Take time to answer this 50-item exam that will test your knowledge about Medical-Surgical Nursing. Questions are from Cardiovascular Nursing, Coronary Care Unit (CCU), and Tracheostomy Care. If you are taking the board examination or NCLEX, then this practice exam is right for you.
We also recommend you to try and answer all exams on our NCLEX page!
EXAM TIP: Manage your free time wisely. Create moments that are fun and relaxing. Invite your friends over and go for a walk or play a favorite video game. The specifics of what you do matter less than ensuring that you do not spend the week before your exams tense and anxious.
Perseverance is failing 19 times and succeeding the 20th.
― Julie Andrews
Topics or concepts included in this exam are:
- Cardiovascular Nursing
- Coronary Care Unit (CCU)
- Tracheostomy Care
Follow the guidelines below to make the most out of this exam:
- Read each question carefully and choose the best answer.
- You are given one minute per question. Spend your time wisely!
- Answers and rationales (if any) are given below. Be sure to read them.
- If you need more clarifications, please direct them to the comments section.
In Exam Mode: All questions are shown but the results, answers, and rationales (if any) will only be given after you’ve finished the quiz. You are given 1 minute per question.
NCLEX Practice Exam 18 (50 Questions)
Practice Mode: This is an interactive version of the Text Mode. All questions are given on a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.
NCLEX Practice Exam 18 (50 Questions)
In Text Mode: All questions and answers are given for reading and answering at your own pace. You can also copy this exam and make a printout.
Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. He presented in the ER with a typical description of pain associated with an MI, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened.
1. The nurse is aware of several important tasks that should all be done immediately in order to give Mr. Duffy the care he needs. Which of the following nursing interventions will relieve his current myocardial ischemia?
A. Stool softeners, rest
B. O2 therapy, analgesia
C. Reassurance, cardiac monitoring
D. Adequate fluid intake, low-fat diet
2. During the first three days that Mr. Duffy is in the CCU, a number of diagnostic blood tests are obtained. Which of the following patterns of cardiac enzyme elevation are most common following an MI?
A. SGOT, CK, and LDH are all elevated immediately.
B. SGOT rises 4-6 hours after infarction with CK and LDH rising slowly 24 hours later.
C. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the LDH (peaks 3-4 days).
D. CK peaks first and remains elevated for 1 to 2 weeks.
3. On his second day in CCU, Mr. Duffy suffers a life-threatening cardiac arrhythmia. Considering his diagnosis, which is the most probable arrhythmia?
A. atrial tachycardia
B. ventricular fibrillation
C. atrial fibrillation
D. heart block
4. Mr. Duffy is placed on digitalis on discharge from the hospital. The nurse planning with him for his discharge should educate him as to the purpose and actions of his new medication. What should she or he teach Mr. Duffy to do at home to monitor his reaction to this medication?
A. take his blood pressure
B. take his radial pulse for one minute
C. check his serum potassium (K) level
D. weigh himself every day
5. You decide to discuss glaucoma prevention. Which of the following diagnostic tests should these clients request from their care provider?
A. fluorescein stain
B. Snellen’s test
D. slit lamp
6. You also explain common eye changes associated with aging. One of these is presbyopia, which is:
A. Refractive error that prevents light rays from coming to a single focus on the retina.
B. Poor distant vision
C. Poor near vision
D. A gradual lessening of the power of accommodation
7. Some of the diabetic clients are interested in understanding what is visualized during funduscopic examination. During your discussion, you describe the macular area as:
A. Head of the optic nerve, seen on the nasal side of the field, lighter in color than the retina.
B. The area of central vision, seen on the temporal side of the optic disc, which is quite avascular.
C. Area where the central retinal artery and vein appear on the retina.
D. Reddish orange in color, sometimes stippled.
8. One of the clients has noted a raised yellow plaque on the nasal side of the conjunctiva. You explain that this is called:
A. A pinguecula, which is normal slightly raised fatty structure under the conjunctiva that may gradually increase with age.
B. Icterus, which may be due to liver disease.
C. A pterygium, which will interfere with vision.
D. Ciliary flush caused by congestion of the ciliary artery.
9. You know that all but one of the following may eventually result in uremia. Which option is not implicated?
A. glomerular disease
B. uncontrolled hypertension
C. renal disease secondary to drugs, toxins, infections, or radiations
D. all of the above
10. You did the initial assessment on Mr. Kaplan when he came to your unit. What classical signs and symptoms did you note?
