PNLE MEDICAL-SURGICAL NURSING ADVANCED CONCEPTS
COMPLETE EXAM GUIDE QUESTIONS AND ANSWERS
|COMPLETE RATIONALE
Question 1
A client has suffered a motor accident and is now suffering from hypovolemic
shock. Nurse Helen should frequently assess the client's vital signs during the
compensatory stage of shock because:
A) Arteriolar constriction occurs
B) The cardiac workload decreases
C) Decreased contractility of the heart occurs
D) The parasympathetic nervous system is triggered
Correct Answer: A) Arteriolar constriction occurs
Explanation: The early compensation of shock is cardiovascular and is seen in
changes in pulse, blood pressure, and pulse pressure. Blood is shunted to vital
centers, particularly the heart and brain, through arteriolar constriction. This
compensatory mechanism maintains perfusion to vital organs.
Question 2
During the first 48 hours after a severe burn of 40% of the client's body surface,
the nurse's assessment should include observations for water intoxication.
Associated adaptations include:
A) Sooty-colored sputum
B) Frothy pink-tinged sputum
C) Twitching and disorientation
D) Urine output below 30 ml per hour
,Correct Answer: C) Twitching and disorientation
Explanation: Excess extracellular fluid moves into cells (water intoxication).
Intracellular fluid excess in sensitive brain cells causes altered mental status,
twitching, sleepiness, and convulsions. This is a serious complication of burn
resuscitation.
Question 3
A client with a head injury has a fixed, dilated right pupil; responds only to painful
stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these
are signs of:
A) Meningeal irritation
B) Subdural hemorrhage
C) Medullary compression
D) Cerebral cortex compression
Correct Answer: D) Cerebral cortex compression
Explanation: Cerebral compression affects pyramidal tracts, resulting in
decorticate rigidity and cranial nerve injury, which cause pupil dilation. These are
signs of severe brain injury with increased intracranial pressure requiring
immediate intervention.
Question 4
After a lateral crushing chest injury, obvious right-sided paradoxical motion of the
client's chest demonstrates multiple rib fractures, resulting in a flail chest. The
complication the nurse should carefully observe for would be:
A) Mediastinal shift
B) Tracheal laceration
C) Open pneumothorax
D) Pericardial tamponade
Correct Answer: A) Mediastinal shift
Explanation: Mediastinal structures move toward the uninjured lung during
inspiration and toward the injured lung during expiration (paradoxical motion),
,reducing oxygenation and venous return. This is a life-threatening complication of
flail chest.
Question 5
A client with obstruction of the common bile duct may show a prolonged bleeding
and clotting time because:
A) Vitamin K is not absorbed
B) The ionized calcium levels fall
C) The extrinsic factor is not absorbed
D) Bilirubin accumulates in the plasma
Correct Answer: A) Vitamin K is not absorbed
Explanation: Vitamin K, a fat-soluble vitamin, is not absorbed from the GI tract in
the absence of bile. Bile enters the duodenum via the common bile duct. Vitamin
K is essential for the synthesis of clotting factors II, VII, IX, and X.
Question 6
When caring for a client with a pneumothorax who has a chest tube in place,
nurse Kate should plan to:
A) Administer cough suppressants at appropriate intervals as ordered
B) Empty and measure the drainage in the collection chamber each shift
C) Apply clamps below the insertion site whenever getting the client out of bed
D) Encourage coughing, deep breathing, and range of motion to the arm on the
affected side
Correct Answer: D) Encourage coughing, deep breathing, and range of motion to
the arm on the affected side
Explanation: All these interventions promote aeration of the re-expanding lung
and maintenance of function in the arm and shoulder on the affected side. Clamps
should not be applied routinely as they can cause tension pneumothorax.
Question 7
A client is admitted for COPD. Which finding would require the nurse's immediate
attention?
A) Nausea and vomiting
, B) Restlessness and confusion
C) Low-grade fever and cough
D) Irritating cough and liquefied sputum
Correct Answer: B) Restlessness and confusion
Explanation: Respiratory failure may be signaled by restlessness, confusion,
somnolence, aggressiveness, central cyanosis, and shortness of breath.
Restlessness and confusion are early signs of hypoxia requiring immediate
assessment.
Question 8
On admission to the hospital a client with an acute asthma episode has
intermittent nonproductive coughing and a pulse oximeter reading of 88%. The
client states, "I feel like this is going to be a bad time this admission. I wish I would
not have gone into that bar with all those people who smoke last night." Which
nursing diagnosis would be most important for this client?
A) Anxiety related to hospitalization
B) Ineffective airway clearance related to potential thick secretions
C) Altered health maintenance related to preventative behaviors associated with
asthma
D) Impaired gas exchange related to bronchoconstriction and mucosal edema
Correct Answer: D) Impaired gas exchange related to bronchoconstriction and
mucosal edema
Explanation: Pulse oximetry reflects oxygenation of arterial blood. The reading of
88% indicates hypoxemia, making Impaired Gas Exchange the priority diagnosis.
While the other diagnoses may be appropriate, they are not the most immediate
threat.
