MEDSURGE 206 PRACTICE EXAM RESULTS NCLEX WITH
RATIONALE APPROVED AND WELL ELABORATED
A client's daughter is sitting by her mother's bedside who was recently transferred to the
Intermediate Care Unit. She states "I don't understand what a brain attack is. The
healthcare provider told me my mother is in serious condition and they are going to run
several tests. I just don't know what is going on. What happened to my mother?" What
is the best response by the nurse?
A) "I am sorry, but according to the Health Insurance Portability and Accounting Act
(HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you about your mother's
serious condition." - ANSWER-B) "Your mother has had a stroke, and the blood supply
to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make
decisions, so the next of kin, her daughter, Gail, needs sufficient information to make
informed decisions. The nurse has the knowledge, and the responsibility, to explain
Nancy's condition to Gail. The nurse should give facts first, and then address her
feelings after the information is provided.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for
development of coronary heart disease (CHD). Which information should the nurse
include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake. - ANSWER-B) Increase
intake of soluble fiber to 10 to 25 grams per day.
Rationale: To reduce risk factors associated with coronary heart disease, the daily
intake of soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol
intake (A) should be limited to 180 mg/day or less. Intake of plant stanols and sterols is
recommended at 2 g/day (C). Saturated fat (D) intake should be limited to 7% of total
daily calories.
,An ER nurse is completing an assessment on a patient that is alert but struggles to
answer questions. When she attempts to talk, she slurs her speech and appears very
frightened. What additional clinical manifestation does the nurse expect to find if nacy's
sysmptoms have been caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds - ANSWER-A) A carotid bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain
attack. A bruit is an abnormal sound heard on auscultation resulting from interference
with normal blood flow. Usually the blood pressure is hypertensive. Initially flaccid
paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not
indicative of a brain attack.
Which clinical manifestation further supports an assessment of a left-sided brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia. - ANSWER-D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as
well as difficulty reading and writing. Symptoms vary from person to person. Aphasia
may occur secondary to any brain injury involving the left hemisphere. Visual field
deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with
right-sided brain attack.
When preparing a patient for a noncontrast computed tomography (CT) scan STAT,
what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure. - ANSWER-B)
Explain that the client will not be able to move her head throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy will have to remain still
throughout the procedure. Allergies to iodine is important if contrast dye is being used
for the CT scan. Premedicating the client to decrease pain prior to the procedure is
unnecessary because CT scanning is a noninvasive and painless procedure. Providing
an explanation of relaxation exercises prior to the procedure is a worthwhile intervention
to decrease anxiety but is not of highest priority.
,A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a
patient. Which data warrants immediate intervention by the nurse concerning this
diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation. - ANSWER-C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items are
strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield
must be used during the procedure. Elevated blood pressure, an allergy to shell fish,
and a history of atrial fibrillation would not affect the MRI.
A female client requests information about using the calendar method of contraception.
Which assessment is most important for the nurse to obtain?
A) Amount of weight gain or weight loss during the previous year.
B) An accurate menstrual cycle diary for the past 6 to 12 months.
C) Skin pigmentation and hair texture for evidence of hormonal changes.
D) Previous birth-control methods and beliefs about the calendar method. - ANSWER-
B) An accurate menstrual cycle diary for the past 6 to 12 months.
Rationale: The fertile period, which occurs 2 weeks prior to the onset of menses, is
determined using an accurate record of the number of days of the menstrual cycles for
the past 6 months, so it is most important to emphasize to the client that accuracy and
compliancy of a menstrual diary (B) is the basis of the calendar method. (A and C) may
be partially related to hormonal fluctuations but are not indicators for using the calendar
method. (D) may demonstrate client understanding and compliancy but is not the most
important aspect.
The nurse knows that lab values sometimes vary for the older client. Which data should
the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A) Increased WBC, decreased RBC.
B) Increased serum bilirubin, slightly increased liver enzymes.
C) Increased protein in the urine, slightly increased serum glucose levels.
D) Decreased serum sodium, an increased urine specific gravity. - ANSWER-C)
Increased protein in the urine, slightly increased serum glucose levels.
Rationale: In older adults, the protein found in urine slightly rises probably as a result of
kidney changes or subclinical urinary tract infections. The serum glucose increases
slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032
to 1.024.
