
Test for hypersensitivity to this drug.
Test for the abnormal anaplastic lymphoma kinase (ALK) gene.
Test for gene abnormalities that will affect the appropriate dose.

Back 37

Test for the abnormal anaplastic lymphoma kinase (ALK) gene.

Front 38

A 5-year-old girl was diagnosed with type 1 diabetes mellitus. The mother says that no one else in her family has had diabetes and asks why her daughter would get it. How should the nurse explain this complex disease?
It is a congenital disorder that she was born with.
It is a single gene disorder, meaning only one gene mutation caused the disease.
It is a multifactorial genetic disorder caused by one or more genes and environmental factors.
It was an acquired genetic mutation, meaning she developed it, but her children will not have it.

Back 38

It is a multifactorial genetic disorder caused by one or more genes and environmental factors.

Front 39

The woman with ovarian cancer would like to know which kind of genetic testing could help prevent her daughters from getting ovarian cancer. What should the nurse tell this patient?
Forensic testing
Carrier screening
Predictive testing
Prenatal diagnostic testing

Back 39

Predictive testing

Front 40

The couple is delivering their first child. What newborn genetic screening should the nurse teach them about (select all that apply)?
Pheylketonuria
Dienoyl-CoA reductase
Polycystic kidney disease
Congenital hypothyroidism
Hereditary nonpolyposis colorectal cancer syndrome

Back 40

Pheylketonuria
Congenital hypothyroidism

Front 41

A patient with a father with polycystic kidney disease does not want to have genetic testing done for polycystic kidney disease because she is worried that she might lose her health insurance if genetic abnormalities are found. Based on the nurse's knowledge of the Genetic Information Nondiscrimination Act (GINA), what should the nurse teach this patient?
GINA should protect her from this happening.
GINA does not extend to cover preexisting conditions.
GINA will only protect her after she is diagnosed with polycystic kidney disease.
GINA health coverage nondiscrimination protection also extends to life insurance.

Back 41

GINA should protect her from this happening.

Front 42

!e function of monocytes in immunity is related to their ability to
a. stimulate the production of T and B lymphocytes.
b. produce antibodies on exposure to foreign substances.
c. bind antigens and stimulate natural killer cell activation.
d. capture antigens by phagocytosis and present them to lymphocytes.

Back 42

capture antigens by phagocytosis and present them to lymphocytes.

Front 43

One function of cell-mediated immunity is
a. formation of antibodies.
b. activation of the complement system.
c. surveillance for malignant cell changes.
d. opsonization of antigens to allow phagocytosis by neutrophils.

Back 43

surveillance for malignant cell changes.

Front 44

!e reason newborns are protected for the "rst 6 months of life
from bacterial infections is because of the maternal transmission of
a. IgG.
b. IgA.
c. IgM.
d. IgE

Back 44

IgG

Front 45

In a type I hypersensitivity reaction the primary immunologic
disorder appears to be
a. binding of IgG to an antigen on a cell surface.
b. deposit of antigen-antibody complexes in small vessels.
c. release of cytokines used to interact with speci"c antigens.
d. release of chemical mediators from IgE-bound mast cells and
basophils.

Back 45

release of chemical mediators from IgE-bound mast cells and
basophils.

Front 46

!e nurse is alerted to possible anaphylactic shock immediately
a%er a patient has received intramuscular penicillin by the development
of
a. edema and itching at the injection site.
b. sneezing and itching of the nose and eyes.
c. a wheal-and-$are reaction at the injection site.
d. chest tightness and production of thick sputum.

Back 46

a. edema and itching at the injection site.

Front 47

!e nurse advises a friend who asks him to administer his allergy
shots that
a. it is illegal for nurses to administer injections outside of a
medical setting.
b. he is quali"ed to do it if the friend has epinephrine in an injectable
syringe provided with his extract.
c. avoiding the allergens is a more e#ective way of controlling
allergies, and allergy shots are not usually e#ective.
d. immunotherapy should only be administered in a setting
where emergency equipment and drugs are available.

Back 47

immunotherapy should only be administered in a setting
where emergency equipment and drugs are available.

Front 48

Association between HLA antigens and diseases is most commonly
found in what disease conditions?
a. Malignancies
b. Infectious diseases
c. Neurologic diseases
d. Autoimmune disorders

Back 48

Autoimmune disorders

Front 49

A patient is undergoing plasmapheresis for treatment of systemic
lupus erythematosus. !e nurse explains that plasmapheresis is
used in her treatment to
a. remove T lymphocytes in her blood that are producing antinuclear
antibodies.
b. remove normal particles in her blood that are being damaged
by autoantibodies.
c. exchange her plasma that contains antinuclear antibodies with
a substitute $uid.
d. replace viral-damaged cellular components of her blood with
replacement whole blood.

Back 49

exchange her plasma that contains antinuclear antibodies with
a substitute $uid.

Front 50

!e most common cause of secondary immunode"ciencies is
a. drugs.
b. stress.
c. malnutrition.
d. human immunode"ciency virus.