Question 9
The nurse is caring for a client on mechanical ventilation. When performing
endotracheal suctioning, the nurse will avoid hypoxia by:
A) Inserting a fenestrated catheter with a whistle tip without suction
B) Completing suction pass in 30 seconds with pressure of 150 mm Hg
COMPLETE EXAM GUIDE QUESTIONS AND ANSWERS
|COMPLETE RATIONALE
Question 1
A client has suffered a motor accident and is now suffering from hypovolemic
shock. Nurse Helen should frequently assess the client's vital signs during the
compensatory stage of shock because:
A) Arteriolar constriction occurs
B) The cardiac workload decreases
C) Decreased contractility of the heart occurs
D) The parasympathetic nervous system is triggered
Correct Answer: A) Arteriolar constriction occurs
Explanation: The early compensation of shock is cardiovascular and is seen in
changes in pulse, blood pressure, and pulse pressure. Blood is shunted to vital
centers, particularly the heart and brain, through arteriolar constriction. This
compensatory mechanism maintains perfusion to vital organs.
Question 2
During the first 48 hours after a severe burn of 40% of the client's body surface,
the nurse's assessment should include observations for water intoxication.
Associated adaptations include:
A) Sooty-colored sputum
B) Frothy pink-tinged sputum
C) Twitching and disorientation
D) Urine output below 30 ml per hour
,Correct Answer: C) Twitching and disorientation
Explanation: Excess extracellular fluid moves into cells (water intoxication).
Intracellular fluid excess in sensitive brain cells causes altered mental status,
twitching, sleepiness, and convulsions. This is a serious complication of burn
resuscitation.
Question 3
A client with a head injury has a fixed, dilated right pupil; responds only to painful
stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these
are signs of:
A) Meningeal irritation
B) Subdural hemorrhage
C) Medullary compression
D) Cerebral cortex compression
Correct Answer: D) Cerebral cortex compression
Explanation: Cerebral compression affects pyramidal tracts, resulting in
decorticate rigidity and cranial nerve injury, which cause pupil dilation. These are
signs of severe brain injury with increased intracranial pressure requiring
immediate intervention.
Question 4
After a lateral crushing chest injury, obvious right-sided paradoxical motion of the
client's chest demonstrates multiple rib fractures, resulting in a flail chest. The
complication the nurse should carefully observe for would be:
A) Mediastinal shift
B) Tracheal laceration
C) Open pneumothorax
D) Pericardial tamponade
Correct Answer: A) Mediastinal shift
Explanation: Mediastinal structures move toward the uninjured lung during
inspiration and toward the injured lung during expiration (paradoxical motion),
,reducing oxygenation and venous return. This is a life-threatening complication of
flail chest.
Question 5
A client with obstruction of the common bile duct may show a prolonged bleeding
and clotting time because:
A) Vitamin K is not absorbed
B) The ionized calcium levels fall
C) The extrinsic factor is not absorbed
D) Bilirubin accumulates in the plasma
Correct Answer: A) Vitamin K is not absorbed
Explanation: Vitamin K, a fat-soluble vitamin, is not absorbed from the GI tract in
the absence of bile. Bile enters the duodenum via the common bile duct. Vitamin
K is essential for the synthesis of clotting factors II, VII, IX, and X.
Question 6
When caring for a client with a pneumothorax who has a chest tube in place,
nurse Kate should plan to:
A) Administer cough suppressants at appropriate intervals as ordered
B) Empty and measure the drainage in the collection chamber each shift
C) Apply clamps below the insertion site whenever getting the client out of bed
D) Encourage coughing, deep breathing, and range of motion to the arm on the
affected side
Correct Answer: D) Encourage coughing, deep breathing, and range of motion to
the arm on the affected side
Explanation: All these interventions promote aeration of the re-expanding lung
and maintenance of function in the arm and shoulder on the affected side. Clamps
should not be applied routinely as they can cause tension pneumothorax.
Question 7
A client is admitted for COPD. Which finding would require the nurse's immediate
attention?
A) Nausea and vomiting
, B) Restlessness and confusion
C) Low-grade fever and cough
D) Irritating cough and liquefied sputum
Correct Answer: B) Restlessness and confusion
Explanation: Respiratory failure may be signaled by restlessness, confusion,
somnolence, aggressiveness, central cyanosis, and shortness of breath.
Restlessness and confusion are early signs of hypoxia requiring immediate
assessment.
Question 8
On admission to the hospital a client with an acute asthma episode has
intermittent nonproductive coughing and a pulse oximeter reading of 88%. The
client states, "I feel like this is going to be a bad time this admission. I wish I would
not have gone into that bar with all those people who smoke last night." Which
nursing diagnosis would be most important for this client?
A) Anxiety related to hospitalization
B) Ineffective airway clearance related to potential thick secretions
C) Altered health maintenance related to preventative behaviors associated with
asthma
D) Impaired gas exchange related to bronchoconstriction and mucosal edema
Correct Answer: D) Impaired gas exchange related to bronchoconstriction and
mucosal edema
Explanation: Pulse oximetry reflects oxygenation of arterial blood. The reading of
88% indicates hypoxemia, making Impaired Gas Exchange the priority diagnosis.
While the other diagnoses may be appropriate, they are not the most immediate
threat.
Question 9
The nurse is caring for a client on mechanical ventilation. When performing
endotracheal suctioning, the nurse will avoid hypoxia by:
A) Inserting a fenestrated catheter with a whistle tip without suction
B) Completing suction pass in 30 seconds with pressure of 150 mm Hg
