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DAVIS ADVANTAGE FOR UNDERSTANDING
MEDICAL-SURGICAL NURSING
6th Edition (Williams & Hopper) | Chapters 1–57 |
Original NCLEX-Style Questions with Rationales
PART 1: FOUNDATIONS OF MEDICAL-SURGICAL
NURSING (Chapters 1–5)
QUESTION 1
A nurse is using evidence-based practice (EBP) to guide patient care. Which action best demonstrates the use of EBP? A) Following unit protocols without question B) Using a medication because it has always been used that way C) Combining clinical expertise with the best available research evidence and patient preferences D) Implementing a new procedure based on a single research study Correct Answer: C) Combining clinical expertise with the best available research evidence and patient preferences Rationale: EBP involves integrating clinical expertise, patient values/preferences, and the best current research evidence. Tradition (A,B) or a single study (D) does not constitute EBP without critical appraisal and integration of other evidence.
QUESTION 2
A nurse is caring for a patient who has been hospitalized for a chronic illness. The patient's adult child asks the nurse, "Will my father ever get better?" What is the nurse's best response? A) "Your father's condition is chronic, so he will never get better." B) "I am not sure; you should ask the doctor." C) "Your father has a chronic condition that may have periods of exacerbation and remission, but we will do our best to manage his symptoms and improve his quality of life." D) "Don't worry; your father will be fine." Correct Answer: C) "Your father has a chronic condition that may have periods of exacerbation and remission, but we will do our best to manage his symptoms and improve his quality of life." Rationale: Chronic illnesses are characterized by periods of exacerbation and remission. The nurse should provide honest, accurate information while offering hope through effective symptom management. Options A (absolutist) and D (dismissive/dishonest) are inappropriate. Option B shifts responsibility inappropriately.
QUESTION 3
A nurse is caring for a patient with a new diagnosis of hypertension. The patient asks, "Why do I need to take medication every day when I feel fine?" What is the nurse's best response? A) "You need to take the medication because the doctor prescribed it." B) "Hypertension is often called the 'silent killer' because it causes damage without symptoms; medication helps prevent heart attack, stroke, and kidney disease." C) "You can stop the medication once your blood pressure is normal." D) "Only take the medication when your blood pressure is high." Correct Answer: B) "Hypertension is often called the 'silent killer' because it causes damage without symptoms; medication helps prevent heart attack, stroke, and kidney disease."
Rationale: Autonomy respects the patient's right to make their own healthcare decisions, even when those decisions conflict with medical advice. Options A and D do not respect patient choice. Option C violates confidentiality.
QUESTION 6
The Joint Commission requires that a patient's pain be assessed: A) Only upon admission B) Only when the patient reports pain C) At regular intervals and whenever the patient's condition changes D) Only after administering pain medication Correct Answer: C) At regular intervals and whenever the patient's condition changes Rationale: The Joint Commission mandates routine pain assessment at regular intervals and with any change in condition. Pain is considered the "fifth vital sign."
QUESTION 7
A nurse is caring for a patient with a terminal illness. The patient tells the nurse, "I am ready to go. I don't want any more treatments." What should the nurse do first? A) Encourage the patient to continue fighting B) Notify the provider of the patient's statement C) Explore the patient's feelings and goals of care D) Document the statement and do nothing else Correct Answer: C) Explore the patient's feelings and goals of care Rationale: The nurse should first explore the patient's statement, assess for depression or uncontrolled symptoms, and discuss goals of care. The provider should be involved, but therapeutic communication is the priority.
QUESTION 8
A patient tells the nurse, "I'm afraid to have surgery." Which response is most therapeutic? A) "You don't need to be afraid; the surgeon is excellent." B) "Tell me more about what concerns you about the surgery." C) "Everyone feels that way before surgery." D) "You should talk to the doctor about your fears." Correct Answer: B) "Tell me more about what concerns you about the surgery." Rationale: This response validates the patient's feelings and invites exploration. Options A and C dismiss the patient's concerns. Option D shifts responsibility without providing support.
