Exam (elaborations) MED SURG/MED SURG (MED SURG) Nclex practice 100 Prep Qs AND Answers with Explanations

Nclex practice 100 Prep Qs AND Answers with Explanations Question 1: (see full question) A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? You selected: Impaired oral mucous membranes Incorrect Correct response: Impaired gas exchange Explanation: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airw ... (more) Remediation: Pneumocystis jiroveci (carinii) pneumonia Pneumocystis carinii pneumonia Question 2: (see full question) Adolescents and adults who were sexually abused as children commonly mutilate themselves. The nurse interprets this behavior as: You selected: use of physical pain to avoid dealing with emotional pain. Correct Explanation: Dealing with the physical pain associated with mutilation is viewed as easier than dealing with the intense anger and emotional pain. The client fears an aggressive outburst when a ... (more) Remediation: Self-mutilation Question 3: (see full question) A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to: You selected: consult a health care provider (HCP) about removing the corns. Correct Explanation: A client with diabetes should be advised to consult a HCP or podiatrist for corn removal because of the danger of traumatizing the foot tissue and potential development of ulcers. ... (more) Remediation: Foot care Diabetes Question 4: (see full question) A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy? You selected: Maintaining the client's fluid and electrolyte balance Correct Explanation: After maintaining respirations, the most important and immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance t ... (more) Remediation: Fluid assessment Burn wound care Question 5: (see full question) A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which statement by the father would most alert the nurse to the need for a psychiatric consultation? You selected: "If he dies, there will be nothing for me to do but join him." Correct Explanation: The statement about joining the son if he dies indicates potential for self-harm and subsequent suicide, always a risk during crisis. Although the father may be charged with reckle ... (more) Remediation: Suicide precautions Question 6: (see full question) A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis? You selected: Risk for injury Correct Explanation: Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting. His ability to cope with the stroke is important, but ... (more) Remediation: Stroke Question 7: (see full question) At which time should the nurse instruct the client to take ibuprofen, prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? You selected: immediately after a meal Correct Explanation: Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an e ... (more) Remediation: Ibuprofen Question 8: (see full question) Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy? You selected: Teach the client to use a folded blanket or pillow to splint the incision. Correct Explanation: A folded bath blanket or pillow placed over the incision will be most effective in helping the client cough and deep breathe after a cholecystectomy. Taking rapid, shallow breaths ... (more) Remediation: Cholecystectomy Teaching Coughing and Splinting Question 9: (see full question) A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How many gtts/min should the nurse count to ensure that the fluid is safely infusing? You selected: 27 gtts/min Correct Explanation: The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60 min/h = 27 gtts/min Remediation: IV infusion, dose and flow rate calculations Question 10: (see full question) Before administering the evening dose of an ordered medication, a nurse on the evening shift finds an unlabeled, filled syringe in a client's medication drawer. What should the nurse do? You selected: Discard the syringe to avoid a medication error. Correct Explanation: As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe practices because they promote error. Remediation: Safe medication administration practices ...continued...