PNLE : Medical Surgical Nursing Exam 4 6.

Thomas Elison is a 79 year old man who is admitted

with diagnosis of dementia. The doctor orders a series of
1. A patient is admitted to the medical surgical unit laboratory tests to determine whether Mr. Elison’s
following surgery. Four days after surgery, the patient dementia is treatable. The nurse understands that the
spikes a 38.9 degrees C oral temperature and exhibits a most common cause of dementia in this population is:
wet, productive cough. The nurse assesses the patient
with understanding that an infection that is acquired A. AIDS
during hospitalization is known as: B. Alzheimer’s disease
C. Brain tumors
A. a community acquired infection D. Vascular disease
B. an iatrogenic infection
C. a nosocomial infection 7. Which of the following nursing interventions is
D. an opportunistic infection contraindicated in the care of a client with acute
osteomyelitis?
2. A client with anemia has a hemoglobin of 6.5 g/dL.
The client is experiencing symptoms of cerebral tissue A. Apply heat compress to the affected area
hypoxia. Which of the following nursing interventions B. Immobilize the affected area
would be most important in providing care? C. Administer narcotic analgesics for pain
D. Administer OTC analgesics for pain
A. Providing rest periods throughout the day
B. Instituting energy conservation techniques 8. A client with congestive heart failure has digoxin
C. Assisting in ambulation to the bathroom (Lanoxin) ordered everyday. Prior to giving the
D. Checking temperature of water prior to bathing medication, the nurse checks the digoxin level which is
therapeutic and ausculates an apical pulse. The apical
3. A client was involved in a motor vehicular accident in pulse is 63 bpm for 1 full minute. The nurse should:
which the seat belt was not worn. The client is
exhibiting crepitus, decrease breath sounds on the left, A. Hold the Lanoxin
complains of shortness of breath, and has a respiratory B. Give the half dose now, wait an hour and give
rate of 34 breaths per minute. Which of the following the other half
assessment findings would concern the nurse most? C. Call the physician
D. Give the Lanoxin as ordered
A. Temperature of 102 degrees F and productive
cough 9. Nurse Marian is caring for a client with haital hernia,
B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg which of the following should be included in her
C. Trachea deviating to the right teaching plan regarding causes:
D. Barrel-chested appearance
A. To avoid heavy lifting
4. The proper way to open an envelop-wrapped sterile B. A dietary plan based on soft foods
package after removing the outer package or tape is to C. Its prevalence in young adults
open the first position of the wrapper: D. Its prevalence in fair-skinned individuals

A. away from the body 10. Joseph has been diagnosed with hepatic
B. to the left of the body encephalopathy. The nurse observes flapping tremors.
C. to the right of the body The nurse understands that flapping tremors associated
D. toward the body with hepatic encephalopathy are also known as:

5. Assessment of a client with possible thrombophlebitis A. aphasia

to the left leg and a deep vein thrombosis is done by B. ascites
pulling up on the toes while gently holding down on the C. astacia
knee. The client complains of extreme pain in the calf. D. Asterixis
This should be documented as:
11. Hyperkalemia can be treated with administration of
A. positive tourniquet test 50% dextrose and insulin. The 50% dextrose:
B. positive homan’s sign
C. negative homan’s sign A. causes potassium to be excreted
D. negative tourniquet test B. causes potassium to move into the cell
C. causes potassium to move into the serum
D. counteracts the effects of insulin
12. Which of the following findings would strongly 18. A 24 year old male patient comes to the clinic after
indicate the possibility of cirrhosis? contracting genital herpes. Which of the following
intervention would be most appropriate?
A. dry skin
B. hepatomegaly A. Encourage him to maintain bed rest for several
C. peripheral edema days
D. Pruritus B. Monitor temperature every 4 hours
C. Instruct him to avoid sexual contact during acute
13. Aling Puring has just been diagnosed with phases of illness
close-angle (narrow-angle) glaucoma. The nurse D. Encourage him to use antifungal agents
assesses the client for which of the following common regularly
presenting symptoms of the disorder?
19. An 8 year old boy is brought to the trauma unit with
A. halo vision a chemical burn to the face. Priority assessment would
B. dull eye pain include which of the following?
C. severe eye and face pain
D. impaired night vision A. Skin integrity
B. BP and pulse
14. Chvostek’s sign is associated with which electrolyte C. Patency of airway
imbalance? D. Amount of pain

A. hypocalcemia 20. A client with anemia due to chemotherapy has a

B. hypokalemia hemoglobin of 7.0 g/dL. Which of the following
C. hyponatremia complaints would be indicative of tissue hypoxia related
D. Hypophosphatenia to anemia?

15. What laboratory test is a common measure of the A. dizziness

renal function? B. fatigue relieved by rest
C. skin that is warm and dry to the touch
A. CBC D. Apathy
B. BUN/Creatinine
C. Glucose 21. Hazel Murray, 32 years old complains of abrupt
D. Alanine amino transferase (ALT) onset of chest and back pain and loss of radial pulses.
The nurse suspects that Mrs. Murray may have:
16. Nurse Edward is performing discharge teaching for a
newly diagnosed diabetic patient scheduled for a fasting A. Acute MI
blood glucose test. The nurse explains to the patient that B. CVA
hyperglycemia is defined as a blood glucose level C. Dissecting abdominal aorta
above: D. Dissecting thoracic aneurysm

A. 100 mg/dl 22. Nurse Alexandra is establishing a plan of care for a

B. 120 mg/dl client newly admitted with SIADH. The priority
C. 130 mg/dl diagnosis for this client would be which of the
D. 150 mg/dl following?

17. Mang Edison is on bed rest has developed an ulcer A. Fluid volume deficit
that is full thickness and is penetrating the subcutaneous B. Anxiety related to disease process
tissue. The nurse documents that this ulcer is in which of C. Fluid volume excess
the following stages? D. Risk for injury

A. Stage 1 23. Nursing management of the client with a UTI should

B. Stage 2 include:
C. Stage 3
D. Stage 4 A. Taking medication until feeling better
B. Restricting fluids
C. Decreasing caffeine drinks and alcohol
D. Douching daily
24. Felicia Gomez is 1 day postoperative from coronary
artery bypass surgery. The nurse understands that a
postoperative patient who’s maintained on bed rest is at
high risk for developing:

A. angina
B. arterial bleeding
C. deep vein thrombosis (DVT)
D. dehiscence of the wound

25. Which of the following statement is true regarding

the visual changes associated with cataracts?

A. Both eyes typically cataracts at the same time

B. The loss of vision is experienced as a painless,
gradual blurring
C. The patient is suddenly blind
D. The patient is typically experiences a painful,
sudden blurring of vision.