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NCLEX Practice Test for Skin and Integumentary Diseases Part 2 Answers and Rationale

admin — Tue, 06 Jul 2010 06:41:47 +0000

1.    Answer C. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.
2.    Answer D. During the acute phase of a burn, the nurse should assess the client’s circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client’s lifestyle and alcohol and tobacco use may be obtained later when the client’s condition has stabilized.
3.    Answer C. When caring for a client, the nurse must first wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed.
4.    Answer C. A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing.
5.    Answer D. As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn’t likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn’t alter physical mobility. A client with burns on the lower portions of both legs isn’t likely to have femoral artery occlusion.
6.    Answer A. In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge.
7.    Answer A. Psoriasis occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups. A genetic predisposition has been recognized in some cases. Emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbations.
8.    Answer C. Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk, as presented in the options, is the decreased sensory perception. Options A, B, and D identify physiological conditions, which are the risk priorities.
9.    Answer B. Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.
10.    Answer D. Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.
11.    Answer C. With the classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood’s light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.
12.    Answer A. The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because the lesions follow nerve pathways, they do not cross the midline of the body. Options B, C, and D are incorrect descriptions of herpes zoster.
13.    Answer A. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.
14.    Answer D. Cryosurgery involves the local application of liquid nitrogen to isolated lesions and causes cell death and tissue destruction. The nurse informs the client that swelling and increased tenderness of the treated area can occur when the skin thaws. Tissue freezing is followed by hemorrhagic blister formation in 1 to 2 days. The nurse instructs the client to clean the treatment site with hydrogen peroxide to prevent secondary infection. A topical antibiotic also may be prescribed. Application of a warm, damp washcloth intermittently to the site will provide relief from any discomfort. Alcohol-soaked dressings will cause irritation. The client does not need to avoid showering.
15.    Answer A. Paronychia, or infection around the nail, is characterized by red, shiny skin, often associated with painful swelling. These infections frequently result from trauma, picking at the nail, or disorders such as dermatitis. Often, these become secondarily infected with bacteria or fungus, which later involves the nail. Warm soaks three or four times a day may reduce pain and pressure; however, incision and drainage of the inflamed site frequently are required. Options B, C, and D are incorrect.
16.    Answer D. Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options A, B, and C are incorrect.
17.    Answer D. In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.
18.    Answer B. The actual cause of acne is unknown. Oily skin or the consumption of foods such as chocolate, nuts, or fatty foods are not causes of acne. Exacerbations that coincide with the menstrual cycle result from hormonal activity. Heat, humidity, and excessive perspiration may play a role in exacerbating acne but does not cause it.
19.    Answer D. Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. The outdoor construction worker would fit into a high-risk category for the development of an integumentary disorder. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. Immobility and lack of nutrition would increase the older person’s risk but the older client is not at as high a risk as the outdoor construction worker. The physical education teacher is at low or no risk of developing an integumentary problem.
20.    Answer B. Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation. Preoperative medication is not necessary with this procedure.
21.     Answer D. For effective tissue healing, adequate intake of protein, vitamin A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high protein diet with plenty of fruits and vegetables to provide these nutrients. The bandage should be secure but not too tight to impede circulation to the area (needed for tissue repair). If the client’s foot feels cold, circulation is impaired, thus inhibiting wound healing.
22.    Answer A. To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.
23.    Answer C. Severe pressure like pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.
24.    Answer A. When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
25.    Answer B. A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client’s PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client’s rectal temperature isn’t significantly elevated and probably results from the fluid volume deficit.
26.    Answer C. Ecchymosis is a type of purpuric lesion and also is known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.
27.    Answer A. Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright red–colored lesion on the trunk or extremities. Spider angiomas have a bright red center with legs that radiate outward. These lesions commonly are seen in liver disease and vitamin B deficiency, although they occasionally can occur without underlying pathology. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Purpura results from hemorrhage into the skin.
28.    Answer D. Reticular skin lesions resemble a net in appearance. Annular lesions are ring-shaped, whereas linear lesions appear in a straight line. Arciform lesions are shaped like an arc.
29.    Answer D. An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia would be manifested by pallor of the skin. Cardiopulmonary disorders may lead to clubbing of the fingers.
30.    Answer C. E. coli normally is found in the intestines and constitutes a common source of infection of wounds and the urinary system. The other microbes listed are part of the normal flora of the skin.

