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LPN MEDICAL SURGICAL ATI NCLEX EXAM
QUESTIONS WITH CORRECT ANSWERS
A nurse is caring for a client with a history of congestive heart failure at risk for development of fluid volume excess. The nurse should monitor for which of the following that is a manifestation of left sided heart failure? Swelling of the fingers and hands Jugular neck vein distension 3+ ankle edema Dyspnea with a cough that is worse at night - ANSWER Dyspnea with a cough that is worse at night Dyspnea with a cough that is worse at night is an indication of left-sided heart failure. Left-sided heart failure causes blood to back up in the heart and lungs with decreased distribution of blood throughout the body. Which client problem should receive highest priority when a client is admitted with an acute exacerbation of rheumatoid arthritis? Difficulty with hygiene and grooming Impaired physical mobility Body-image disturbance Anxiety - ANSWER Impaired physical mobility When setting priorities for nursing care, physiological needs should be addressed first according to Maslow's Hierarchy of Needs. Reducing the client's pain will help with other needs, such as hygiene and grooming. A nurse is caring for a client with hypoparathyroidism. Because of the potential electrolyte disturbance associated with this diagnosis, the nurse should observe the client for evidence of which of the following? Elevated blood pressure Involuntary muscle spasms Cold intolerance Weight loss - ANSWER Involuntary muscle spasms A decrease in parathormone secretion leads to hypocalcemia (decreased serum calcium levels), which may cause tetany. Involuntary muscle spasms are a common symptom associated with hypothyroidism.
A client with glaucoma is admitted for surgery the following day. The client is to continue treating the glaucoma with pilocarpine (Pilocar) 2% 1 drop 4 times a day. While instilling this medication, an appropriate nursing action is which of the following? Instruct the client to blink several times after instillation of the medication. Ask the client to look straight ahead. Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min. Dab excess medication from the eye using a cotton ball 10 to 15 seconds after instillation. - ANSWER Place the medication in the conjunctival sac applying pressure to the puncta for 1 to 2 min. Eye drops are instilled into the conjunctival sac and pressure applied to the puncta for 1 to 2 min to prevent loss of medication into the nasal lacrimal duct and into the systemic circulation. A client has sprained an ankle while playing soccer. For the first 24 hr following the injury, the nurse should instruct the client to do which of the following? Perform gentle range of motion (ROM) exercises on the ankle joint to prevent contractures. Keep moist heat on the ankle to prevent muscle spasm. Keep the foot in a dependent position to aide circulation to the foot. Keep ice on the ankle to prevent edema. - ANSWER Keep ice on the ankle to prevent edema. Ice or cold will constrict blood vessels to the injured area decreasing swelling. Nerve impulse transmission will also be reduced, resulting in analgesia to the injured area and a reduction of muscle spasms. Ice applications should not exceed 20 to 30 min per application. A nurse is assisting with the discharge of a client newly diagnosed with diabetes. When reviewing information about proper foot care, which of the following would be appropriate to include? Soak feet every night in warm water. Wear clean cotton socks daily. Walk barefoot at home when possible. Get fitted for shoes in the morning. - ANSWER Wear clean cotton socks daily. Cotton socks should be worn by clients who are diabetic. They are soft and will wick excess moisture away from the foot. Following a transient ischemic attack (TIA), a client is alert, slightly confused, and has a blood pressure of 204/102 mm Hg. The client is also incontinent of
Total hip arthroplasty is a surgical procedure to reconstruct a diseased hip joint. The head of the femur is removed, along with the lining of the acetabulum (hip socket). The head of the femur is replaced with a metal ball and stem, and the acetabulum is replaced with a plastic or metal cup. Following surgery, the client must be on "hip precautions" to prevent dislocation of the new hip joint. The abduction pillow is a wedge-shaped pillow that is placed between the legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body following total hip replacement during position changes or client movement. TQLogicTM The most important step of TQLogic used in answering this question is comprehension and relies on basic nursing knowledge. In examining the critical element of the test question, the issue of the question is the purpose of an abductor pillow following hip arthroplasty. An abduction pillow or splint is used following total hip arthroplasty to prevent adduction beyond the midline of the body and prevent possible dislocation. A client who is admitted to the hospital after experiencing a tonic clonic seizure is scheduled for a routine electroencephalogram (EEG). In preparing the client for the EEG, the nurse should explain that the client will undergo which of the following? Remain NPO 6 to 8 hr prior to the EEG. Receive a sedative the night prior to the EEG. Receive a thorough shampoo prior to the EEG. Have no dietary restrictions prior to the test. - ANSWER Receive a thorough shampoo prior to the EEG. The client's hair must be washed thoroughly prior to the EEG. Hairsprays, oils, and other hair preparations interfere with recording results of the EEG. A client is experiencing stomatitis as a result of chemotherapy and radiation therapy. Which statement made by the client indicates to the nurse that reinforcement of teaching is necessary? "I will use a soft toothbrush or toothette for oral care." "I will use lemon and glycerine swabs after meals." "I will remove my dentures except while eating." "I will rinse my mouth frequently with hydrogen peroxide." - ANSWER "I will use lemon and glycerine swabs after meals." This statement indicates that further teaching is necessary. Lemon and glycerin swabs promote drying and are irritating to mucous membranes. The client should not use lemon and glycerin swabs for oral care if she already has inflamed tissues inside the mouth. A client is returning from surgery with a radium implant for the treatment of endometrial cancer. In planning this client's care, which action would be consistent with the client's diagnosis?
