NCLEX Med Surg Answers

NCLEX Med Surg Answers

• A patient is scheduled for a cardiac catheterization this afternoon. Which of the following, if noted in the

patient’s chart by the nurse, is a contraindication to the test?

• The patient is allergic to clams.* (Because it’s shellfish and can react to iodine in surgery)
• The patient is allergic to eggs.
• The patient is unable to lie on her right side for more than 15 minutes.
• The patient has a history of asthma.
• The nurse on the surgical unit receives a call from the operating room to administer a preoperative medication to

a client scheduled for surgery. After giving the ordered medication, the nurse discovers the consent form for the surgery has not been signed. Which of the following actions should the nurse take NEXT?

• Transfer the client to the operating room.
• Call the physician.
• Inform the nursing supervisor. *(best option)
• Call the operating room and inform them that the surgery must be canceled.
• Which of the following situations is an example of negligence?
• The UAP (Unlicensed Assistive Personnel) fills a water basin with warm water while the patient with depression

combs her hair.

• A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water.
• The nurse observes a UAP enter the room of a patient on contact precautions wearing gloves and a gown.
• The nurse checks the distal pulses of a patient’s legs two hours after they have returned from a cardiac

catheterization. *(vital signs should be checked within first 15 minutes of surgery and should be checked periodically for the first 2 hours) D The nurse should have checked the patient’s distal pulse immediately after the cardiac catheterization.

• The home health nurse visits the home of a client diagnosed with moderate-stage Alzheimer’s disease. The

patient is pleasantly confused and lives with his son-in-law and daughter. Which of the following observations, if made by the nurse, is MOST concerning?

• The rugs are secured safely to the floor.
• The door has a lock with a bolt. *(person w/Alzheimer can still get out. Need a lock w/key)
• There are extension cords on the floors behind furniture.
• The stovetops do not turn on without activation of a hidden switch in the nearby drawer.

B Doors need to have locks in atypical locations (eg, tops of doors) to prevent the patient from nighttime confused wandering.

• Which of the following materials would the graduate nurse require to test the function of a patient’s

glossopharyngeal nerve?

• Soft cotton swab and a toothpick.
• Tongue depressor. *(check gag reflexes)
• A stethoscope.
• A handheld mirror.

B The glossopharyngeal nerve can be tested for function by assessing gag reflex. The tongue depressor checks gag reflex.

• A client comes to the local clinic complaining that sometimes his heart pounds and he has trouble sleeping. The

physical exam is normal. The nurse learns that the client has recently started a new job with expanded responsibilities and is worried about succeeding. Which of the following responses by the nurse is BEST?

• “You could benefit from counseling.”
• “You appear to have concerns about your ability to do your job.” *
• “It’s normal to feel anxious when starting a new job.”
• “Have you talked to your family about your concerns?”

B Use reflection to repeat the patient’s words back at them

• The nurse in an emergency room receives a call from an ambulance alerting that a bomb has gone off in a nearby

shopping center and a minimum of forty victims will be arriving shortly for medical care. What action should the nurse take NEXT?

• Prepare enough stretchers to accommodate overflow.
• Alert the nursing supervisor. *
• Tell the ambulance crew to take half the victims to the next-nearest hospital.
• Alert the rest of the ER nurses that they will be working mandatory double shifts.

B There is most likely a disaster plan in place, which must be implemented by the nursing supervisor. The ER nurse must go up the chain of command to resolve this issue.

• A patient with rheumatoid arthritis complains to the nurse that exercise is very painful for her. What does the

nurse recommend to the patient?

• “I’m sure it doesn’t hurt that much to exercise, right?”
• “Do not exercise if your joints hurt. Instead, try again the next day.”
• “Use ice packs on the joints that hurt after you exercise.”
• “Try taking a warm bath in the morning before you begin your exercise.” *

D Exercise will always be painful for a patient with rheumatoid arthritis, but if they skip exercise, they can develop contractures. Warm baths and heating pads can help to loosen and relax joints for better function with less pain in exercise.

• The charge nurse implements a change in the nursing assistant’s job description. The change increases the

nursing assistant’s responsibilities. A nurse with 20 years of service on the unit verbally agrees to the change, but her behaviors indicate otherwise. Which of the following actions by the charge nurse is MOST appropriate?

• Ask the nursing assistants to accommodate the nurse.
• Schedule an appointment to speak with the nurse in private.
• Enable an open discussion during a prescheduled meeting. *(avoid interpersonal relationship problem)
• Inform the charge nurse that you have observed her verbal agreement differs from her behavior.

C Do not directly confront the nurse or ask anyone to accommodate her. Instead, use a meeting to bring up the issue and allow her peers to speak positively about the change. Peer pressure can be an effective tool.

1.10.After a cardiac catheterization, the nurse instructs the patient to lie in which of the following positions?

The patient needs to be on bedrest, on their back, to avoid moving their leg and possibly restarting bleeding in the femoral artery.

*Answer: supine/flat w/both legs extended

11.A 22-year-old patient and her husband come to the ER after a fall down the stairs. The patient has a black eye, avoids looking at the nurse, and gives yes/no answers to the nurse’s assessment questions. Which of the following actions should the nurse take NEXT?

• Ask the patient if she hit her head when she fell.
• Ask the patient how she fell down the stairs.
• Report the patient’s husband for abuse to the nurse’s immediate supervisor.
• Ask the patient to produce a urine sample in the presence of the nurse. *(try to get patient in private to ask

personal questions to get them to talk more) D The goal is to get the patient away from her potential abuser and ask her, face to face, “Are you being abused?” If so, you can offer help. You may NEVER report a capable adult unless they ask for it.

12.The nursing team consists of one RN, two LPNs, and one nursing assistant. The nurse determines that assignments are appropriate if the nursing assistant is assigned to which of the following patients?

• A patient diagnosed with CVA three days ago who needs assistance ambulating to the bathroom. *
• A patient diagnosed with cerebral palsy requiring medication.
• A patient with sepsis who needs an IV push medication.
• A client with a colostomy requesting assistance with an irrigation.

A The nursing assistant can walk patients to the bathroom. The patient with cerebral palsy and the client with the colostomy can each see an LPN. The patient with sepsis needs an RN.

13.A nurse’s aide comes to the nurse and expresses concerns about a patient’s T-tube. The aide says, “I’m kind of worried because it’s drained 700mL over the course of our shift. That’s a lot!” Which of the following responses does the nurse give to the aide?

• “That is a small amount of drainage for a T-tube. Once I had a patient who drained 2,000mL in one shift!”
• “That is an excessive amount of drainage for a T-tube. I will further assess the patient.”
• “That is a normal amount of drainage for a T-tube because this is his fifth day after surgery.”
• “That is a normal amount of drainage for a T-tube because this is his first day after surgery.” * (T-Tube is for