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NCLEX Practice Test for Skin and Integumentary Diseases Part 2

admin — Sat, 03 Jul 2010 05:46:07 +0000

1.    Nurse Jay is performing wound care. Which of the following practices violates surgical asepsis?
a.    Holding sterile objects above the waist
b.    Considering a 1″ edge around the sterile field as being contaminated
c.    Pouring solution onto a sterile field cloth
d.    Opening the outermost flap of a sterile package away from the body

2.    During the acute phase of a burn, the nurse in-charge should assess which of the following?
a.    Client’s lifestyle
b.    Alcohol use
c.    Tobacco use
d.    Circulatory status

3.    Nurse Kate is changing a dressing and providing wound care. Which activity should she perform first?
a.    Assess the drainage in the dressing.
b.    Slowly remove the soiled dressing
c.    Wash hands thoroughly.
d.    Put on latex gloves.

4.    Nurse May is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?
a.    Turn and reposition the client at least once every 8 hours.
b.    Vigorously massage lotion into bony prominences.
c.    Post a turning schedule at the client’s bedside.
d.    Slide the client, rather than lifting, when turning.

5.    Nurse Jane formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?
a.    Related to fat emboli
b.    Related to infection
c.    Related to femoral artery occlusion
d.    Related to circumferential eschar

6.    The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment?
a.    Lips
b.    Sacrum
c.    Earlobes
d.    Back of the hands

7.    Which of the following individuals is least likely to be at risk of developing psoriasis?
a.    A 32 year-old-African American
b.    A woman experiencing menopause
c.    A client with a family history of the disorder
d.    An individual who has experienced a significant amount of emotional distress

8.    Which of the following clients would least likely be at risk of developing skin breakdown?
a.    A client incontinent of urine feces
b.    A client with chronic nutritional deficiencies
c.    A client with decreased sensory perception
d.    A client who is unable to move about and is confined to bed

9.    The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client?
a.    Cold compress to the affected area
b.    Warm compress to the affected area
c.    Intermittent heat lamp treatments four times daily
d.    Alternating hot and cold compresses continuously

10.    The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder?
a.    Clear, thin nail beds
b.    Red-purplish scaly lesions
c.    Oily skin and no episodes of pruritus
d.    Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions

11.    The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the male client’s chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test?
a.    Patch test
b.    Skin biopsy
c.    Culture of the lesion
d.    Woo’s light examination

12.    The nurse is assigned to care for a female client with herpes zoster (Shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?
a.    Clustered skin vesicles
b.    A generalized body rash
c.    Small blue-white spots with a red base
d.    A fiery red, edematous rash on the cheeks

13.    When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following?
a.    An irregular shaped lesion
b.    A small papule with a dry, rough scale
c.    A firm, nodular lesion topped with crust
d.    A pearly papule with a central crater and a waxy border

14.    The nurse prepares discharge instructions for a male client following cryosurgery for the treatment of a malignant skin lesion. Which of the following should the nurse include in the instruction?
a.    Avoid showering for 7 to 10 days
b.    Apply ice to the site to prevent discomfort
c.    Apply alcohol-soaked dressing twice a day
d.    Clean the site with hydrogen peroxide to prevent infection

15.    Nurse Carl reviews the client’s chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment?
a.    Red shiny skin around the nail bed
b.    White taut skin in the popliteal area
c.    White silvery patches on the elbows
d.    Swelling of the skin near the parotid gland

16.    A male client arrives at the emergency room and has experienced frostbites to the right hand. Which of the following would the nurse note on assessment of the client’s hand?
a.    A pink, edematous hand
b.    A fiery red skin with edema in the nail beds
c.    Black fingertips surrounded by an erythematous rash
d.    A white color to the skin, which is insensitive to touch

17.    The evening nurse reviews the nursing documentation in the male client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?
a.    Intact skin
b.    Full-thickness skin loss
c.    Exposed bone, tendon, or muscle
d.    Partial-thickness skin loss of the dermis

18.    Nurse Ivy is implementing a teaching plan to a group of adolescents regarding the causes of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder?
a.    “Acne is caused by oily skin”
b.    “The actual cause is not known”
c.    “Acne is caused by eating chocolate”
d.    “Acne is caused as a result of exposure to heat and humidity”

19.    The nurse is reviewing the health care record of a male clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder?
a.    An adolescent
b.    An older female
c.    A physical education teacher
d.    An outdoor construction worker

20.    A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is:
a.    “There is no pain associated with this procedure”
b.    “The local anesthetic may cause a burning or stinging sensation”
c.    A preoperative medication will be given so you will be sleeping and will not feel any pain”
d.    “There is some pain, but the physician will prescribe an opioid analgesic following the procedure”

21.     The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching?
a.    “I’ll limit my intake of protein.”
b.    “I’ll make sure that the bandage is wrapped tightly.”
c.    “My foot should feel cold.”
d.    “I’ll eat plenty of fruits and vegetables.”