A. fruity-smelling breath.
B. Weakness, anorexia, pruritus
C. Polyuria, polydipsia, polyphagia
D. Ruddy complexion
11. Numerous drugs have been used on Mr. Kaplan in an attempt to stabilize him. Regarding his diagnosis and management of his drugs, you know that:
A. The half-life of many drugs is decreased in uremia; thus dosage may have to be increased to be effective.
B. Drug toxicity is a major concern in uremia; individualization of therapy and often a decrease in dose is essential.
C. Drug therapy is not usually affected by this diagnosis
D. Precautions should be taken with prescription drugs, but most OTC medications are safe for him to use.
12. The point of maximal impulse (PMI) is an important landmark in the cardiac exam. Which statement best describes the location of the PMI in the healthy adult?
A. Base of the heart, 5th intercostal space, 7-9 cm to the left of the midsternal line.
B. Base of the heart, 7th intercostal space, 7-9 cm to the left of the midsternal line.
C. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
D. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
13. During the physical examination of the well adult client, the health care provider auscultates the heart. When the stethoscope is placed on the 5th intercostal space along the left sternal border, which valve closure is best evaluated?
14. The pulmonic component of which heart sound is best heard at the 2nd LICS at the LSB?
15. The coronary arteries furnish blood supply to the myocardium. Which of the following is a true statement relative to the coronary circulation?
A. the right and left coronary arteries are the first of many branches off the ascending aorta
B. blood enters the right and left coronary arteries during systole only
C. the right coronary artery forms almost a complete circle around the heart, yet supplies only the right ventricle
D. the left coronary artery has two main branches, the left anterior descending and left circumflex: both supply the left ventricle
Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve.
16. Ms. Baker has decided to have surgical correction of her stenosed valve at this time because her subjective complaints of dyspnea, hemoptysis, orthopnea, and paroxysmal nocturnal dyspnea have become unmanageable. These complaints are probably due to:
17. On physical exam of Ms. Baker, several abnormal findings can be observed. Which of the following is not one of the usual objective findings associated with mitral stenosis?
A. low-pitched rumbling diastolic murmur, precordial thrill, and parasternal lift
B. small crepitant rales at the bases of the lungs
C. weak, irregular pulse, and peripheral and facial cyanosis in severe disease
D. chest x-ray shows left ventricular hypertrophy
18. You are seeing more clients with diagnoses of mitral valve prolapse. You know those mitral valve prolapse is usually a benign cardiac condition, but may be associated with atypical chest pain. This chest pain is probably caused by:
A. ventricular ischemia
B. dysfunction of the left ventricle
C. papillary muscle ischemia and dysfunction
D. cardiac arrhythmias
19. The most common lethal cancer in males between their fifth and seventh decades is:
A. cancer of the prostate
B. cancer of the lung
C. cancer of the pancreas
D. cancer of the bowel
20. Of the four basic cell types of lung cancer listed below, which is always associated with smoking?
B. squamous cell carcinoma (epidermoid)
C. undifferentiated carcinoma
D. bronchoalveolar carcinoma
A. Helping the client deal with depression secondary to the diagnosis and its treatment
B. Explaining that the reactions to chemotherapy are minimal
C. Careful observation of the IV site of the administration of the drugs
D. Careful attention to blood count results
22. Which of the following operative procedures of the thorax is paired with the correct definition?
A. Pneumonectomy: removal of the entire lung
B. Wedge resection: removal of one or more lobes of a lung
C. Decortication: removal of the ribs or sections of ribs
D. Thoracoplasty: removal of fibrous membrane that develops over visceral pleura as a result of emphysema
Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking mid-sentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA.