Talking with the client about ways to deal with alopecia Encouraging the client to do active range of motion exercises Keeping forceps and lead container in room Restricting all visitors while the implant is in place - ANSWER Keeping forceps and lead container in room Forceps and a lead container should be kept in the room for use if the implant slips out of the client. A client who works in carpentry is seen by the triage nurse. The client complains of severe right eye pain with a gritty sensation. When obtaining a history from this client, which question has the highest priority? "Do you have any allergies?" "What were you working with at the time the manifestations occurred?" "Were you wearing goggles or glasses at your job?" "Did you flush your eye out at work?" - ANSWER "Did you flush your eye out at work?" The first action to decrease additional risk of injury is to flush out the eye as soon as possible after entry by a foreign body. If this was not done at the worksite, it needs to be done immediately. A client who had a craniotomy is sitting in a chair with the nurse present in the room. While the client is sitting, he begins to experience a grand mal seizure. At this time, the most important nursing intervention is which of the following? Provide oxygen. Turn the client onto his side. Provide privacy. Lower the client to the floor. - ANSWER Lower the client to the floor. When a client begins to have a seizure while sitting or standing, the nurse should gently lower the client to the floor to protect the client from injury; therefore, this intervention has the highest priority. A client has a platelet count of 18,000 cells/mL. An appropriate nursing intervention is to do which of the following? Avoid intramuscular injections (IM). Administer oxygen via nasal cannula. Maintain a no visitors policy. Provide meticulous oral hygiene every 3 to 4 hr. - ANSWER Avoid intramuscular injections (IM). The platelet count is dangerously low indicating thrombocytopenia (decreased platelet count). Any invasive procedure, such as an IM injection,
Implementing seizure precautions is correct. Due to the inflammatory response of the brain to the arbovirus the client is at risk for seizures. Precautions should be implemented to ensure client safety if a seizure does occur. While reviewing an admission assessment for a client with an exacerbation of asthma, the nurse learns the client has several food allergies. The most important nursing action in promoting this client's safety is to do which of the following? Place an allergy bracelet on the client's wrist. Provide the dietitian with a list of the client's allergies. Observe the client carefully for signs of anaphylaxis. Have epinephrine available on the clinical unit. - ANSWER Provide the dietitian with a list of the client's allergies. Providing the dietitian with a list of the client's allergies will most likely prevent the client from being served a tray with a hidden allergen. A hidden allergen may be an ingredient used in the preparation of the meal. This is the highest risk to the client. A client who had a traumatic amputation of the arm at the elbow is reporting pain in the hand of the amputated limb. The client has dressing changes prescribed twice daily, hydrocodone (Vicodin) and gabapentin (Neurontin) PRN, and cefuroxime sodium (Ceftin) 750 mg 3 times daily IV. Which of the following actions by the nurse is appropriate? Administer prescribed dose of gabapentin (Neurontin). Administer prescribed dose of hydrocodone (Vicodin). Contact the provider for a change in the antibiotic prescribed. Increase the frequency of the dressing changes. - ANSWER Administer prescribed dose of gabapentin (Neurontin). This client is experiencing phantom limb pain. Even though amputated limbs are no longer attached to the body, a client can feel pain in the amputated limb, especially after a traumatic amputation. Opiates are not effective for this type of pain. Beta-blockers, antispasmodics and anticonvulsants such as gabapentin, are more effective for treating this type of pain. A nurse is caring for a client who underwent a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). The client's bladder is continuously irrigated with saline via a three-way catheter PRN. Which of the following findings should be reported immediately to the provider? An output less than the input coming from the catheter Report of bladder spasms Drainage that resembles ketchup coming from the catheter
