NCLEX Med Surg Exam New Latest Version

NCLEX Med Surg Exam New Latest Version with All Questions and 100% Correct Answers

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement?

• Ketorolac (toradol)
• Lorazepam (Ativan)
• Gabapentin (Neurontin)
• Hydromorphone (Dilaudid) --------- Correct Answer ---------- D. Opioid pain

medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids.

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal

neuralgia, the nurse will:

• assess whether the patient is doing daily facial exercises
• question whether the patient is using an eye shield at night
• ask the patient about social activities with family and friends
• remind the patient to chew on the unaffected side of the mouth --------- Correct

Answer ---------- C. Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia?

• support selection of a high-protein diet
• discuss options for sexuality and fertility
• assist in planning a prescribed bowel program
• use quad coughing to strengthen cough efforts --------- Correct Answer ---------- C.

Fecal impaction is common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

A young adult patient who is in the rehabilitation phase after having deep partial- thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving?

• I'm glad the scars are only temporary
• I will avoid using a pillow, so my neck will be OK
• I bet my boyfriend won't even want to look at me anymore 1 / 3

• Do you think dark beige makeup foundation would cover this scar on my cheek -------

-- Correct Answer ---------- D. The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

The nurse caring for a patient admitted with burns over 30% of the body surface assesses the urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function?

• Continue to monitor the urine output
• Monitor for increased WBC
• Assess that blisters and edema have subsided
• Prepare the patient for discharge from the burn unit --------- Correct Answer ----------
• The patient's urine output indicated that the patient is entering the acute phase of the

burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?

• Bananas
• Orange gelatin
• Vanilla Milkshake
• Whole grain bagel --------- Correct Answer ---------- A. A patient with a burn injury

needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are good source of potassium, but are not high in protein and calories

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

• Oral temperature
• Peripheral pulses
• Extremity movement
• Pupil reaction to light --------- Correct Answer ---------- C. All patients with electrical

burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

• / 3

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take?a.Remove non-adherent clothing and watch.b.Apply an alkaline solution to the affected area.c.Place cool compresses on the area of exposure.d.Cover the affected area with dry, sterile dressings. --------- Correct Answer ---------- A.With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove non-adherent clothing, shoes, watches, jewelry, glasses or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?a.Stay at the bedside and reassure the patient.b.Administer the ordered morphine sulfate IV.c.Assess orientation and level of consciousness.d.Use pulse oximetry to check the oxygen saturation. --------- Correct Answer ---------- D.Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?a.Auscultate the patient's lung sounds.b.Determine the extent and depth of the burns.c.Infuse the ordered lactated Ringer's solution.d.Administer the ordered hydromorphone (Dilaudid). --------- Correct Answer ---------- A. A patient with facial and chest burns is at risk for inhalation injury, and assessment of

• / 3