23. The episodes Mr. Liberatore has been experiencing are probably:
A. small cerebral hemorrhages
B. TIA’s or transient ischemic attacks
C. Secondary to hypoglycemia
D. Secondary to hyperglycemia
24. Mr. Liberatore suffers a left-sided CVA. He is right-handed. The nurse should expect:
A. left-sided paralysis
B. visual loss
C. no alterations in speech
D. no impairment of bladder function
25. Upper motor neuron disease may be manifested in which of the following clinical signs?
A. spastic paralysis, hyperreflexia, presence of Babinski reflex
B. flaccid paralysis, hyporeflexia
C. muscle atrophy, fasciculations
D. decreased or absent voluntary movement
26. During your assessment of Julie, she tells you all visual symptoms are gone but that she now has a severe pounding headache over her left eye. You suspect Julie may have:
A. a tension headache
B. the aura and headache of migraine
C. a brain tumor
D. a conversion reaction
27. You explain to Julie and her mother that migraine headaches are caused by:
A. an allergic response triggered by stress
B. dilation of cerebral arteries
C. persistent contraction of the muscles of the head, neck, and face
D. increased intracranial pressure
28. A thorough history reveals that hormonal changes associated with menstruation may have triggered Julie’s migraine attack. In investigating Julie’s history what factors would be least significant in migraine?
A. seasonal allergies
B. trigger foods such as alcohol, MSG, chocolate
C. family history of migraine
D. warning sign of onset, or aura
29. A client with muscle contraction headache will exhibit a pattern different for Julie’s. Which of the following is more compatible with tension headache?
A. severe aching pain behind both eyes
B. headache worse when bending over
C. a bandlike burning around the neck
D. feeling of tightness bitemporally, occipitally, or in the neck
Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified.
30. Glioma is an intracranial tumor. Which of the following statements about gliomas do you know to be false?
A. 50% of all intracranial tumors are gliomas
B. gliomas are usually benign
C. they grow rapidly and often cannot be totally excised from the surrounding tissue
D. most glioma victims die within a year after diagnosis
31. Acoustic neuromas produce symptoms of progressive nerve deafness, tinnitus, and vertigo due to pressure and eventual destruction of:
D. The ossicles
32. Whether Mr. Snyder’s tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include all of the following except:
33. Mr. Snyder is scheduled for surgery in the morning, and you are surprised to find out that there is no order for an enema. You assess the situation and conclude that the reason for this is:
A. Mr. Snyder has had some mental changes due to the tumor and would find an enema terribly traumatic
B. Straining to evacuate the enema might increase the intracranial pressure
C. Mr. Snyder had been on clear liquids and then was NPO for several days, so an enema is not necessary
D. An oversight and you call the physician to obtain the order
34. Postoperatively Mr. Snyder needs vigilant nursing care including all of the following except:
A. Keeping his head flat
B. Assessments q ½ hour of LOC, VS, pupillary responses, and mental status
C. Helping him avoid straining at stool, vomiting, or coughing
D. Providing a caring, supportive atmosphere for him and his family
35. Potential post intracranial surgery problems include all but which of the following?
A. increased ICP
B. extracranial hemorrhage
D. leakage of cerebrospinal fluid
Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.
36. You are responsible for teaching Mrs. Hogan deep breathing and coughing exercises. Why are these exercises especially important for Mrs. Hogan?
A. they prevent postoperative atelectasis and pneumonia
B. the incision in gallbladder surgery is in the subcostal area, which makes the client reluctant to take a deep breath and cough
C. because she is probably overweight and will be less willing to breathe, cough, and move postoperatively
37. On the morning of Mrs. Hogan’s planned cholecystectomy, she awakens with a pain in her right scapular area and thinks she slept in poor position. While doing the pre-op checklist, you note that on her routine CB report, her WBC is 15,000. Your responsibility at this point is:
A. to notify the surgeon at once; this is an elevated WBC indicating an inflammatory reaction
B. to record this finding in a prominent place on the pre-op checklist and in your preop notes
C. to call the laboratory for a STAT repeat WBC
D. None. This is not an unusual finding
38. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow the giving of the pre op medication?
A. have her void soon after receiving the medication
B. allow her family to be with her before the medication takes effect
C. bring her valuables to the nursing station
D. reinforce pre op teaching
39. Mrs. Hogan is transported to the recovery room following her cholecystectomy. As you continue to check her vital signs you note a continuing trend in Mrs. Hogan’s status: her BP is gradually dropping and her pulse rate is increasing. Your most appropriate nursing action is to:
A. order whole blood for Mrs. Hogan from the lab
B. increase IV fluid rate of infusion and place in trendelenburg position
C. immediately report signs of shock to the head nurse and/or surgeon and monitor VS closely
D. place in lateral sims position to facilitate breathing
40. Mrs. Hogan returns to your clinical unit following discharge from the recovery room. Her vital signs are stable and her family is with her. Postoperative leg exercises should be initiated:
A. after the physician writes the order
B. after the family leaves
C. if Mrs. Hogan will not be ambulated early
41. An oropharyngeal airway may:
A. Not be used in a conscious patient.
B. Cause airway obstruction.
C. Prevent a patient from biting and occluding an ET tube.
D. Be inserted “upside down” into the mouth opening and then rotated into the proper orientation as it is advanced into the mouth.