A report of feeling a strong urge to urinate - ANSWER Drainage that resembles ketchup coming from the catheter Drainage that resembles ketchup coming from the catheter indicates arterial bleeding which should be reported to the surgeon. A nurse is caring for a client with arteriosclerosis. When reviewing the client's chart, which of the following factors should the nurse realize is associated with the development of arteriosclerosis? Cholesterol level is 195 mg. HDL serum levels are elevated. LDL serum levels are elevated. Cholesterol level is 135 mg. - ANSWER LDL serum levels are elevated. Elevated LDLs increases a client's risk for arteriosclerosis. The high lipoproteins should be HIGH and the low should be LOW, and the very low should be VERY LOW. At the start of the night shift, an assistive personnel (AP) brings the nurse a list of client reports. Which client does the nurse need to check first? The client with emphysema who is reporting dyspnea The client with ulcerative colitis who is reporting diarrhea The client with benign prostate hypertrophy (BPH) who is reporting dysuria The client with laryngeal cancer who is reporting dysphagia - ANSWER The client with emphysema who is reporting dyspnea Using the airway, breathing, and circulation (ABC) priority framework, the nurse should check the client who is having difficulty breathing first. Dyspnea is a common report from clients with emphysema, but the nurse realizes that this is the client with the greatest physiologic risk. A client in a community clinic tests positive on a Mantoux skin test but does not demonstrate active lesions on a chest x-ray. When assisting with the development of the plan of care for this client, the nurse should reinforce that isoniazid (INH) therapy will have to be taken for which of the following time frames? For the rest of the client's life Until the client has a negative sputum sample Daily for approximately 1 year Until the client has a non-reactive Mantoux - ANSWER Daily for approximately 1 year INH prophylaxis is taken for approximately 9 months to 1 year. However, in that time frame, noncompliance is a major problem and has contributed to the development of multiple medication-resistant strains of TB. The client will need to be monitored carefully to ensure compliance for the duration of the treatment period.
Push the peritoneal catheter in approximately 1 inch further. - ANSWER Turn the client from side to side. Sometimes the peritoneal catheter is buried in the omentum, which will slow or stop the outflow drainage. If the fluid is not draining properly, it is helpful to move the client from side to side to facilitate removal of peritoneal drainage. A nurse is completing the evening observations on a client in balanced skeletal traction admitted the previous evening for a fractured left femur. Which observation should the nurse report to the charge nurse? Swelling and bruising of the thigh Report of leg pain and at the pin site Dyspnea and chest petechiae Report of muscle spasms in the affected leg - ANSWER Dyspnea and chest petechiae Dyspnea and chest petechiae are unexpected findings, suggestive of a fat embolus, which must be reported to the charge nurse. Clients with fractures of the long bones, such as the femur, are at increased risk for fat emboli. Fat emboli typically occur 12 to 24 hr after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The charge nurse should be notified of this assessment immediately as the client may rapidly progress into acute respiratory failure and shock. In preparation for a sigmoid colon resection, the nurse is reinforcing information about the colostomy that will be performed. Which statement by the client will require further clarification? "Because most of my colon is still intact and functioning, my stool will be formed." "My stoma will appear large at first, but it will shrink over the next few weeks." "My colostomy will begin to function 2 to 4 days after surgery." "My diet will have to change dramatically." - ANSWER "My diet will have to change dramatically." This statement would need further clarification. Most clients require no change in their diet patterns: foods that were not well tolerated prior to surgery (gas-producing foods) will probably continue to be poorly tolerated after surgery. Clients are instructed to try foods and evaluate their effect upon the GI tract. TEST-TAKING STRATEGY: Whenever you are confronted with a question that asks for "further clarification" the CORRECT answer will be the INCORRECT choice. A client is diagnosed with endocarditis following rheumatic heart disease. Which comment made by the client indicates to the nurse that she understands discharge teaching in relation to endocarditis?