Back 50

drugs

Front 51

What accurately describes rejection following transplantation?
a. Hyperacute rejection can be treated with OKT3.
b. Acute rejection can be treated with sirolimus or tacrolimus.
c. Chronic rejection can be treated with tacrolimus or cyclosporine.
d. Hyperacute reaction can usually be avoided if crossmatching is
done before the transplantation.

Back 51

Hyperacute reaction can usually be avoided if crossmatching is
done before the transplantation.

Front 52

In a person having an acute rejection of a transplanted kidney,
what would help the nurse understand the course of events (select
all that apply)?
a. A new transplant should be considered.
b. Acute rejection can be treated with OKT3.
c. Acute rejection usually leads to chronic rejection.
d. Corticosteroids are the most successful drugs used to treat
acute rejection.
e. Acute rejection is common a%er a transplant and can be treated
with drug therapy.

Back 52

Acute rejection is common a%er a transplant and can be treated
with drug therapy.

Acute rejection can be treated with OKT3.

Front 53

Which statement made by the nurse is most appropriate in teaching patient interventions to minimize the effects of seasonal allergic rhinitis?
"You will need to get rid of your pets."
"You should sleep in an air-conditioned room."
"You would do best to stay indoors during the winter months."
"You will need to dust your house with a dry feather duster twice a week."

Back 53

"You should sleep in an air-conditioned room."

Front 54

When caring for a patient with a known latex allergy, the nurse would monitor the patient closely for a cross-sensitivity to which foods (select all that apply)?
Grapes
Oranges
Bananas
Potatoes
Tomatoes

Back 54

Bananas
Potatoes
Tomatoes
grapes

Front 55

Ten days after receiving a bone marrow transplant, a patient develops a skin rash on his palms and soles, jaundice, and diarrhea. What is the most likely etiology of these clinical manifestations?
The patient is experiencing a type I allergic reaction.
An atopic reaction is causing the patient's symptoms.
The patient is experiencing rejection of the bone marrow.
Cells in the transplanted bone marrow are attacking the host tissue.

Back 55

Cells in the transplanted bone marrow are attacking the host tissue.

Front 56

A patient's low hemoglobin and hematocrit have necessitated a transfusion of packed red blood cells (RBCs). Shortly after the first unit of RBCs starts to infuse, the patient develops signs and symptoms of a transfusion reaction. Which type of hypersensitivity reaction has the patient experienced?
Type I
Type II
Type III
Type IV

Back 56

Type II

Front 57

A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, what is the nurse's priority action?
Monitor the patient's fluid balance.
Assess the patient's need for analgesia.
Monitor for signs and symptoms of an adverse reaction.
Assess the patient for changes in level of consciousness.

Back 57

Monitor for signs and symptoms of an adverse reaction.

Front 58

A healthy 65-year-old man who lives at home is at the clinic requesting a "flu shot." When assessing the patient, what other vaccinations should the nurse ask the patient about receiving (select all that apply)?
Shingles
Pneumonia
Meningococcal
Haemophilus influenzae type b (Hib)
Measles, mumps, and rubella (MMR)

Back 58

Shingles
Pneumonia

Front 59

On initial assessment of an older patient, the nurse knows to look for certain types of diseases because which immunologic response increases with age?
Autoimmune response
Cell-mediated immunity
Hypersensitivity response
Humoral immune response

Back 59

Autoimmune response

Front 60

A 21-year-old student had taken amoxicillin once as a child for an ear infection. She is given an injection of Penicillin V and develops a systemic anaphylactic reaction. What manifestations would be seen first?
Dyspnea
Dilated pupils
Itching and edema
Wheal-and-flare reaction

Back 60

Itching and edema

Front 61

The patient with an allergy to bee stings was just stung by a bee. After administering oxygen, removing the stinger, and administering epinephrine, the nurse notices the patient is hypotensive. What should be the nurse's first action?
Administer IV diphenhydramine (Benadryl).
Administer nitroprusside as soon as possible.
Anticipate tracheostomy with laryngeal edema.
Place the patient recumbent and elevate the legs.

Back 61

Place the patient recumbent and elevate the legs.

Front 62

The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment?
It will gather platelets for use later when needed.
It will cause anemia because it removes whole blood and RBCs are damaged.
It will remove the IgG autoantibodies and antigen complexes from the plasma.
It will remove the peripheral stem cells in order to cure the autoimmune disease.

Back 62

It will remove the IgG autoantibodies and antigen complexes from the plasma.

Front 63

The patient with diabetes mellitus has been ill for some time with a severe lung infection needing corticosteroids and antibiotics. The patient does not feel like eating. The nurse understands that this patient is likely to develop
major histoincompatibility.
primary immunodeficiency.
secondary immunodeficiency.
acute hypersensitivity reaction.

Back 63

secondary immunodeficiency.

Front 64

Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications?
"My drug dosages will be lower because the medications enhance each other."
"Taking more than one medication will put me at risk for developing allergies."
"I will be more prone to malignancies because I will be taking more than one drug."
"The lower doses of my medications can prevent rejection and minimize the side effects."

Back 64

"The lower doses of my medications can prevent rejection and minimize the side effects."