Nclex Questions Med/surg Chapters 1-12

Front 1

When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, what phase of the nursing process is being used?
Planning
Diagnosis
Evaluation
Implementation

Back 1

Implementation

Front 2

When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data. What is this format called?
Concept map
Critical pathway
Clinical pathway
Nursing care plan

Back 2

Concept map

Front 3

A nurse is providing care for a patient who had transurethral resection of his prostate this morning. The patient is receiving continuous bladder irrigation, but his urinary catheter is now occluded. The nurse is now planning to phone the patient's health care provider and communicate using the SBAR (Situation-Background-Assessment-Recommendation) format. Which statement is a component of communication using SBAR?
"What do you think could be causing this occlusion?"
"I think that we should manually irrigate his catheter."
"What do you know about this patient and his history?"
"Could you please provide some direction for his care?"

Back 3

"I think that we should manually irrigate his catheter."

Front 4

What factor has been most clearly identified as an influence on the future of nursing practice?
Aging of the American population and increases in chronic illnesses
Increasing birth rates coupled with decreased average life expectancy
Increased awareness of determinants of health and improved self-care
Apathy around health behaviors and the relationship of lifestyle to health

Back 4

Aging of the American population and increases in chronic illnesses

Front 5

A group of nurses have a plan to implement evidence-based practice (EBP) for care of patients with pressure ulcers. What will this change in practice encompass (select all that apply)?
Consulting with the wound care and ostomy nurse
The preferences of patients and their particular circumstances
Nurses' expertise and their bodies of experience and knowledge
The traditions that surround pressure ulcer practices on the unit
Journal articles that address the care of patients with pressure ulcers

Back 5

Consulting with the wound care and ostomy nurse
The preferences of patients and their particular circumstances
Nurses' expertise and their bodies of experience and knowledge
Journal articles that address the care of patients with pressure ulcers

Front 6

A registered nurse (RN) has delegated the administration of IV medications to a licensed practical/vocational nurse (LPN/LVN). Which statement accurately describes delegation?
The RN should first teach the LPN how to administer IV medications.
Ultimate responsibility for the execution of the task now lies with the LPN.
The RN is still accountable for the quality of care and procedures that the patient receives.
The RN is responsible for observing and evaluating the administration of IV medications by the LPN.

Back 6

The RN is still accountable for the quality of care and procedures that the patient receives.

Front 7

Nurses deliver patient-centered care in collaboration with the interdisciplinary health care team within the framework of a care delivery model. In which care delivery model does the nurse plan and coordinate the aspects of patient care with other disciplines with a focus on continuity of care and interdisciplinary collaboration even when the nurse is absent?
Team nursing model
Primary nursing model
Total patient care model
Case management nursing model

Back 7

Primary nursing model

Front 8

Which interventions are independent nursing actions (select all that apply)?
IV reinsertion
Assessing lung sounds
Medication administration
First postoperative dressing change
Obtaining informed consent from the patient

Back 8

IV reinsertion
Assessing lung sounds

Front 9

Telehealth includes using devices to provide which types of care for the patient (select all that apply)?
Administering medications
Evaluation of weight loss
Video assessment of wounds
Monitoring peak flow meter results
Real-time blood pressure assessment

Back 9

Evaluation of weight loss
Video assessment of wounds
Monitoring peak flow meter results
Real-time blood pressure assessment

Front 10

Which individual is most likely to experience health care disparities?
A 65-year-old upper class Hispanic male living in the city
A 78-year-old Native American male living on a reservation
A 50-year-old middle-class white female living in a rural area
A 72-year-old African American retired attorney living in a condo

Back 10

A 78-year-old Native American male living on a reservation

Front 11

The nurse identifies a patient at high risk for health care disparities. What should be included as important nursing interventions to reduce health care disparities (select all that apply)?
Passive listening
Relationship building
Taking foreign language classes
Participating in cross-cultural education
Using standardized evidence-based guidelines

Back 11

Relationship building
Participating in cross-cultural education
Using standardized evidence-based guidelines

Front 12

When obtaining an admission history on a Mexican American older male patient, which cultural value would the nurse recognize as most likely to be important to this patient?
Patriarchal
Self-reliance
Science-based
Harmony with nature

Back 12

Patriarchal

Front 13

Culturally competent nursing care for a Jewish patient would include which diet?
Kosher
Vegetarian
Word of wisdom
Low carbohydrate

Back 13

Kosher

Front 14

Which nursing action is most indicative of stereotyping?
The nurse advocates for bronchodilators to be prescribed for all newly admitted African American patients.
The nurse helps a recent immigrant to explore ways to pay for her newly prescribed antihypertensive medications.
The nurse prioritizes the assessment of obesity when providing care for African American and Mexican American women.
The nurse arranges for translation services to be provided for a patient who has recently emigrated from Sri Lanka and does not speak English.

