Med Surg Test 1 NCLEX Style Questions {ALREADY GRADED A+ } NEWEST VERSION

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Med Surg Test 1 NCLEX Style Questions

{ALREADY GRADED A+ } NEWEST VERSION

• A client admitted to the cardiothoracic surgical intensive care unit after cardiac

bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to determine patency of the client's arterial line? A. Blood pressure B. Capillary refill and pulse C. Neurologic function

D. Questioning the client about the pain level at the site Correct Answer: B

• The nurse who is starting the shift finds a client with an IV that is leaking all over the

bed linens. What does the nurse do initially? A. Assess the insertion site. B. Check connections. C. Check the infusion rate. D. Discontinue the IV and start another. Correct

Answer: A

• A client who is receiving intravenous antibiotic treatments every 6 hours has an

intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take? A. Change the set immediately. B. Change the set in about 4 hours. C. Change the set in the next 12 to 24 hours. D. Nothing; the set is for long-term use. Correct Answer: B

• A 22-year-old client is seen in the emergency department (ED) with acute right lower

quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's

intravenous solution? A. 24 B. 22 C. 18 D. 14 Correct Answer: C

• A client admitted to the intensive care unit is expected to remain for 3 weeks. The

nurse has orders to start an IV. Which vascular access device is best for this client? A.Midline catheter B. Peripherally inserted central catheter (PICC) C. Short peripheral

catheter D. Tunneled central catheter Correct Answer: A

• The nurse is admitting clients to the same-day surgery unit. Which insertion site for

routine peripheral venous catheters does the nurse choose most often? A. Back of the hand for an older adult B. Cephalic vein of the forearm C. Lower arm on the side of a radical

mastectomy D. Subclavian vein Correct Answer: B

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• The nurse is teaching a hospitalized client who is being discharged about how to

care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education? A. "I can continue my 20-mile running schedule as I have for the past 10 years." B. "I can still go about my normal activities of daily living." C."I have less chance of getting an infection because the line is not in my hand." Correct

Answer: A

• A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new

IV' without a needle? That seems expensive." How does the nurse respond? A. "OSHA, a government agency, requires us to use this new type of IV." B. "These systems are designed to save time, not money." C. "They minimize health care workers' exposure to

contaminated needles." Correct Answer: C

• A client is to receive an IV solution of 5?xtrose and 0.45% normal saline at 125

mL/hr. Which system provides the safest method for the nurse to accurately administer this solution? A. Controller B. Glass container C. Infusion pump D. Syringe

pump Correct Answer: C

• The nurse checking an IV fluid order questions its accuracy. What does the nurse

do first? A. Asks the charge nurse about the order B. Contacts the health care provider who ordered it C. Contacts the pharmacy for clarification D. Starts the fluid as ordered, with

plans to check it later Correct Answer: B

• Which statement is true about the special needs of older adults receiving IV

therapy? A. Placement of the catheter on the back of the client's dominant hand is preferred. B. Skin integrity can be compromised easily by the application of tape or dressings. C. To avoid rolling the veins, a greater angle of 25 degrees between the skin and the catheter will improve success with venipuncture. D. When the catheter is inserted into

the forearm, excess hair should be shaved before insertion. Correct Answer: B

• A client is being admitted to the burn unit from another hospital. The client has an

intraosseous IV that was started 2 days ago, according to the client's medical record.What does the admitting nurse do first? A. Anticipate an order to discontinue the intraosseous IV and start an epidural IV. B. Call the previous hospital to verify the date. C.Immediately discontinue the intraosseous IV. D. Nothing; this is a long-term treatment.