E. All of the above.
42. Endotracheal intubation:
A. Can be attempted for up to 2 minutes before you need to stop and ventilate the patient.
B. Reduces the risk of aspiration of gastric contents.
C. Should be performed with the neck flexed forward making the chin touch the chest.
D. Should be performed after a patient is found to be not breathing and two breaths have been given but before checking for a pulse.
43. When giving bag-valve mask ventilations:
A. Rapid and forceful ventilations are desirable so that adequate ventilation will be assured
B. Effective ventilations can always be given by one person.
C. Cricoid pressure may prevent gastric inflation during ventilations.
D. Tidal volumes will always be larger than when giving mouth to pocket mask ventilations.
44. If breath sounds are only heard on the right side after intubation:
A. Extubate, ventilate for 30 seconds then try again.
B. The patient probably only has one lung, the right.
C. You have intubated the stomach.
D. Pull the tube back and listen again.
45. An esophageal obturator airway (EOA):
A. Can be inserted by any person trained in ACLS.
B. Requires visualization of the trachea before insertion.
C. Never causes regurgitation.
D. Should not be used with a conscious person, pediatric patients, or patients who have swallowed caustic substances.
46. During an acute myocardial infarct (MI):
A. A patient may have a normal appearing ECG.
B. Chest pain will always be present.
C. A targeted history is rarely useful in making the diagnosis of MI.
D. The chest pain is rarely described as crushing, pressing, or heavy.
47. The most common lethal arrhythmia in the first hour of an MI is:
A. Pulseless Ventricular Tachycardia
C. Ventricular fibrillation
D. First-degree heart block.
48. Which of the following is true about verapamil?
A. It is used for wide-complex tachycardia.
B. It may cause a drop in blood pressure.
C. It is a first line drug for Pulseless Electrical Activity.
D. It is useful for treatment of severe hypotension.
A. Is always given for a heart rate less than 60 bpm.
B. Cannot be given via ET tube.
C. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of cardiac arrest.
D. When given IV, should always be given slowly.
50. Asystole should not be “defibrillated.”
C. Partially False
D. Partially True
Answers and Rationale
Here are the answers and rationale for this exam. Counter check your answers to those below and tell us your scores. If you have any disputes or need more clarification on a certain question, please direct them to the comments section.
1. Answer: B. O2 therapy, analgesia
- Option B: All the nursing interventions listed are important in the care of Mr. Duffy. However, relief of his pain will be best achieved by increasing the O2 content of the blood to his heart and relieving the spasm of coronary vessels.
2. Answer: C. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the LDH (peaks 3-4 days).
- Option C: Although the timing of initial elevation, peak elevation, and duration of elevation vary with sources, current literature favors option letter c.
3. Answer: B. ventricular fibrillation
- Option B: Ventricular irritability is common in the early post-MI period, which predisposes the client to ventricular arrhythmias.
- Options C and D: Heart block and atrial arrhythmias may also be seen post-MI but ventricular arrhythmias are more common.
4. Answer: B. take his radial pulse for one minute
- Option B: All options have some validity. However, option B relates best to the action of digitalis. If the pulse rate drops below 60 or is markedly irregular, the digitalis should be held and the physician consulted.
- Option A: Blood pressure measurement is also helpful; providing the client has the right size cuff and he or she and/or significant other understand the technique and can interpret the results meaningfully.
- Option C: Serum potassium levels should be monitored periodically in clients on digitalis and diuretics, as potassium balance is essential for prevention of arrhythmias. However, the client cannot do this at home.
- Option D: Daily weights may make the client alert to fluid accumulation, an early sign of CHF.
5. Answer: C. tonometry
- Option A: This is most often used to detect corneal lesions;
- Option B: This is a test for visual acuity;
- Option D: This is used to focus on layers of the cornea and lens looking for opacities and inflammation.
6. Answer: D. A gradual lessening of the power of accommodation
- Option A: This defines astigmatism.
- Option B: This defines myopia.
- Option C: This defines hyperopia.
