Free NCLEX Medical Surgical Nursing Questions and Answers — Questions and Answers
Question 1: After undergoing gall bladder surgery, Hazel returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place. She still laments feeling sick. How would the nurse proceed?
- Check the patency of the nasogastric tube for any obstruction. (Correct answer)
- Change the patient’s position.
- Administer the prescribed antiemetic.
- Call the physician immediately.
Correct answer: Check the patency of the nasogastric tube for any obstruction.
One of the most frequent side effects of general anesthesia is nausea. However, stomach distention may exacerbate this problem, particularly in a patient who has had abdominal surgery. The NGT insertion aids in solving the issue. The nurse can identify the root of the issue and implement the required intervention by checking the NGT's patency for any impediment.
Question 2: Among the following remarks made by the client to the nurse may be a CAD risk factor.
- “I exercise every other day.”
- “I smoke 1 1/2 packs of cigarettes per day.” (Correct answer)
- “My father died of Myasthenia Gravis.”
- “My cholesterol is 180.”
Correct answer: “I smoke 1 1/2 packs of cigarettes per day.”
One of the main modifiable risk factors for coronary artery disease has been identified as smoking. It can be prevented with exercise and by keeping serum cholesterol levels within normal ranges.
Question 3: Because older persons frequently complain of discomfort, the nurse must carefully evaluate this complaint.
- have a decreased pain threshold
- have altered mental function
- experience reduced sensory perception (Correct answer)
- are expected to experience chronic pain
Correct answer: experience reduced sensory perception
In the old, degenerative changes take place. The aged may respond to pain less strongly due to decreased touch acuity, changes in brain circuits, and slowed sensory input processing.
Question 4: Angina pectoris patient is being sent home with nitroglycerin tablets. What advice from the list below does the nurse include in her instruction?
- “Place one tablet under your tongue. If the pain is not relieved in 15 minutes, go to the hospital.”
- “Continue your activity, and if the pain does not go away in 10 minutes, begin taking the nitro tablets one every 5 minutes for 15 minutes, then go lie down.”
- “When your chest pain begins, lie down, and place one tablet under your tongue. If the pain continues, take another tablet in 5 minutes.”
- “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved. (Correct answer)
Correct answer: “Place one Nitroglycerine tablet under the tongue every five minutes for three doses. Go to the hospital if the pain is unrelieved.
Myocardial ischemia associated with a diminished coronary blood flow is the primary cause of angina pectoris. Nitroglycerin administration results in coronary vasodilation, which enhances coronary blood flow, in 3–5 minutes. After three pills, if the chest pain has not subsided, an abrupt coronary blockage may be the cause, which necessitates rapid medical intervention.
Question 5: After falling from a two-story structure, a 56-year-old construction worker was found unconscious and sent to the hospital. The nurse would be particularly concerned if the assessment results showed:
- Bleeding from ears (Correct answer)
- Reactive pupils
- A depressed fontanel
- An elevated temperature
Correct answer: Bleeding from ears
A comprehensive assessment must be made by the nurse since it may reveal changes in cerebral function, elevated intracranial pressures, fractures, and bleeding. Only basal skull fractures, which frequently result in elevated intracranial pressure and brain herniation, cause bleeding from the ears.
Question 6: A patient's husband queries the nurse about the low-protein diet prescribed due to severe liver disease. Which of the nurse's statements better explains the goal of the diet?
- “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.” (Correct answer)
- “The liver heals better with a high carbohydrates diet rather than protein.”
- “Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”
- “Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
Correct answer: “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
The GI tract's enzymatic and bacterial breakdown of food and blood proteins is the main source of ammonia. Therefore, a diet low in protein will result in less ammonia being produced.
Question 7: The patient had a Billroth procedure for a stomach ulcer. After surgery, the client's NGT drainage is thick, the volume of secretions has significantly decreased during the last two hours, and he feels like throwing up. The best nursing course of action is to:
- Discontinue the low-intermittent suction
- Irrigate the NGT with 50 cc of sterile
- Reposition the NGT by advancing it gently NSS
- Notify the MD of your findings (Correct answer)
Correct answer: Notify the MD of your findings
The client's experience of nausea and the decrease in the amount of thick NGT discharge are indicators of potential abdominal distention brought on by NGT obstruction. To avoid strain and rupture at the location of the anastomosis brought on by stomach distention, this should be notified right once to the doctor.
Free NCLEX Medical Surgical Nursing Questions and Answers
After undergoing gall bladder surgery, Hazel returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place.
She still laments feeling sick.
How would the nurse proceed?