22.    Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:
a.    range of motion.
b.    protein intake.
c.    going outdoors.
d.    fluid ingestion.

23.    Following a small-bowel resection, a male client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:
a.    erythema.
b.    leukocytosis.
c.    pressurelike pain.
d.    swelling.

24.    While in a skilled nursing facility, a female client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:
a.    “All family members will need to be treated.”
b.    “If someone develops symptoms, tell him to see a physician right away.”
c.    “Just be careful not to share linens and towels with family members.”
d.    “After you’re treated, family members won’t be at risk for contracting scabies.”

25.    The nurse is assessing a male client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
a.    Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg
b.    Urine output of 20 ml/hour
c.    White pulmonary secretions
d.    Rectal temperature of 100.6° F (38° C)

26.    A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms?
a.    Purpura
b.    Petechiae
c.    Ecchymosis
d.    Erythema

27.    An older client’s physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin?
a.    Cherry angioma
b.    Spider angioma
c.    Venous star
d.    Purpura

28.    A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions. The nurse expects that these lesions will appear to be:
a.    Ring-shaped
b.    Linear
c.    Shaped like an arc
d.    Net-like appearance

29.    A male client seen in an ambulatory clinic has a butterfly rash across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?
a.    Hyperthyroidism
b.    Perncious anemia
c.    Cardiopulmonary disorders
d.    Systemic lupus erythematosus (SLE)

30.    A female client with cellulites of the lower leg has had cultures done on the affected area. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin?
a.    Staphylococcus epidermidis
b.    Staphylococcus aureus
c.    Escherichia coli (E. coli)
d.    Candida albicans

Answers and Rationale

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NCLEX Practice Test for Skin and Integumentary Diseases Part 1 Answers and Rationale