7. Answer: B. The area of central vision, seen on the temporal side of the optic disc, which is quite avascular.
- Options A and C: These refer to the optic disc.
- Option D: This describes the color of the retina.
8. Answer: A. A pinguecula, which is normal slightly raised fatty structure under the conjunctiva that may gradually increase with age.
- Option A: Correct by definition.
9. Answer: D. all of the above
- Options A, B and C: These are potential causes of renal damage and eventually renal failure. Individuals can live very well with only one healthy kidney.
10. Answer: B. Weakness, anorexia, pruritus
- Option B: Weakness and anorexia are due to progressive renal damage; pruritus is secondary to presence of urea in the perspiration.
- Option A: Fruity-smelling breath is found in diabetic ketoacidosis.
- Option C: Polyuria, polydipsia, polyphagia are signs of DM and early diabetic ketoacidosis. Oliguria is seen in chronic renal failure.
- Option D: The skin is more sallow or brown as renal failure continues.
11. Answer: B. Drug toxicity is a major concern in uremia; individualization of therapy and often a decrease in dose is essential.
- Option B: Metabolic changes and alterations in excretion put the client with uremia at risk for development of toxicity to any drug. Thus alteration in drug schedule and dosage is necessary for safe care.
12. Answer: C. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
- Option C: The PMI is the impulse at the apex of the heart caused by the beginning of ventricular systole. It is generally located in the 5th left ICS, 7-9 cm from the MSL or at, or just medial to, the MCL.
13. Answer: A. Tricuspid
- Option A: The sound created by closure of the tricuspid valve is heard at the 5th LICS at the LSB.
- Option B: Pulmonic closure is best heard at the 2nd LICS, LSB.
- Option C: Aortic closure is best heard at the 2nd RICS, RSB.
- Option D: Mitral valve closure is best heard at the PMI landmark (apex)
14. Answer: B. S2
- Option A: S1 is caused by mitral and tricuspid valve closure;
- Option B: S2 is caused by the aortic and pulmonic valve closure;
- Options C and D: S3 and S4 are generally considered abnormal heart sounds in adults and are best heard at the apex.
15. Answer: D. the left coronary artery has two main branches, the left anterior descending and left circumflex: both supply the left ventricle
- Option D: The right and left coronary arteries are the only branches off the ascending aorta; blood enters these arteries mainly during diastole; the right coronary artery also often supplies a small portion of the left ventricle.
16. Answer: C. pulmonary hypertension
- Option C: Pulmonary congestion secondary to left atrial hypertrophy causes these symptoms.
- Option D: The left ventricle does not hypertrophy in mitral stenosis.
- Option B: Right heart failure would cause abdominal discomfort and peripheral edema.
- Option A: Pericardial thickening does not occur.
17. Answer: D. chest x-ray showed left ventricular hypertrophy
- Option D: Evidence of left atrial enlargement may be seen on chest x-ray and ECG.
- Options A, B, and C: The other objective findings may be seen in chronic mitral stenosis with episodes of atrial fibrillation and right heart failure.
18. Answer: C. papillary muscle ischemia and dysfunction
- Option A: Ventricular ischemia does not occur with prolapsed mitral valve.
- Options B and D: These are not painful conditions in themselves.
19. Answer: B. cancer of the lung
- Option B: The incidence of lung cancer is also rapidly rising in women.
20. Answer: B. squamous cell carcinoma (epidermoid)
- Option B: Textbooks of medicine and nursing classify primary pulmonary carcinoma somewhat differently. However most agree that squamous cell or epidermoid carcinoma is always associated with cigarette smoking.
21. Answer: B. Explaining that the reactions to chemotherapy are minimal
- Option B: There are numerous severe reactions to chemotherapy such as stomatitis, alopecia, bone marrow depression, nausea and vomiting.
- Options A, C, and D: These are important nursing considerations.
22. Answer: A. Pneumonectomy: removal of the entire lung
- Option B: Wedge resection is the removal of part of a segment of the lung.
- Option C: Decortication is the removal of a fibrous membrane that develops over the visceral pleura.
- Option D: Thoracoplasty is the removal of ribs or sections of ribs.
23. Answer: B. TIA’s or transient ischemic attacks
- Option B: A TIA is a temporary reduction in blood flow to the brain, manifesting itself in symptoms like those Mr. Liberatore experiences.