QUESTION 9
A nurse is caring for a patient from a culture that values family decision- making. The patient's family asks the nurse not to tell the patient about a terminal diagnosis. What should the nurse do? A) Respect the family's wishes and withhold the information B) Tell the patient the diagnosis immediately C) Explore the family's concerns and involve an ethics consult D) Discharge the patient from the facility Correct Answer: C) Explore the family's concerns and involve an ethics consult Rationale: This is an ethical dilemma between patient autonomy and cultural values. The nurse should explore the family's concerns, educate them about the patient's rights, and involve an ethics committee or consult for guidance. Withholding information may violate legal standards.
QUESTION 12
A nurse is caring for a patient with a fever of 40°C (104°F). The patient is shivering. Which nursing action is most appropriate? A) Apply a cooling blanket immediately B) Remove all blankets and clothing C) Administer antipyretic and provide a light blanket D) Sponge the patient with cold water Correct Answer: C) Administer antipyretic and provide a light blanket Rationale: Shivering indicates the body is trying to generate heat. Removing blankets or applying cold will increase shivering and discomfort. Antipyretic treats the fever; a light blanket provides comfort without trapping heat.
QUESTION 13
A nurse is preparing to insert an indwelling urinary catheter for a female patient. After donning sterile gloves, the nurse accidentally touches the inside of the sterile drape with a non-sterile glove. What should the nurse do? A) Continue the procedure because the drape is still mostly clean B) Replace the sterile drape with a new one C) Pour sterile antiseptic over the contaminated area D) Discard all supplies and start over with a new kit Correct Answer: D) Discard all supplies and start over with a new kit Rationale: Once a sterile field is contaminated, it must be re-established with all new sterile supplies. The inside of the sterile drape is part of the sterile field. Partial replacement is insufficient.
QUESTION 14
A nurse is providing oral care to an unconscious patient. The patient suddenly begins to cough and gag. What is the nurse's priority action? A) Continue the oral care to finish quickly B) Turn the patient's head to the side and suction the mouth C) Raise the head of the bed to 90 degrees D) Stop oral care and administer oxygen Correct Answer: B) Turn the patient's head to the side and suction the mouth Rationale: Coughing and gagging indicate fluid or secretions may be entering the airway. Turning the head to the side allows drainage, and suction clears the airway. Raising the head is not safe if the patient is actively gagging.
QUESTION 15
The nurse is caring for a patient with a nasogastric (NG) tube attached to low intermittent suction. The nurse notes that the gastric aspirate is dark brown with coffee-ground-like particles. What should the nurse do? A) Increase the suction pressure B) Irrigate the tube with 100 mL of sterile water C) Notify the provider of possible gastric bleeding D) Document as a normal finding Correct Answer: C) Notify the provider of possible gastric bleeding Rationale: Coffee-ground emesis/aspirate indicates upper GI bleeding (blood digested by gastric acid). The provider should be notified. Irrigating could worsen bleeding. Increasing suction is not indicated.
QUESTION 16
A nurse is caring for a patient with a pressure injury on the sacrum. Which finding indicates wound healing?
C) Ensuring two fingers can fit between the vest and the patient's chest D) Tying the vest straps to the side rail for easy access Correct Answer: D) Tying the vest straps to the side rail for easy access Rationale: Restraints must be tied to the movable bed frame (not side rails) because side rails can move and cause injury or strangulation. A quick- release knot and two-finger check are correct.
QUESTION 19
A nurse is providing foot care to a patient with diabetes. Which action is unsafe? A) Soaking the feet in warm water for 20 minutes B) Drying thoroughly between the toes C) Applying lotion to the tops and bottoms of the feet D) Cutting the patient's toenails Correct Answer: D) Cutting the patient's toenails Rationale: Diabetic patients should not have their toenails cut by a nurse unless specifically ordered and the nurse is trained. Diabetics have reduced sensation and poor healing; improper nail cutting can lead to ulcers and amputation. Nail care should be done by a podiatrist.
QUESTION 20
A nurse is caring for a patient with a chest tube. The chest tube becomes disconnected from the drainage system. What should the nurse do first? A) Clamp the chest tube B) Place the end of the tube in sterile water C) Notify the provider D) Reconnect the tube to the drainage system
Correct Answer: B) Place the end of the tube in sterile water Rationale: Placing the tube end in sterile water creates a water seal and prevents air from entering the pleural space. Clamping can cause tension pneumothorax. Reconnecting can introduce air. The provider should be notified after immediate action.