admin — Thu, 01 Jul 2010 08:40:45 +0000

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1.    Answer A. When caring for a client with upper torso burns, the nurse’s primary goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. Option B isn’t appropriate because burns aren’t a disease. Option C and D may be appropriate, but don’t command a higher priority than option A because they don’t reflect immediately life-threatening problems.
2.    Answer A. Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.
3.    Answer C. Sunscreen should be applied even on overcast days, because the sun’s rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn’t guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun’s rays onto the skin.
4.    Answer D. The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client’s burns cover 36% of the body surface area.
5.    Answer A. Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body’s first line of defense. To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn’t remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.
6.    Answer A. A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don’t accompany psoriasis.
7.    Answer C. A potent topical corticosteroid may increase the client’s risk for injury because it may be absorbed percutaneously, causing the same adverse effects as systemic corticosteroids. Topical corticosteroids aren’t involved in significant drug interactions. These preparations cause vasoconstriction, not vasodilation. A potent topical corticosteroid rarely is prescribed for use on the face, neck, or intertriginous sites because application on these areas may lead to increased adverse effects.
8.    Answer A. Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature delivery. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.
9.    Answer B. The most significant adverse reactions to gentamicin and other aminoglycosides are ototoxicity (indicated by vertigo, tinnitus, and hearing loss) and nephrotoxicity (indicated by urinary cells or casts, oliguria, proteinuria, and reduced creatinine clearance). These adverse reactions are most common in elderly and dehydrated clients, those with renal impairment, and those receiving concomitant therapy with another potentially ototoxic or nephrotoxic drug. Gentamicin isn’t associated with aplastic anemia, cardiac arrhythmias, or seizures.
10.    Answer C. A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times a day for 7 days. Terconazole and tioconazole are used to treat vulvovaginal candidiasis. Sulconazole nitrate is used to treat tinea versicolor.
11.    Answer C. When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.
12.    Answer B. Rings or donuts aren’t to be used because they restrict circulation. Foam mattresses evenly distribute pressure. Gel pads redistribute with the client’s weight. The water bed also distributes pressure over the entire surface.
13.    Answer B. The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound. In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound. In the maturation phase, cells and vessels return to normal and the scab sloughs off.
14.    Answer A. In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn’t a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.
15.    Answer C. Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isn’t associated with palpitations, dizziness, or a metallic taste.
16.    Answer D. Intertrigo refers to irritation of opposing skin surfaces caused by friction. Spontaneously occurring wheals occur in hives. A fungus that enters the skin surface and causes infection is a dermatophyte. Inflammation of a hair follicle is called folliculitis.
17.    Answer A. The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.
18.    Answer D. Although many drugs are used to treat skin disorders, topical agents — not I.V. or oral agents — are the mainstay of treatment.
19.    Answer A. When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
20.    Answer B. Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. The client’s nails should be kept trimmed to avoid scratching; however, mitts aren’t necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo.
21.    Answer A. Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. None of the other options results from exercise
22.    Answer B. To prevent the spread of scabies in other hospitalized clients, the nurse should isolate the client’s bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client’s condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn’t require enteric precautions because the mites aren’t found on feces.
23.    Answer B. Applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin’s upper layer. Although emollients make the skin feel soft, this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient doesn’t prevent skin inflammation.
24.    Answer A. To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.
25.    Answer D. With a superficial partial thickness burn such as a solar burn (sunburn), the nurse’s main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.
26.    Answer B. To avoid burning and sloughing, the client must protect the graft from direct sunlight. The other three interventions are helpful to the client and his recovery but are less important.
27.    Answer B. Adults and children with gonorrhea may develop gonococcal conjunctivitis by touching the eyes with contaminated hands. The client should avoid sexual intercourse until treatment is completed, which usually takes 4 to 7 days, and a follow-up culture confirms that the infection has been eradicated. A client who doesn’t refrain from intercourse before treatment is completed should use a condom in addition to informing sex partners of the client’s health status and instructing them to wash well after intercourse. Meningitis and widespread CNS damage are potential complications of untreated syphilis, not gonorrhea.
28.    Answer D. To prevent eye discomfort, the client must protect the eyes for 48 hours after taking medication for photochemotherapy. Protecting the eyes for a shorter period increases the risk of eye injury.
29.    Answer C. A female client with genital herpes simplex is at increased risk for cervical cancer. Genital herpes simplex isn’t a risk factor for cancer of the ovaries, uterus, or vagina.
30.    Answer C. Applying direct pressure to an injury is the initial step in controlling bleeding. For severe or arterial bleeding, pressure point control can be used. Pressure points are those areas where large blood vessels can be compressed against bone: femoral, brachial, facial, carotid, and temporal artery sites. Elevation reduces the force of flow, but direct pressure is the first step. A tourniquet may further damage the injured extremity and should be avoided unless all other measures have failed.

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NCLEX Practice Test for Skin and Integumentary Diseases Part 1

admin — Sun, 27 Jun 2010 02:07:34 +0000

1.    When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?
a.    Ineffective airway clearance related to edema of the respiratory passages
b.    Impaired physical mobility related to the disease process
c.    Disturbed sleep pattern related to facility environment
d.    Risk for infection related to breaks in the skin

2.    In a female client with burns on the legs, which nursing intervention helps prevent contractures?
a.    Applying knee splints
b.    Elevating the foot of the bed
c.    Hyperextending the client’s palms
d.    Performing shoulder range-of-motion exercises

3.    A male client comes to the physician’s office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?
a.    “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”
b.    “Use a sunscreen with a sun protection factor of 6 or higher.”
c.    “Apply sunscreen even on overcast days.”
d.    “When at the beach, sit in the shade to prevent sunburn.”

4.    A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
a.    18%
b.    27%
c.    30%
d.    36%

5.    Which nursing intervention can help a client maintain healthy skin?
a.    Keep the client well hydrated.
b.    Avoid bathing the client with mild soap.
c.    Remove adhesive tape quickly from the skin.
d.    Recommend wearing tight-fitting clothes in hot weather.

6.    A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
a.    Scale
b.    Crust
c.    Ulcer
d.    Scar

7.    A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?
a.    Related to potential interactions between the topical corticosteroid and other prescribed drugs
b.    Related to vasodilatory effects of the topical corticosteroid
c.    Related to percutaneous absorption of the topical corticosteroid
d.    Related to topical corticosteroid application to the face, neck, and intertriginous sites

8.    A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
a.    During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.
b.    Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days
c.    Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms.
d.    A client with genital herpes lesions can have sexual contact but must use a condom.