, Which postmenopausal client's complaint should the nurse refer to the healthcare
provider?
A) Breasts feel lumpy when palpated.
B) History of white nipple discharge.
C) Episodes of vaginal bleeding.
D) Excessive diaphoresis occurs at night. - ANSWER-C) Episodes of vaginal bleeding.
Rationale: Postmenopausal vaginal bleeding (C) may be an indication of endometrial
cancer, which should be reported to the healthcare provider. Compared to a new-onset
of a single lump, breasts that feel lumpy (A) overall may be a normal variant or a finding
consistent with nonmalignant fibrocystic disease. Up to 80% of women experience (B),
depending on sexual stimulation or hormonal levels, and is no longer recommended as
a reportable symptom when discovered during breast self-exam (BSE). The client may
need further teaching concerning (D), a disturbing symptom, but it is not as important as
(C).
The nurse is assisting a client out of bed for the first time after surgery. What action
should the nurse do first?
A) Place a chair at a right angle to the bedside.
B) Encourage deep breathing prior to standing.
C) Help the client to sit and dangle legs on the side of the bed.
D) Allow the client to sit with the bed in a high Fowler's position. - ANSWER-D) Allow
the client to sit with the bed in a high Fowler's position.
Rationale: The first step is to raise the head of the bed to a high Fowler's position (D),
which allow venous return to compensate from lying flat and vasodilating effects of
perioperative drugs. (A, B, and C) are implemented after (D).
The nurse is receiving report from surgery about a client with a penrose drain who is to
be admitted to the postoperative unit. Before choosing a room for this client, which
information is most important for the nurse to obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac® in place.
D) If the client's wound is infected. - ANSWER-D) If the client's wound is infected.
Rationale: Penrose drains provide a sinus tract or opening and are often used to
provide drainage of an abscess. The fact that the client has a penrose drain should alert
the nurse to the possibility that the client is infected. To avoid contamination of another
postoperative client, it is most important to place an infected client in a private room (D).
A penrose drain does not require (A). Although (B) is information that should be
considered, it does not have the priority of (D). (C) is used to drain fluid from a dead
space and is not important in choosing a room.
RATIONALE APPROVED AND WELL ELABORATED
A client's daughter is sitting by her mother's bedside who was recently transferred to the
Intermediate Care Unit. She states "I don't understand what a brain attack is. The
healthcare provider told me my mother is in serious condition and they are going to run
several tests. I just don't know what is going on. What happened to my mother?" What
is the best response by the nurse?
A) "I am sorry, but according to the Health Insurance Portability and Accounting Act
(HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you about your mother's
serious condition." - ANSWER-B) "Your mother has had a stroke, and the blood supply
to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make
decisions, so the next of kin, her daughter, Gail, needs sufficient information to make
informed decisions. The nurse has the knowledge, and the responsibility, to explain
Nancy's condition to Gail. The nurse should give facts first, and then address her
feelings after the information is provided.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for
development of coronary heart disease (CHD). Which information should the nurse
include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake. - ANSWER-B) Increase
intake of soluble fiber to 10 to 25 grams per day.
Rationale: To reduce risk factors associated with coronary heart disease, the daily
intake of soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol
intake (A) should be limited to 180 mg/day or less. Intake of plant stanols and sterols is
recommended at 2 g/day (C). Saturated fat (D) intake should be limited to 7% of total
daily calories.
,An ER nurse is completing an assessment on a patient that is alert but struggles to
answer questions. When she attempts to talk, she slurs her speech and appears very
frightened. What additional clinical manifestation does the nurse expect to find if nacy's
sysmptoms have been caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds - ANSWER-A) A carotid bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain
attack. A bruit is an abnormal sound heard on auscultation resulting from interference
with normal blood flow. Usually the blood pressure is hypertensive. Initially flaccid
paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not
indicative of a brain attack.
Which clinical manifestation further supports an assessment of a left-sided brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia. - ANSWER-D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as
well as difficulty reading and writing. Symptoms vary from person to person. Aphasia
may occur secondary to any brain injury involving the left hemisphere. Visual field
deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with
right-sided brain attack.