QUESTION 21
A nurse is caring for a patient with a new tracheostomy. Which action is essential for maintaining a patent airway? A) Deflate the cuff before suctioning B) Suction the tracheostomy every 2 hours regardless of need C) Keep an obturator at the patient's bedside D) Change the inner cannula once per week Correct Answer: C) Keep an obturator at the patient's bedside Rationale: An obturator is needed to reinsert the tracheostomy tube if it becomes dislodged. The cuff should be inflated (not deflated) during suctioning to prevent aspiration. Suctioning is as needed, not routine. The inner cannula should be changed daily or as needed.
QUESTION 22
A nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS). The patient opens eyes to pain, makes incomprehensible sounds, and withdraws to pain. What is the GCS score? A) 6 B) 7 C) 8 D) 9 Correct Answer: C) 8
QUESTION 25
A nurse is preparing to insert a urinary catheter. The nurse inadvertently inserts the catheter into the patient's vagina. What should the nurse do? A) Leave the catheter in the vagina and insert a new sterile catheter into the urethra B) Remove the catheter and restart with new supplies C) Withdraw the catheter slightly and redirect toward the urethra D) Flush the catheter with sterile water to clear the path Correct Answer: A) Leave the catheter in the vagina and insert a new sterile catheter into the urethra Rationale: If the catheter enters the vagina, it should be left there as a landmark to avoid re-entering the vagina with the second catheter. A new sterile catheter should be inserted into the urethra. The vaginal catheter is removed after the urethral catheter is placed.
QUESTION 26
A nurse is assessing a patient's pain using the PQRST mnemonic. The "P" stands for: A) Pain scale B) Provocation/Palliation C) Pattern D) Position Correct Answer: B) Provocation/Palliation Rationale: PQRST: P = Provocation/Palliation (what makes pain better or worse), Q = Quality (describe pain), R = Region/Radiation (where is pain, does it spread), S = Severity (scale 0-10), T = Timing (when did it start, how long does it last).
QUESTION 27
A nurse is caring for a patient who has a new diagnosis of heart failure. The patient asks, "What does ejection fraction mean?" What is the nurse's best response? A) "It is the amount of blood your heart pumps with each beat, expressed as a percentage." B) "It is the pressure inside your heart's chambers." C) "It is the thickness of your heart muscle." D) "It is the rate at which your heart beats." Correct Answer: A) "It is the amount of blood your heart pumps with each beat, expressed as a percentage." Rationale: Ejection fraction (EF) is the percentage of blood pumped out of the left ventricle with each contraction. Normal EF is 50-70%. Low EF (<40%) indicates heart failure with reduced ejection fraction (HFrEF).
QUESTION 28
A nurse is caring for a patient with a fever. The provider orders a blood culture. Which action is correct? A) Obtain the culture after starting antibiotics B) Obtain the culture before starting antibiotics C) Obtain the culture from an indwelling line D) Obtain the culture from a peripheral site that is not cleansed Correct Answer: B) Obtain the culture before starting antibiotics Rationale: Blood cultures should be obtained before starting antibiotics to increase yield and avoid false negatives. The site should be cleansed with antiseptic. Peripheral venipuncture is preferred over indwelling lines.
QUESTION 31
A nurse is teaching a patient with a new diagnosis of hypertension about lifestyle modifications. Which instruction is correct? A) "Reduce dietary sodium intake to less than 2,300 mg per day." B) "Limit alcohol consumption to 3 drinks per day for men." C) "Engage in aerobic exercise for 15 minutes once per week." D) "Maintain a body mass index (BMI) below 30." Correct Answer: A) "Reduce dietary sodium intake to less than 2, mg per day." Rationale: Sodium <2,300 mg/day is recommended. Alcohol should be limited to 2 drinks/day for men (1 for women). Exercise should be 30 minutes most days of the week. BMI should be below 25 (not 30) for optimal blood pressure control.