9.    A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug?
a.    Aplastic anemia
b.    Ototoxicity
c.    Cardiac arrhythmias
d.    Seizures

10.    A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
a.    “Apply one applicator of terconazole intravaginally at bedtime for 7 days.”
b.    “Apply one applicator of tioconazole intravaginally at bedtime for 7 days.”
c.    “Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days.”
d.    “Apply sulconazole nitrate twice daily by massaging it gently into the lesions.”

11.    Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest How should the nurse apply this topical agent?
a.    With a circular motion, to enhance absorption
b.    With an upward motion, to increase blood supply to the affected area
c.    In long, even, outward, and downward strokes in the direction of hair growth
d.    In long, even, outward, and upward strokes in the direction opposite hair growth

12.    Nurse Meredith is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it’s meant to protect?
a.    Polyurethane foam mattress
b.    Ring or donut
c.    Gel flotation pad
d.    Water bed

13.    Nurse Rudolf documents the presence of a scab on a client’s deep wound. The nurse identifies this as which phase of wound healing?
a.    Inflammatory
b.    Migratory
c.    Proliferative
d.    Maturation

14.    In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?
a.    A urine output consistently above 100 ml/hour
b.    A weight gain of 4 lb (2 kg) in 24 hours
c.    Body temperature readings all within normal limits
d.    An electrocardiogram (ECG) showing no arrhythmias

15.    A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause:
a.    palpitations.
b.    dizziness.
c.    diarrhea.
d.    metallic taste.

16.    A female client sees a dermatologist for a skin problem. Later, the nurse reviews the client’s chart and notes that the chief complaint was intertrigo. This term refers to which condition?
a.    Spontaneously occurring wheals
b.    A fungus that enters the skin’s surface, causing infection
c.    Inflammation of a hair follicle
d.    Irritation of opposing skin surfaces caused by friction

17.    A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
a.    turn him frequently.
b.    perform passive range-of-motion (ROM) exercises.
c.    reduce the client’s fluid intake.
d.    encourage the client to use a footboard.

18.    A male client visits the physician’s office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe:
a.    an I.V. corticosteroid.
b.    an I.V. antibiotic.
c.    an oral antibiotic.
d.    a topical agent.

19.    While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:
a.    “All family members will need to be treated.”
b.    “If someone develops symptoms, tell him to see a physician right away.”
c.    “Just be careful not to share linens and towels with family members.”
d.    “After you’re treated, family members won’t be at risk for contracting scabies.”

20.    When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care?
a.    Placing mitts on the client’s hands
b.    Administering systemic antibiotics as prescribed
c.    Applying topical antibiotics as prescribed
d.    Continuing to administer antibiotics for 21 days as prescribed

21.    A female client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise because it may:
a.    dislodge the autografts.
b.    increase edema in the arms.
c.    increase the amount of scarring.
d.    decrease circulation to the fingers.

22.    Nurse Troy discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:
a.    wash hands, apply a pediculicide to the client’s scalp, and remove any observable mites.
b.    isolate the client’s bed linens until the client is no longer infectious.
c.    notify the nurse in the day surgery unit of a potential scabies outbreak.
d.    place the client on enteric precautions.

23.    Dr. Smith prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
a.    “This makes the skin feel soft.”
b.    “This prevents evaporation of water from the hydrated epidermis.”
c.    “This minimizes cracking of the dermis.”
d.    “This prevents inflammation of the skin.”

24.    Following a full-thickness (third-degree) burn of his left arm, a female client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:
a.    range of motion.
b.    protein intake.
c.    going outdoors.
d.    fluid ingestion.

25.    A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:
a.    fluid resuscitation.
b.    infection.
c.    body image.
d.    pain management.

26.    The nurse is providing home care instructions to a client who has recently had a skin graft. It’s most important that the client remember to:
a.    use cosmetic camouflage techniques.
b.    protect the graft from direct sunlight.
c.    continue physical therapy.
d.    apply lubricating lotion to the graft site.

27.    A male client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction?
a.    “Avoid sexual intercourse until you’ve completed treatment, which takes 14 to 21 days.”
b.    “Wash your hands thoroughly to avoid transferring the infection to your eyes.”
c.    “If you have intercourse before treatment ends, tell sexual partners of your status and have them wash well after intercourse.”
d.    “If you don’t get treatment, you may develop meningitis and suffer widespread central nervous system (CNS) damage.”