When preparing a patient for a noncontrast computed tomography (CT) scan STAT,
what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure. - ANSWER-B)
Explain that the client will not be able to move her head throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy will have to remain still
throughout the procedure. Allergies to iodine is important if contrast dye is being used
for the CT scan. Premedicating the client to decrease pain prior to the procedure is
unnecessary because CT scanning is a noninvasive and painless procedure. Providing
an explanation of relaxation exercises prior to the procedure is a worthwhile intervention
to decrease anxiety but is not of highest priority.
,A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a
patient. Which data warrants immediate intervention by the nurse concerning this
diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation. - ANSWER-C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items are
strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield
must be used during the procedure. Elevated blood pressure, an allergy to shell fish,
and a history of atrial fibrillation would not affect the MRI.
A female client requests information about using the calendar method of contraception.
Which assessment is most important for the nurse to obtain?
A) Amount of weight gain or weight loss during the previous year.
B) An accurate menstrual cycle diary for the past 6 to 12 months.
C) Skin pigmentation and hair texture for evidence of hormonal changes.
D) Previous birth-control methods and beliefs about the calendar method. - ANSWER-
B) An accurate menstrual cycle diary for the past 6 to 12 months.
Rationale: The fertile period, which occurs 2 weeks prior to the onset of menses, is
determined using an accurate record of the number of days of the menstrual cycles for
the past 6 months, so it is most important to emphasize to the client that accuracy and
compliancy of a menstrual diary (B) is the basis of the calendar method. (A and C) may
be partially related to hormonal fluctuations but are not indicators for using the calendar
method. (D) may demonstrate client understanding and compliancy but is not the most
important aspect.
The nurse knows that lab values sometimes vary for the older client. Which data should
the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A) Increased WBC, decreased RBC.
B) Increased serum bilirubin, slightly increased liver enzymes.
C) Increased protein in the urine, slightly increased serum glucose levels.
D) Decreased serum sodium, an increased urine specific gravity. - ANSWER-C)
Increased protein in the urine, slightly increased serum glucose levels.
Rationale: In older adults, the protein found in urine slightly rises probably as a result of
kidney changes or subclinical urinary tract infections. The serum glucose increases
slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032
to 1.024.
, Which postmenopausal client's complaint should the nurse refer to the healthcare
provider?
A) Breasts feel lumpy when palpated.
B) History of white nipple discharge.
C) Episodes of vaginal bleeding.
D) Excessive diaphoresis occurs at night. - ANSWER-C) Episodes of vaginal bleeding.
Rationale: Postmenopausal vaginal bleeding (C) may be an indication of endometrial
cancer, which should be reported to the healthcare provider. Compared to a new-onset
of a single lump, breasts that feel lumpy (A) overall may be a normal variant or a finding
consistent with nonmalignant fibrocystic disease. Up to 80% of women experience (B),
depending on sexual stimulation or hormonal levels, and is no longer recommended as
a reportable symptom when discovered during breast self-exam (BSE). The client may
need further teaching concerning (D), a disturbing symptom, but it is not as important as
(C).
The nurse is assisting a client out of bed for the first time after surgery. What action
should the nurse do first?
A) Place a chair at a right angle to the bedside.
B) Encourage deep breathing prior to standing.
C) Help the client to sit and dangle legs on the side of the bed.
D) Allow the client to sit with the bed in a high Fowler's position. - ANSWER-D) Allow
the client to sit with the bed in a high Fowler's position.
Rationale: The first step is to raise the head of the bed to a high Fowler's position (D),
which allow venous return to compensate from lying flat and vasodilating effects of
perioperative drugs. (A, B, and C) are implemented after (D).
The nurse is receiving report from surgery about a client with a penrose drain who is to
be admitted to the postoperative unit. Before choosing a room for this client, which
information is most important for the nurse to obtain?
A) If suctioning will be needed for drainage of the wound.
B) If the family would prefer a private or semi-private room.
C) If the client also has a Hemovac® in place.
D) If the client's wound is infected. - ANSWER-D) If the client's wound is infected.
Rationale: Penrose drains provide a sinus tract or opening and are often used to
provide drainage of an abscess. The fact that the client has a penrose drain should alert
the nurse to the possibility that the client is infected. To avoid contamination of another
postoperative client, it is most important to place an infected client in a private room (D).
A penrose drain does not require (A). Although (B) is information that should be
considered, it does not have the priority of (D). (C) is used to drain fluid from a dead
space and is not important in choosing a room.