Correct Answer: A

• The nurse is to administer a unit of whole blood to a postoperative client. What

does the nurse do to ensure the safety of the blood transfusion? A. Asks the client to both say and spell his or her full name before starting the blood transfusion B. Ensures that

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another qualified health care professional checks the unit before administering C. Checks the blood identification numbers with the laboratory technician at the blood bank at the time it is dispensed D. Makes certain that an IV solution of 0.9% normal saline is infusing

into the client before starting the unit Correct Answer: B

• The nurse is administering a drug to a client through an implanted port. Before

giving the medication, what does the nurse do to ensure safety? A. Administer 5 mL of a heparinized solution. B. Check for blood return. C. Flush the port with 10 mL of normal

saline. D. Palpate the port for stability. Correct Answer: B

• A client who takes corticosteroids daily for rheumatoid arthritis requires insertion

of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does the nurse teach the new graduate nurse to use for this client? A. Midline catheter B.Nontunneled percutaneous central catheter C. Peripherally inserted central catheter D.

Short peripheral catheter Correct Answer: A

• When flushing a client's central line with normal saline, the nurse feels resistance.

Which action does the nurse take first? A. Decrease the pressure being used to flush the line. B. Obtain a 10-mL syringe and reattempt flushing the line. C. Stop flushing and try to aspirate blood from the line. D. Use "push-pull" pressure applied to the syringe while

flushing the line. Correct Answer: C

• A severely dehydrated client requires a rapid infusion of normal saline and needs a

midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task? A. RN who is certified in administration of chemotherapy medications B. RN with 2 years of experience in the ED skilled at short peripheral catheters C. RN with 10 years of experience on a medical-surgical unit D. RN

with certified registered nurse infusion (CRNI) certification Correct Answer: D

• The nurse is inserting a peripheral intravenous (IV) catheter. Which client

statement is of greatest concern during this procedure? A. "I hate having IVs started." B."It hurts when you are inserting the line." C. "My hand tingles when you poke me." D. "My IV

lines never last very long." Correct Answer: C

• A 70-year-old client with severe dehydration is ordered an infusion of an isotonic

solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first? A. Assess the midline IV insertion site. B. Have the client cough and deep-breathe. C.Notify the health care provider about the crackles. D. Slow the rate of the IV infusion.

Correct Answer: D

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• The nurse is documenting peripheral venous catheter insertion for a client. What

does the nurse include in the note? (Select all that apply.) A. Client's name and hospital number B. Client's response to the insertion C. Date and time inserted D. Type and size of device E. Type of dressing applied F. Vein used for insertion Correct Answer: B, C, D, E, F

• The nurse is starting a peripheral IV catheter on a recently admitted client. What

actions does the nurse perform before insertion of the line? (Select all that apply.) A.Apply povidone-iodine to clean skin, dry for 2 minutes. B. Clean the skin around the site. C.Prepare the skin with 70% alcohol or chlorhexidine. D. Shave the hair around the area of insertion. E. Wear clean gloves and touch the site only with fingertips after applying

antiseptics. Correct Answer: A, B, C

• The nurse is revising an agency's recommended central line catheter-related

bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication? (Select all that apply.) A. During insertion, draping the area around the site with a sterile barrier B. Immediately removing the VAD when it is no longer needed C. Making certain that observers of the insertion are instructed to look away

• Thorough hand hygiene before insertion E. Using chlorhexidine for skin disinfection

Correct Answer: B, D, E

• Colostomy surgery is categorized as what type of surgery? A. Cosmetic B. Curative

C. Diagnostic D. Palliative Correct Answer: D

• In going through the preoperative checklist, the nurse notices that the client's

armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? A. Call admissions. B.Cancel the surgery. C. Contact the surgeon. D. Talk to the operating team. Correct Answer: D

• As the nurse obtains the informed consent, the client asks, "Now what exactly are

they going to do to me?" What is the nurse's response? A. Contact the anesthesiologist.

• Contact the surgeon. C. Explain the procedure. D. Have the client sign the form. Correct

Answer: B

• The nurse is educating a client who is about to undergo cardiac surgery with

general anesthesia. Which statement by the client indicates the need for further instruction? A. "I will wake up with a tube in my throat." B. "I will have a bandage on my chest." C. "My family will not be able to see me right away." D. "Pain medication will take

away my pain." Correct Answer: D

• An older client's adult child tells the nurse that the client does not want life

support. What does the nurse do first? A. Call the legal department to draft the