28.    A female client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and for 8 hours afterward and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for:
a.    4 hours.
b.    8 hours.
c.    24 hours.
d.    48 hours.

29.    A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:
a.    cancer of the ovaries.
b.    cancer of the uterus.
c.    cancer of the cervix.
d.    cancer of the vagina.

30.    Which of the following is the initial intervention for a male client with external bleeding?
a.    Elevation of the extremity
b.    Pressure point control
c.    Direct pressure
d.    Application of a tourniquet

Answers and Rationale

How to Pass the NCLEX

NCLEX Practice Test for Skin and Integumentary Diseases Part 1 Answers and Rationale Share this on Facebook Tweet This! Email this via...
NCLEX Practice Test for Skin and Integumentary Diseases Part 2 Share this on Facebook Tweet This! Email this via...
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Gastrointestinal Diseases NCLEX Review Questions Part 2 Answers and Rationale

admin — Tue, 22 Jun 2010 08:57:26 +0000

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1.    Answer D. Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Therefore, antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria don’t synthesize vitamins A, D, or E.
2.    Answer B. Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn’t related to acute pancreatitis.
3.    Answer B. For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn’t allow proper visualization of the large intestine.
4.    Answer A. A Mallory-Weiss tear is associated with massive bleeding after a tear occurs in the mucous membrane at the junction of the esophagus and stomach. There is a strong relationship between ethanol usage, resultant vomiting, and a Mallory-Weiss tear. The bleeding is coming from the stomach, not from the lungs as would be true in some cases of tuberculosis. A Mallory-Weiss tear doesn’t occur from chest injuries or falls and isn’t associated with eating spicy foods.
5.    Answer A. Tube feeding solutions and tubing should be changed every 24 hours, or more frequently if the feeding requires it. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings.
6.    Answer B. Meperidine’s onset of action is 15 to 30 minutes. It peaks between 30 and 60 minutes and has a duration of action of 2 to 4 hours.
7.    Answer C. A hepatic disorder, such as cirrhosis, may disrupt the liver’s normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
8.    Answer B. Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. The other conditions are less likely to exhibit fluid volume deficit.
9.    Answer A. The nurse should irrigate the tube with cola because its effervescence and acidity are suited to the purpose, it’s inexpensive, and it’s readily available in most homes. Advancing the NG tube is inappropriate because the tube is designed to stay in the stomach and isn’t long enough to reach the intestines. Applying intermittent suction or using a syringe for aspiration is unlikely to dislodge the material clogging the tube but may create excess pressure. Intermittent suction may even collapse the tube.
10.    Answer B. For a client with pancreatitis, the physician will probably avoid prescribing morphine because this drug may trigger spasms of the sphincter of Oddi (a sphincter at the end of the pancreatic duct), causing irritation of the pancreas. Meperidine has a somewhat shorter duration of action than morphine. The two drugs are equally addictive. Morphine isn’t associated with hepatic dysfunction.
11.    Answer C. Young women with Chronic low self esteem — are at highest risk for anorexia nervosa because they perceive being thin as a way to improve their self-confidence. Hopelessness and Powerlessness are inappropriate nursing diagnoses because clients with anorexia nervosa seldom feel hopeless or powerless; instead, they use food to control their desire to be thin and hope that restricting food intake will achieve this goal. Anorexia nervosa doesn’t result from a knowledge deficit, such as one regarding good nutrition.
12.    Answer A. Endoscopy permits direct evaluation of the upper GI tract and can detect 90% of bleeding lesions. An upper GI series, or barium study, usually isn’t the diagnostic method of choice, especially in a client with acute active bleeding who’s vomiting and unstable. An upper GI series is also less accurate than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn’t necessarily reveal whether the lesion is bleeding. Hb levels and HCT, which indicate loss of blood volume, aren’t always reliable indicators of GI bleeding because a decrease in these values may not be seen for several hours. Arteriography is an invasive study associated with life-threatening complications and wouldn’t be used for an initial evaluation.
13.    Answer A. Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn’t transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.
14.    Answer B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.
15.    Answer D. The liver is vital in the synthesis of clotting factors, so when it’s diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors. Although administering whole blood, albumin, and packed cells will contribute to hemostasis, those products aren’t specifically used to treat hemostasis. Platelets are helpful, but the best answer is cryoprecipitate and fresh frozen plasma.
16.    Answer B. To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren’t gastric irritants.
17.    Answer D. I.V. infusions containing normal saline solution and potassium should be given first to maintain fluid and electrolyte balance. For the client’s comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to aid in the diagnosis of bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication often is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.
18.    Answer B. Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Dysphagia isn’t associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.
19.    Answer A. An NG tube that fails to drain during the postoperative period should be reported to the physician immediately. It may be clogged, which could increase pressure on the suture site because fluid isn’t draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line.
20.    Answer B. Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client’s BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.
21.    Answer A. Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don’t occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.
22.    Answer D. Risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren’t risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.
23.    Answer D. The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.
24.    Answer B. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client’s vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
25.    Answer B. Paregoric has an additive effect of constipation when used with anticholinergic drugs. Antiarrhythmics, anticoagulants, and antihypertensives aren’t known to interact with paregoric.
26.    Answer A. Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can’t absorb them after an ileostomy
27.    Answer C. Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth. A regular diet is incorrect. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk shouldn’t be given because it increases gastric acid production, which could prolong bleeding. A liquid diet is the first diet offered after bleeding and shock are controlled.
28.    Answer B. Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn’t radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.
29.    Answer C. To maintain enteric precautions, the nurse must wash the hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.
30.    Answer C. Hepatitis A can be caused by consuming contaminated water, milk, or food — especially shellfish from contaminated water. Hepatitis B is caused by blood and sexual contact with an infected person. Hepatitis C is usually caused by contact with infected blood, including receiving blood transfusions.