QUESTION 32
The nurse is teaching a patient about the signs of a myocardial infarction (heart attack). Which symptom is most common in women? A) Crushing chest pain radiating to the left arm B) Shortness of breath, fatigue, and nausea C) Syncope (fainting) without warning D) Severe headache and visual changes Correct Answer: B) Shortness of breath, fatigue, and nausea Rationale: Women are more likely than men to experience atypical MI symptoms: shortness of breath, fatigue, nausea, indigestion, and back or jaw pain. Crushing chest pain is classic but less common in women.
QUESTION 33
A nurse is caring for a patient with atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory test should the nurse monitor to evaluate the effectiveness of warfarin? A) aPTT B) INR C) Platelet count D) Bleeding time Correct Answer: B) INR Rationale: Warfarin is monitored using INR (international normalized ratio). Therapeutic INR for atrial fibrillation is typically 2.0-3.0. aPTT monitors heparin. Platelet count monitors for thrombocytopenia. Bleeding time is not specific.
QUESTION 34
A nurse is assessing a patient's breath sounds. The nurse hears high-pitched, musical sounds during expiration. These sounds are documented as: A) Rhonchi B) Wheezes C) Crackles D) Stridor Correct Answer: B) Wheezes Rationale: Wheezes are high-pitched, musical sounds typically heard during expiration (or inspiration/expiration) caused by narrowed airways (asthma, COPD). Rhonchi are low-pitched snoring sounds. Crackles are popping sounds. Stridor is a high-pitched crowing sound heard on inspiration.
QUESTION 35
A nurse is caring for a patient with pneumonia who is prescribed antibiotics. Which finding indicates that treatment is effective? A) Temperature increases from 38°C to 39°C B) White blood cell count decreases toward normal C) Cough becomes more productive with green sputum D) Oxygen saturation decreases from 94% to 90% Correct Answer: B) White blood cell count decreases toward normal Rationale: Decreasing WBC count indicates the body is fighting the infection effectively. Increasing fever, worsening cough, and decreasing SpO2 indicate deterioration.
QUESTION 38
A nurse is caring for a patient with asthma who is experiencing an acute exacerbation. The patient's peak expiratory flow rate is 50% of personal best. The patient is wheezing and has a respiratory rate of 30 breaths/min. Which medication should the nurse administer first? A) Oral prednisone B) Inhaled albuterol (short-acting beta agonist) C) Inhaled fluticasone (corticosteroid) D) Intravenous magnesium Correct Answer: B) Inhaled albuterol (short-acting beta agonist) Rationale: Albuterol is the first-line rescue bronchodilator for acute asthma exacerbation. Corticosteroids (oral or inhaled) are adjunctive but take longer to work. Magnesium is for severe, refractory cases.
QUESTION 39
A nurse is caring for a patient with a pulmonary embolism (PE). Which assessment finding indicates the patient's condition is worsening?
A) Respiratory rate decreases from 28 to 20 breaths/min B) Oxygen saturation increases from 88% to 94% C) Heart rate increases from 90 to 120 bpm D) Blood pressure increases from 110/70 to 120/80 mmHg Correct Answer: C) Heart rate increases from 90 to 120 bpm Rationale: Increasing heart rate (tachycardia) may indicate worsening hypoxia, increased right heart strain, or impending hemodynamic compromise. Improving respiratory rate, SpO2, and stable BP indicate improvement.
QUESTION 40
A nurse is caring for a patient with new-onset shortness of breath and chest pain. The provider orders a d-dimer test. The nurse understands that a d- dimer test is used to: A) Diagnose a myocardial infarction B) Rule out a pulmonary embolism (if negative) C) Confirm a pulmonary embolism (if positive) D) Diagnose pneumonia Correct Answer: B) Rule out a pulmonary embolism (if negative) Rationale: A negative d-dimer is useful to rule out PE in low-risk patients. A positive d-dimer is non-specific (elevated in many conditions) and requires further testing (e.g., CT pulmonary angiography).
QUESTION 41
A nurse is caring for a patient with acute pancreatitis. Which finding is expected? A) Left upper quadrant pain that radiates to the back B) Right lower quadrant pain