Back 14

The nurse advocates for bronchodilators to be prescribed for all newly admitted African American patients.

Front 15

The nurse is performing an assessment of a 78-year-old Chinese American woman who wears a jade bracelet on her left wrist. The nurse asks the patient about the significance of the bracelet and whether it can be removed prior to the patient's scheduled diagnostic procedure. What has the nurse demonstrated?
Diversity
Stereotyping
Ethnocentrism
Cultural competence

Back 15

Cultural competence

Front 16

The adult children of a male patient who is Hindu have requested a vegetarian diet for their father. What is the nurse's most appropriate response?
Order a vegetarian diet for the patient.
Assess the family's rationale for choosing this particular diet.
Teach the family about the relationship between protein intake and wound healing.
Explore the benefits of a low-meat, high-protein diet with the family and the dietitian.

Back 16

Order a vegetarian diet for the patient

Front 17

A 72-year-old Nigerian man comes to the United States to visit his adult son. The son tries to encourage his father to have the testing and treatment for a chronic productive cough. The adult son has a positive attitude and believes in the American medical treatment because what has happened to the child while living in the United States?
Acculturation
Ethnocentrism
Race awareness
Cultural imposition

Back 17

Acculturation

Front 18

The nurse is interested in developing her cultural competence. What roles can she take to do so?
Develop understanding of all ethnic groups.
Identify the one culture about which she is interested in being competent.
Have extended contact with a cultural group to enhance understanding of its values and beliefs.
Understand the specific information about the patient's culture so the understanding can be applied to caring for the patient.

Back 18

Have extended contact with a cultural group to enhance understanding of its values and beliefs.

Front 19

During an admission history and physical assessment, the patient describes symptoms to the nurse. What should these descriptions be documented as?
Objective data
Subjective data
Generalized data
Comprehensive data

Back 19

Subjective

Front 20

The nurse would place assessment findings related to vision and hearing under which functional health pattern?
Activity-rest pattern
Cognitive-perceptual pattern
Self-perception/self-concept pattern
Health-perception/health-management pattern

Back 20

Cognitive-perceptual pattern

Front 21

Which action most clearly demonstrates a nursing focus rather than a medical focus?
The nurse recommends a change to the patient's insulin sliding scale.
The nurse interprets the results of the patient's most recent glucose tolerance test.
The nurse assesses the benefits of changing the patient to a new oral antihyperglycemic.
The nurse assesses the effect that a recent diagnosis of diabetes has on the patient's lifestyle and routines.

Back 21

The nurse assesses the effect that a recent diagnosis of diabetes has on the patient's lifestyle and routines.

Front 22

A 72-year-old woman has sought care for restless legs syndrome, a problem that has been causing her increasing loss of sleep in recent weeks. The woman states that she attributes the problem to inadequate calcium intake, and she has responded by integrating more dairy products into her diet. Which aspects of symptom investigation does the nurse recognize as present in this situation (select all that apply)?
Quality
Timing
Severity
Radiation
Precipitating and palliative

Back 22

Timing
Radiation
Precipitating and palliative

Front 23

During the nurse's initial health assessment of an older adult patient, the nurse notes that the patient often makes self-deprecating statements, saying that "I'm just a nuisance to my children now" and "It would be easier for everyone if I didn't have to be such a burden to them." The nurse would document a problem in which functional health pattern?
Value-belief pattern
Cognitive-perceptual pattern
Coping–stress tolerance pattern
Self-perception/self-concept pattern

Back 23

Self-perception/self-concept pattern

Front 24

In which situation would the nurse most likely conduct a comprehensive assessment?
When performing resuscitation on a trauma patient
When assessing the progression of a patient's ascites and edema
When admitting a patient to a medical unit from the emergency department
When assessing a patient who has been receiving rehabilitation following a stroke

Back 24

When admitting a patient to a medical unit from the emergency department

Front 25

Indicate which data would be classified as objective data (select all that apply).
Earache
Dizziness
Pitting edema
Cyanosis of lips
Shortness of breath
Hyperactive peristalsis

Back 25

Pitting edema
Cyanosis of lips
Hyperactive peristalsis

Front 26

Before counting the apical heart rate, which nursing assessment technique should the nurse use to find the correct place to listen to the point of maximal impulse (PMI)?
Inspection
Percussion
Auscultation
Light palpation