More NCLEX Review coming up…

Gastrointestinal Diseases NCLEX Review Questions Part 1 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Gastrointestinal Diseases NCLEX Review Questions Part 2 Share this on Facebook Tweet This! Email this via...
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Gastrointestinal Diseases NCLEX Review Questions Part 2

admin — Sun, 20 Jun 2010 10:49:33 +0000

1.    During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria. Antibiotic therapy may interfere with synthesis of which vitamin and may lead to hypoprothrombinemia?
a.    vitamin A
b.    vitamin D
c.    vitamin E
d.    vitamin K

2.    When evaluating a male client for complications of acute pancreatitis, the nurse would observe for:
a.    increased intracranial pressure.
b.    decreased urine output.
c.    bradycardia.
d.    hypertension.

3.    A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially?
a.    Lying on the right side with legs straight
b.    Lying on the left side with knees bent
c.    Prone with the torso elevated
d.    Bent over with hands touching the floor

4.    A male client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been “spitting up blood.” A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client’s wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
a.    “Tell me about your husband’s alcohol usage.”
b.    “Is your husband being treated for tuberculosis?”
c.    “Has your husband recently fallen or injured his chest?”
d.    “Describe spices and condiments your husband uses on food.”

5.    Which of the following nursing interventions should the nurse perform for a female client receiving enteral feedings through a gastrostomy tube?
a.    Change the tube feeding solutions and tubing at least every 24 hours.
b.    Maintain the head of the bed at a 15-degree elevation continuously.
c.    Check the gastrostomy tube for position every 2 days.
d.    Maintain the client on bed rest during the feedings.

6.    A male client is recovering from a small-bowel resection. To relieve pain, the physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours. How soon after administration should meperidine’s onset of action occur?
a.    5 to 10 minutes
b.    15 to 30 minutes
c.    30 to 60 minutes
d.    2 to 4 hours

7.    The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
a.    Dyspnea and fatigue
b.    Ascites and orthopnea
c.    Purpura and petechiae
d.    Gynecomastia and testicular atrophy

8.    Which condition is most likely to have a nursing diagnosis of fluid volume deficit?
a.    Appendicitis
b.    Pancreatitis
c.    Cholecystitis
d.    Gastric ulcer

9.    While a female client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client’s family how to deal with it at home, what should the nurse do?
a.    Irrigate the tube with cola.
b.    Advance the tube into the intestine.
c.    Apply intermittent suction to the tube.
d.    Withdraw the obstruction with a 30-ml syringe.

10.    A male client with pancreatitis complains of pain. The nurse expects the physician to prescribe meperidine (Demerol) instead of morphine to relieve pain because:
a.    meperidine provides a better, more prolonged analgesic effect.
b.    morphine may cause spasms of Oddi’s sphincter.
c.    meperidine is less addictive than morphine.
d.    morphine may cause hepatic dysfunction.