- Options C and D: Although hypoglycemia and hyperglycemia can cause some drowsiness and/or disorientation, the episodes Mr. Liberatore experiences fit the pattern of TIA because of his quick recovery with no sequelae and no treatment.
24. Answer: B. visual loss
- Option B: Visual field loss is a common side effect of CVA. In right-handed persons the speech center (Broca’s area) is most commonly in the left brain.
- Option A: Because of the crossover of the motor fibers, a CVA in the left brain will produce a right-sided hemiplegia.
- Option C: Thus, Mr. Liberatore will probably have some speech disturbance and right-sided paralysis.
- Option D: Often bladder control is diminished following CVA.
25. Answer: A. spastic paralysis, hyperreflexia, presence of babinski reflex
- Options B, C, and D: These describe lower motor neuron disease.
26. Answer: B. the aura and headache of migraine
- Option B: The warning sign or aura is associated with migraine although not everyone with migrane has an aura. Migraine is usually unilateral and described as pounding. Julie’s symptoms are most compatible with migraine.
27. Answer: B. dilation of cerebral arteries
- Option B: The vascular theory best explains migraine and often diagnosis is confirmed through a trial of ergotamine, which constricts the dilated, pulsating vessels.
28. Answer: A. seasonal allergies
- Option A: Sinus headache often accompanies seasonal allergies.
- Option C: Many factors may contribute to migraine. Usually the client comes from a family that has migrated, which may have been called “sick headache” due to accompanying nausea and vomiting.
- Option D: Often there is an aura.
- Option B: Stress, diet, hormonal changes, and fatigue may all be implicated in migraine.
29. Answer: D. feeling of tightness bitemporally, occipitally, or in the neck
- Options A and B: These describe sinus headache; option A may also be compatible with headache secondary to eyestrain; option B is also compatible with migraine.
- Option C: This would be correct if stated a bandlike “tightness” around the head instead of “burning”
30. Answer: B. gliomas are usually benign
- Option B: Gliomas are malignant tumors.
31. Answer: C. CN8
- Option C: CN8, the acoustic nerve or vestibulocochlear nerve, is the most commonly affected CN in acoustic neuroma.
- Options A and B: As the tumor progresses, CN5 and CN7 can be affected.
32. Answer: D. increased pulse rate, drop in blood pressure
- Option D: As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to rise, vital signs may vary considerably.
33. Answer: B. Straining to evacuate the enema might increase the intracranial pressure
- Option B: Any activity that increases ICP could possibly cause brain herniation. Straining to expel an enema is one example of how the increased ICP can be further aggravated.
34. Answer: A. Keeping his head flat
- Option A: Postoperatively clients who have undergone craniotomy usually have their heads elevated to decrease local edema and also decrease ICP.
35. Answer: B. extracranial hemorrhage
- Option B: Hemorrhage is predominantly intracranial, although there may be some bloody drainage on external dressings.
- Option A: Increased ICP may result from hemorrhage or edema.
- Option D: CSF leakage may result in meningitis.
- Option C: Seizures are another postoperative concern.
36. Answer: B. the incision in gallbladder surgery is in the subcostal area, which makes the client reluctant to take a deep breath and cough
- Option A: This is true: the rationale for deep breathing and coughing is to prevent postoperative pulmonary complications such as pneumonia and atelectasis.
- Option B: The risk of pulmonary problems is somewhat increased in clients with biliary tract surgery because of their high abdominal incisions.
- Option C: This assumes the stereotype of the person with gallbladder disease – fair, fat and forty – which is not necessarily the case. Splinting the incision with the hands or a pillow is very helpful in controlling the pain during coughing.
37. Answer: A. to notify the surgeon at once; this is an elevated WBC indicating an inflammatory reaction
- Option A: A WBC count of 15,000 probably indicates acute cholecystitis, especially considering Mrs. Hogan’s new pain. The surgeon should be called as he/she may treat the acute attack medically and delay the surgery for several days, weeks, or months.
38. Answer: B. allow her family to be with her before the medication takes effect
- Options A, C, and D: These should all take place prior to administration of the drugs. The family may also be involved earlier but certainly should have that time immediately after the medication is given and before it takes full effect to be with their loved ones. Good planning of nursing care can facilitate this.
39. Answer: C. immediately report signs of shock to the head nurse and/or surgeon and monitor VS closely
- Option C: These are signs of impending shock, which may be true shock or a reaction to anesthesia. Your most appropriate action is to report your findings quickly and accurately and to continue to monitor Mrs. Hogan carefully.
