Free Practice Test for NCLEX | Medical Surgical Nursing

1. Alzheimer's patient incontinent of urine during the night times. The nursing care includes

a) Offers bed pan every 2 hours
b) Limit fluids during evening times
c) Foley's catheter


ANSWERS
a) Offers bed pan every 2 hours-NO, would be appropriate to bring the client to the toilet or commode every 2 hours during the day, but this action means you disturb the client's sleep.
 
b) Limit fluids during evening times, BEST ANSWER-(Source: Black & Hawks, Medical-Surgical Nursing 7th edition) Specific interventions for the Alzheirmer's client with urinary incontinence: "Sometimes the client forgets where the bathroom is located. Having bright lights and frequently taking the client there may help control incontinence. Fluid intake after the dinner meal can be restricted to maintain continence during the night."

 c) Foley's catheter-NO, would increase risk of lower urinary tract infection, inappropriate and not necessary.

2. After immediate post operative hysterectomy patient to observe (or) Nursing care includes

a) Observe vaginal bleeding
b) Urine output
c) Vital signs


ANSWERS
c) Vital signs-BEST ANSWER, as this provides the best/most information about the client's response to surgery and anesthesia.

3. Dilantin prescribed to the patient, instructions to patient include

a) Reticulocyte counts
b) Platelet counts


ANSWERS
a) Reticulocyte counts-Yes, this will test for decreased reticulocyte count a sign that the patient is developing aplastic anemia, a potentially life threatening side effect of Dilantin therapy.

b) Platelet counts-No, however Dilantin can decrease the platelet count and result in thrombocytopenia. Aplastic anemia is considered to be more serious (Davis Drug Guide)

4. On the ECG found a straight line, first Nurse

a) Assess the patient
b) Cardiopulmonary resuscitation
c) IV fluids


ANSWER
a) Assess the patient-BEST ANSWER, always assess the patient to be sure there is no equipment malfunction, and/or to confirm the information on the monitor.

5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate

a) Urine output 30-40ml/hr
b) BP
c) Vital signs
d) Skin turgor

a) Urine output 30-40ml/hr BEST ANSWER, the patient's fluid balance/hydration status is best evaluated by assessing urine output. Urine output should be between 0.5 and 1.0 mL/kg/hr, which for a 130 lb adult would be between 29.5 -59 mL/hr. Most nursing textbooks consider 30 mL/hr of urine output to indicate appropriate fluid balance/hydration.

b) BP
c) Vital signs
d) Skin turgor

For b, c, and d many other factors can affect these findings. Urine output directly correlates with the patient's hydration status/fluid balance.

6. 20 week pregnant most concerned

a) Butterfly rash on both cheeks and nose
b) Uterus palpate at the level of symphysis pubis
c) Sereous fluid drain in the breasts
d) Breast enlargement

ANSWERS
a) Butterfly rash on both cheeks and nose-NO this is Cholasma the "mask of pregancy", result of hormonal changes in pregnancy.

b) Uterus palpate at the level of symphysis pubis-BEST ANSWER this correlates with 12 weeks gestation and the patient in the question is 20 weeks. This is a significant difference.

c) Sereous fluid drain in the breasts-NO, leaking of clear fluid from the breasts during pregnancy is not unusual.

d) Breast enlargement-NO, the breast enlarge during pregnancy.

7. The sterile technique is broken when:

a) The sterile field and supplies are wet
b) Clean the area peripheral to center


ANSWERS
a) The sterile field and supplies are wet-BEST ANSWER, this would allow microorganisms to enter the sterile field through the wet surface.

b) Clean the area peripheral to center-NO, this is inappropriate technique but response a, specifically describes how a sterile field can be contaminated and is an important principle in maintaining sterile fields.

8. The metal piece is embedded on the left eye

a) Pressure dressing is applied on the left eye
b) Dressing is applied on both eyes
c) Irrigate the eye with saline


ANSWERS
a) Pressure dressing is applied on the left eye-NO, this would "push" the object further into the eye.

b) Dressing is applied on both eyes-BEST ANSWER, you want to keep the left eye still, and because both eyes move together the uninjured eye must be covered to prevent movement in the injured eye.

c) Irrigate the eye with saline-NO, the object is embedded, meaning deep within the eye. Irrigation will not remove the object but theoretically it could cause it to move resulting in further damage.

9. After cerebral angiogram, patient is

a) Encourage fluids
b) obseve contrast medium in the urine
c) walking


ANSWERS
a) Encourage fluids-BEST ANSWER, when ever contrast medium/X-ray dyes are administer the client is hydrated to facilitate excretion of the dye.

b) obseve contrast medium in the urine-NO, should not be observable to patient or nurse.

c) walking-NO, bedrest would be maintained for a prescribed period of time.

10. Using clean, non sterile gloves, care is appropriate

a) wash the genitelia........YES/NO


ANSWER
YES/NO- YES, this is not a sterile procedure.