"I will force fluids to prevent dehydration." "I will notify my doctor before I have invasive surgery or dental procedures." "I will stay on a low-protein and low-potassium diet." "I will wear a mask when I go out into crowds." - ANSWER "I will notify my doctor before I have invasive surgery or dental procedures." Preventing a reoccurrence of rheumatic endocarditis is the goal of notifying the provider prior to invasive surgical or dental procedures. The client will need prophylactic antibiotic therapy prior to any invasive procedure that can result in risk for a streptococcal infection. A nurse is caring for a client in acute renal failure. Which of the following manifestations should the nurse expect the client to exhibit? Anuria Polyphagia Weight loss Bradycardia - ANSWER Anuria Anuria (no urine output) occurs during acute renal failure. A client with type 1 diabetes mellitus has a capillary blood glucose reading of 48 mg/dL. Which of the following should the nurse expect to find? Kussmaul respirations Diaphoresis Decreased skin turgor Ketonuria - ANSWER Diaphoresis Hypoglycemia is a complication that occurs in clients with insulin-dependent diabetes mellitus. Hypoglycemia develops when the client's blood glucose level is below 70 mg/dL and can occur secondary to a precipitous decrease in blood glucose that is still within the expected reference range. Common symptoms of hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion. A middle-adult assistive personnel (AP) is assigned to give a bath to a client with herpes zoster (shingles). The AP asks if this disease is contagious because there is an isolation sign on the client's door. Which response by the nurse would be appropriate at this time? "Adults have a natural immunity from casual exposure to children who have had chickenpox." "You should have immunity from the varicella vaccination you received as an infant." "You cannot get shingles if you have had chickenpox."
When a nurse brings a hospitalized client with AIDS (acquired immune deficiency syndrome) the morning dose of zalcitabine (Hivid), the client states, "I have this awful burning sensation in my fingers and toes. They are numb and tingling." What response by the nurse is appropriate at this time? "I'll just give you half of the prescribed dose this morning." "Take the medication. It should begin to help the manifestations caused by AIDS soon." "I'll hold the medication and notify your provider immediately." "Let me know when the feelings subside, and I'll bring the medication back."
- ANSWER "I'll hold the medication and notify your provider immediately." Zalcitabine may cause peripheral neuropathy, characterized by numbness, tingling, burning, or pain of the extremities. This is also a common problem with didanosine (Videx), an antiviral agent used to treat clients with AIDS. If zalcitabine is not discontinued promptly when the client begins to show manifestations of peripheral neuropathy, it may become progressive and irreversible. Even if zalcitabine is discontinued promptly, the peripheral neuropathy may not be completely reversible. If, after discontinuing the medication, the manifestations improve, then zalcitabine may be reintroduced at half the previously prescribed dose. A nurse is preparing to administer an intramuscular injection. The most important action by the nurse to prevent direct injection of the medication into the venous system is to do which of the following? Aspirate the syringe after insertion of needle. Insert the needle at a 45º angle. Use the Z track method of injection. Inject the medication slowly. - ANSWER Aspirate the syringe after insertion of needle. The syringe is aspirated by pulling back on the plunger to determine if any blood enters the syringe. If blood returns, the medication will enter the venous system if it is injected. Many intramuscular medications are not safe for intravenous administration. An assistive personnel (AP) discovers a fire in the utility room. Which action by the AP would require the nurse to intervene? Turning off electrical equipment Moving clients who are in the immediate area of the fire Opening the doors and windows to let the smoke out Activating the nearest fire alarm - ANSWER Opening the doors and windows to let the smoke out Opening doors and windows makes the fire worse by providing more oxygen. Doors and windows should be shut.