40. Answer: D. stat
- Option D: Leg exercises, deep breathing and coughing, moving, and turning should begin as soon as the client’s condition is stable.
- Option B: The family can be extremely helpful in encouraging the client to do them, in supporting the incision, etc.
- Option A: A doctor’s order is not necessary – this is a nursing responsibility.
41. Answer: E. All of the above.
- Option E: An oropharyngeal airway should be used in an unconscious patient. In a conscious or semiconscious patient, its use may cause laryngospasm or vomiting. An oropharyngeal airway that is too long may push the epiglottis into a position that obstructs the airway. It is often used with an ETT to prevent biting and occlusion. It is usually inserted upside down and then rotated into the correct orientation as it approaches full insertion.
42. Answer: B. Reduces the risk of aspiration of gastric contents.
- Option A: This is wrong because an attempt should not last longer than 30 seconds.
- Option C: Unless the injury is suspected the neck should be slightly flexed and the head extended the ‘sniffing position’.
- Option D: After securing an airway and successfully ventilating the patient with two breaths you should then check for a pulse. If there is no pulse begin chest compressions. Intubation is part of the secondary survey ABC’s.
43. Answer: C. Cricoid pressure may prevent gastric inflation during ventilations.
- Option C: Cricoid pressure may prevent gastric inflation during ventilations and may also prevent regurgitation by compressing the esophagus.
- Option A: This may cause gastric insufflation thus increasing the risk for regurgitation and aspiration. With adults, breaths should be delivered slowly and steadily over 2 seconds.
- Option B: Effective ventilation using bag-valve mask usually requires at least two well-trained rescuers.
- Option D: A frequent problem with bag-valve mask ventilations is the inability to provide adequate tidal volumes.
44. Answer: D. Pull the tube back and listen again.
- Option D: Most likely you have a right mainstem bronchus intubation. Pulling the tube back a few centimeters may be all you need to do.
45. Answer: D. Should not be used with a conscious person, pediatric patients, or patients who have swallowed caustic substances.
- Option A: EOA insertion should only be attempted by persons highly proficient in their use.
- Option B: Moreover, since visualization is not required the EOA may be very useful in patient’s when intubation is contraindicated or not possible.
- Option C: Vomiting and aspiration are possible complications of insertion and removal of an EOA.
46. Answer: A. A patient may have a normal appearing ECG.
- Option A: Which is why a normal ECG alone cannot be relied upon to rule out an MI.
- Option B: Chest pain does not always accompany an MI. This is especially true of patients with diabetes.
- Option C: A targeted history is often crucial in making the diagnosis of acute MI.
- Option D: The chest pain associated with an acute MI is often described as heavy, crushing pressure, ‘like an elephant sitting on my chest.’
47. Answer: C. Ventricular fibrillation
- Option C: Moreover, ventricular fibrillation is 15 times more likely to occur during the first hour of an acute MI than the following twelve hours which is why it is vital to decrease the delay between onset of chest pain and arrival at a medical facility. First-degree heart block is not a lethal arrhythmia.
48. Answer: B. It may cause a drop in blood pressure.
- Option B: Verapamil usually decreases blood pressure, which is why it is sometimes used as an antihypertensive agent.
- Option A: Verapamil may be lethal if given to a patient with V-tach, therefore it should not be given to a tachycardic patient with a wide complex QRS.
- Option C: Verapamil is a calcium channel blocker and may actually cause PEA if given too fast intravenously or if given in excessive amounts. The specific antidote for overdose from verapamil, or any other calcium channel blocker, is calcium.
- Option D: Verapamil may cause hypotension.
49. Answer: C. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of cardiac arrest.
- Option A: Only give atropine for symptomatic bradycardias. Many physically fit people have resting heart rates less than 60 bpm.
- Option B: Atropine may be given via an endotracheal tube.
- Option D: Administering atropine slowly may cause paradoxical bradycardia.
50. Answer: A. True
- Option A: Asystole is not amenable to correction by defibrillation. But there is a school of thought that holds that asystole should be treated like V-fib, i.e., defibrillate it. The thinking is that human error or equipment malfunction may result in misidentifying V-fib as asystole. Missing V-fib can have deadly consequences for the patient because V-fib is highly amenable to correction by defibrillation.
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