Nurse Rodelio has been appointed to a patient with Raynaud’s disease. Nurse Rodelio understands that the etiology of the disease is unknown but it is described by
A. Episodic vasospastic disorder of capillaries
B. Episodic vasospastic disorder of small veins
C. Episodic vasospastic disorder of the aorta
D. Episodic vasospastic disorder of the small arteries
Medical Surgical Answer D. Raynaud’s disease is defined by vasospasms of the small cutaneous arteries that involve fingers and toes.
Nurse Leong should demonstrate to the male patient with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because
A. More accurate
B. Can be done by the patient
C. It is easy to perform
D. It is not influenced by drugs
Medical Surgical Answer A. Urine testing gives an indirect measure that may be influenced by kidney function while blood glucose testing is a more direct and accurate measure.
Monya weighed 210 pounds on entry to the hospital. After 2 days of diuretic therapy, Monya weighs 205.5 pounds. The nurse could determine the amount of fluid Monya has lost
A. 0.3 L
B. 1.5 L
C. 2.0 L
D. 3.5 L
Medical Surgical Answer C. One liter of fluid generally weighs 2.2 pounds. A 4.5-pound weight loss equals about 2L.
Nurse Jessa is informed that the shift of body fluids compared with Intravenous administration of albumin happens in the process of
C. Active transport
Medical Surgical Answer A. Osmosis is the passage of fluid from an area of lesser solute concentration to an area of greater solute concentration.
Robert a 42-year-old patient with a fractured right tibia has a leg cast and he is going with crutches to ambulate. Nurse Marilou assess for which sign and symptom that symbolizes complication associated with crutch walking?
A.Left leg discomfort
B. Weak biceps brachii
C. Triceps muscle spasm
D. Forearm weakness
Medical Surgical Answer D. Forearm muscle weakness is a likely sign of radial nerve injury generated by crutch pressure on the axillae.
Which of the following observations should the nurse instruct the neutropenic patient and his family to avoid?
A. Performing oral hygiene after every meal
B. Using suppositories or enemas
C. Performing perineal hygiene after each bowel movement
D. Using a filter mask
Medical Surgical Answer B. Neutropenic patient is at risk for infection particularly bacterial infection of the gastrointestinal and respiratory tract.
Nclex nursing question and rationale related to fundamental nursing.
A female patient is encountering a painful and rigid abdomen and is diagnosed with a perforated peptic ulcer. The operation has been scheduled and a nasogastric tube is included. The nurse should place the patient before surgery in
A. Sims position
B. Supine position
C. Semi-fowlers position
D. Dorsal recumbent position
Medical Surgical Answer C. Semi-fowler’s position will limit the emptied stomach contents in the lower part of the abdominal cavity.
Which nursing intervention guarantees an adequate ventilating shift after surgery?
A. Remove the airway only when the patient is fully conscious
B. Assess for hypoventilation by auscultating the lungs
C. Position client laterally with the neck extended
D. Maintain humidified oxygen via nasal cannula
Medical Surgical Answer C. Positioning the patient sideways with the neck extended does not prevent the airway so that drainage of secretions and oxygen and carbon dioxide exchange can happen.
Aries who have experienced thoracic surgery have a chest tube attached to a water-seal drainage system connected to suction. The appearance of extreme bubbling is known in the water-seal chamber, the nurse should
A. “Strip” the chest tube catheter
B. Check the system for air leaks
C. Recognize the system is functioning correctly
D. Decrease the amount of suction pressure
Medical Surgical Answer B. Excessive bubbling means an air leak that must be eliminated to permit lung expansion.
A patient who has been diagnosed with hypertension is being developed to restrict intake of sodium. The nurse would know that the teachings are useful if the patient states that
A. I can eat celery sticks and carrots
B. I can eat broiled scallops
C. I can eat shredded wheat cereal
D. I can eat spaghetti on rye bread
Medical Surgical Answer C. Wheat cereal has a low sodium content.