A client diagnosed with emphysema is being prepared for discharge. Which instruction reinforced by the nurse would be beneficial for improving the client's gas exchange? Reinforcing teaching for the client to use pursed-lip breathing Encouraging the client to limit fluids to 1,500 mL per day Demonstrating the proper technique for chest breathing Reinforcing teaching about home oxygen therapy at 5 L/min - ANSWER Reinforcing teaching for the client to use pursed-lip breathing Pursed-lip breathing slows expiration, prevents collapse of lung units, and facilitates effective gas exchange. A client questions the nurse concerning the usual course of multiple sclerosis (MS). Which of the following is an appropriate response by the nurse? "Each client is different; we cannot predict what will happen." "I can see that you are worried, but it's too soon to predict what will happen." "Acute episodes are usually followed by remissions, which may last varying lengths of time." "It's too early to think about the future; let's focus on the present and take one day at a time." - ANSWER "Acute episodes are usually followed by remissions, which may last varying lengths of time." The client has asked the nurse an information-seeking question. The nurse provides factual information while giving the client some realistic hope. A client has just received a cardiac pacemaker. Which statement by the client demonstrates to the nurse an understanding of the pacemaker's purpose? "The pacemaker will help stimulate my heart to beat when my heart rate is slow or irregular." "I don't have to take my antihypertensive medications since my pacemaker will regulate my body's blood flow." "Having a pacemaker means that I will never have a heart attack." "I cannot stand in front of our new microwave oven when it is on." - ANSWER "The pacemaker will help stimulate my heart to beat when my heart rate is slow or irregular." Maintaining a regular heartbeat at a predetermined rate is the primary purpose of a cardiac pacemaker.
Laryngeal stridor and a hoarse voice are correct. Laryngeal stridor and a hoarse voice are unexpected findings and may be an indication of swelling in the area of the surgery or damage to the laryngeal nerve. This should be reported to the provider before respiratory distress develops. A positive Trousseau's sign is correct. A Positive Trousseau's sign is an indication of hypocalcemia, a complication of thyroid removal. This occurs when the parathyroid glands are also removed and regulation of serum calcium is impaired. Which nursing action is appropriate when trying to control epistaxis? Have the client learn forward and gently blow clots from the nose. Instruct client to sit with head hyperextended. Apply ice compresses to the client's forehead and the back of the neck. Pinch the soft portion of the nares for 10 to 15 min. - ANSWER Pinch the soft portion of the nares for 10 to 15 min. Applying direct pressure by pinching the nares for 10 to 15 min is effective to control the bleeding of most episodes of epistaxis. A provider prescribes a confused and combative client to be placed in a jacket restraint and wrist restraints. To prevent injury to the client, the most important nursing action is which of the following? Remove the restraints and observe the extremities for circulation at least every 2 hr. Explain the reason for the restraints to the client and the client's family. Use a square knot when securing the restraint to the bed frame. Document the use of restraints in the client's chart. - ANSWER Remove the restraints and observe the extremities for circulation at least every 2 hr. Skin, nerve, and musculoskeletal injuries to the client are a possibility as a result of poor circulation caused by the restraints if they are not removed at intervals for careful observation. This nursing action is also the only option listed that will help prevent injury. A nurse making rounds finds a client in the waiting room who is confused, has clammy skin, and his hands are tremoring. The nurse should do which of the following?
Check the client's blood glucose using a glucometer. Check the client's oxygen level using a pulse oximeter. Call a code blue. Implement seizure precautions. - ANSWER Check the client's blood glucose using a glucometer. These are manifestations of hypoglycemia that are consistent with diabetes and a blood glucose level should be done to validate this suspicion. This client needs to be assessed for the presence of ketones in the urine, a blood sugar, and arterial blood gases to determine the degree of acidosis and elevation of the blood sugar. A nursing assistant asks the nurse what type of precautions are necessary when caring for a client newly diagnosed with tuberculosis. The nurse instructs the nursing assistant to do which of the following? (Select all that apply.) Wash your hands before and after client care. Prepare to move the client to a negative pressure private room. Wear a surgical mask when in the client's room. Wear a gown and gloves when bathing the client. Give the client an impermeable paper bag for used tissues. - ANSWER Washing your hands before and after client care is correct. Standard precautions should be used with all clients. Standard precautions require that hands be washed before and after all client contact and at any time the hands have been soiled. Preparing to move the client to a negative pressure private room is correct. The client requires a private room that provides at least six exchanges of air per hour. Wearing a surgical mask when in the client's room is incorrect. Staff must wear a specially fitted N95 or particulate respirator mask. A surgical mask does not provide adequate protection. Wearing a gown and gloves when bathing the client is correct. A gown and gloves should be worn when providing personal care and contamination of clothing with pulmonary secretions is possible. Giving the client an impermeable paper bag for used tissues is correct. A paper bag that is impermeable to leakage of its contents should be used for tissues that contain sputum.