Back 26

Light palpation

Front 27

The patient was admitted via the emergency department (ED) with respiratory distress. What statement best describes the initial assessment of the patient on the medical-surgical unit?
An emergency assessment should be performed to ensure the patient's safety.
A focused assessment should be performed to be sure the ED did not miss anything.
A focused assessment should be performed to determine if new problems have arisen.
A comprehensive assessment should be performed to determine the patient's response to the

Back 27

A comprehensive assessment should be performed to determine the patient's response to the respiratory distress and treatment

Front 28

Which techniques would be most appropriate to enhance patient learning (select all that apply)?
Obtain frequent feedback.
Have a quiet environment.
Explain information in great detail.
Involve the patient and caregiver in the process.
Emphasize relevancy of the information to the patient's lifestyle.

Back 28

Obtain frequent feedback.
Have a quiet environment.

Involve the patient and caregiver in the process.
Emphasize relevancy of the information to the patient's lifestyle.

Front 29

What would be one method of individualizing learning for a patient's unique needs?
Use prepackaged learning materials.
Only teach the patient "need-to-know" information.
Have the patient arrange topic cards in order of priority.
Have the patient watch a video and then read a pamphlet.

Back 29

Have the patient arrange topic cards in order of priority.

Front 30

Which actions best demonstrate the nurses' awareness of learning styles and the role that they play in patient and caregiver teaching (select all that apply)?
Assess patients' learning styles prior to teaching.
Use materials that appeal to a variety of learning styles.
Prioritize the learning style with which he or she is most familiar and comfortable.
Provide written instructions to younger patients while using visual and audio aids when teaching older patients.
Provide visual and audio aids to younger patients while using written instructions when teaching older patients.

Back 30

Assess patients' learning styles prior to teaching.
Use materials that appeal to a variety of learning styles.

Front 31

The nurse notes that a male patient regularly asks about the purpose and potential side effects of each oral medication that he has received during his time in the hospital. How should the nurse best interpret the patient's questions?
The patient has an auditory learning style.
The patient is identifying his learning needs.
The patient is exhibiting a high level of health literacy.
The patient is experiencing anxiety related to his diagnosis and treatment.

Back 31

The patient is identifying his learning needs.

Front 32

A 44-year-old female patient with a long-standing history of type 1 diabetes has brought a number of printouts from websites to her most recent visit with her primary care provider. What direction should the nurse provide to the patient regarding health information on the Internet?
"It is best to make sure that you avoid websites that are not associated with a government agency."
"You may have some good information there, but it is best to focus only on the information the doctor provides to you."
"There is a great deal of misinformation on the Internet, so it is best to focus on printed material rather than electronic sources."
"I encourage you to find websites that are credible and reliable, and I can give you some information on making those decisions if you like."

Back 32

"I encourage you to find websites that are credible and reliable, and I can give you some information on making those decisions if you like."

Front 33

The nursing student is assigned to use motivational interviewing to motivate the patient to change dietary eating behaviors. Which statement shows the use of this technique?
"Tell me about the concerns you have about changing your diet."
"You have a big weakness for ice cream; we will need to change that."
"I feel sorry for you, but you must change your diet if you plan to feel better."
"I would not want to change my diet, but I would sure do it instead of getting sicker."

Back 33

"Tell me about the concerns you have about changing your diet."

Front 34

The patient says she prefers to watch how things are done rather than to read the information or instructions to learn about how to take care of herself. Which teaching strategy would be best for this patient?
Watch a DVD.
Read the pamphlet.
Talk about it with the nurse.
Use the Internet to read about it.

Back 34

Watch a DVD.

Front 35

Which teaching strategy would be best to offer to a 20-year-old patient?
Lecture or books
Websites or podcasts
Television or pamphlets
Role play or support group

Back 35

Websites or podcasts

Front 36

Which question elicits additional information to evaluate the patient's understanding?
"Can you show me how to change your dressing?"
"Do you understand how to change your dressing?"
"Do you think you can change your dressing at home?"
"What will you do if the dressing has excess drainage?"

Back 36

"What will you do if the dressing has excess drainage?"

Front 37

Based on adult learning principles, which situation indicates that the patient is ready to learn about taking enoxaparin (Lovenox) injections at home?
The patient is requesting pain medication.
The patient is too tired to stay awake to watch the teaching DVD.
The patient wants to practice before actually injecting himself with the needle.
The patient is nervous and says he cannot do it when he picks up the bottle of medication.

Back 37

The patient wants to practice before actually injecting himself with the needle.