Medical Surgical Nursing NCLEX RN Questions
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Question 1 of 5.
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
A. Report the 24-hour drainage amount at 12. Clamp the T-tube.
B. Evaluate the tube for patency.
C. Irrigate the T-tube.
D. Continue to monitor the drainage.
Explanation: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.
Question 2 of 5.
A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first:
A. Administer the morphine.
B. Obtain a 12-lead ECG.
C. Obtain the blood work.
D. Order the chest radiograph.
Explanation: Administering morphine first relieves pain, reducing myocardial oxygen demand and stabilizing the client. ECG and blood work follow to confirm diagnosis, but pain management is the priority.
Question 3 of 5.
If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by:
A. Explaining how the old behavior leads to poor health.
B. Withholding praise until the new behavior is well established.
C. Rewarding the client whenever the acceptable behavior is performed.
D. Instilling mild fear into the client to extinguish the behavior.
Explanation: Positive reinforcement, such as rewarding adaptive behaviors, encourages the client to continue healthy habits. Fear or delayed praise is less effective for behavior modification.
Question 4 of 5.
Which of the following is not a risk factor for the development of atherosclerosis?
A. A family history of early heart attack.
B. Late onset of puberty.
C. Total blood cholesterol level greater than 220 mg/dL.
D. Elevated fasting blood glucose concentration.
Explanation: Late onset of puberty is not a risk factor for atherosclerosis. Family history, high cholesterol, and elevated glucose are established risk factors.
Question 5 of 5.
The nurse's discharge teaching plan for the client with heart failure should stress the importance of which of the following?
A. Maintaining a high-fiber diet.
B. Walking 2 miles every day.
C. Obtaining daily weights at the same time each day.
D. Remaining sedentary for most of the day.
Explanation: Daily weights at the same time detect fluid retention early, a key strategy to prevent heart failure exacerbations.
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