11.    Mandy, an adolescent girl is admitted to an acute care facility with severe malnutrition. After a thorough examination, the physician diagnoses anorexia nervosa. When developing the plan of care for this client, the nurse is most likely to include which nursing diagnosis?
a.    Hopelessness
b.    Powerlessness
c.    Chronic low self esteem
d.    Deficient knowledge

12.    Which diagnostic test would be used first to evaluate a client with upper GI bleeding?
a.    Endoscopy
b.    Upper GI series
c.    Hemoglobin (Hb) levels and hematocrit (HCT)
d.    Arteriography

13.    A female client who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the nurse’s best response?
a.    “You may have eaten contaminated restaurant food.”
b.    “You could have gotten it by using I.V. drugs.”
c.    “You must have received an infected blood transfusion.”
d.    “You probably got it by engaging in unprotected sex.”

14.    When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
a.    Obstruction of the appendix may increase venous drainage and cause the appendix to rupture.
b.    Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
c.    The appendix may develop gangrene and rupture, especially in a middle-aged client.
d.    Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

15.    A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are:
a.    whole blood and albumin.
b.    platelets and packed red blood cells.
c.    fresh frozen plasma and whole blood.
d.    cryoprecipitate and fresh frozen plasma.

16.    To prevent gastroesophageal reflux in a male client with hiatal hernia, the nurse should provide which discharge instruction?
a.    “Lie down after meals to promote digestion.”
b.    “Avoid coffee and alcoholic beverages.”
c.    “Take antacids with meals.”
d.    “Limit fluid intake with meals.”

17.    The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?
a.    Administering pain medication
b.    Obtaining a blood sample for laboratory studies
c.    Preparing to insert a nasogastric (NG) tube
d.    Administering I.V. fluids

18.    A female client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
a.    The client doesn’t exhibit rectal tenesmus.
b.    The client is free from esophagitis and achalasia.
c.    The client reports diminished duodenal inflammation.
d.    The client has normal gastric structures.

19.    A male client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client’s nasogastric (NG) tube has stopped draining. How should the nurse respond?
a.    Notify the physician
b.    Reposition the tube
c.    Irrigate the tube
d.    Increase the suction level

20.    What laboratory finding is the primary diagnostic indicator for pancreatitis?
a.    Elevated blood urea nitrogen (BUN)
b.    Elevated serum lipase
c.    Elevated aspartate aminotransferase (AST)
d.    Increased lactate dehydrogenase (LD)

21.    A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
a.    yellow sclerae.
b.    light amber urine.
c.    circumoral pallor.
d.    black, tarry stools.

22.    Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
a.    a sedentary lifestyle and smoking.
b.    a history of hemorrhoids and smoking.
c.    alcohol abuse and a history of acute renal failure.
d.    alcohol abuse and smoking.

23.    While palpating a female client’s right upper quadrant (RUQ), the nurse would expect to find which of the following structures?
a.    Sigmoid colon
b.    Appendix
c.    Spleen
d.    Liver

24.    A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse’s first response is to:
a.    call the physician.
b.    place saline-soaked sterile dressings on the wound.
c.    take a blood pressure and pulse.
d.    pull the dehiscence closed.

25.    The nurse is monitoring a female client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation?
a.    Antiarrhythmic drugs
b.    Anticholinergic drugs
c.    Anticoagulant drugs
d.    Antihypertensive drugs

26.    A male client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
a.    increasing fluid intake to prevent dehydration.
b.    wearing an appliance pouch only at bedtime.
c.    consuming a low-protein, high-fiber diet.
d.    taking only enteric-coated medications.

27.    The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
a.    Regular diet
b.    Skim milk
c.    Nothing by mouth
d.    Clear liquids

28.    A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:
a.    severe abdominal pain radiating to the shoulder.
b.    anorexia, nausea, and vomiting.
c.    eructation and constipation.
d.    abdominal ascites.

29.    A female client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:
a.    place the client in a private room.
b.    wear a mask when handling the client’s bedpan.
c.    wash the hands after touching the client.
d.    wear a gown when providing personal care for the client.

30.    Which of the following factors can cause hepatitis A?
a.    Contact with infected blood
b.    Blood transfusions with infected blood
c.    Eating contaminated shellfish
d.    Sexual contact with an infected person

Answers and Rationale

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Gastrointestinal Diseases NCLEX Review Questions Part 1 Share this on Facebook Tweet This! Email this via...
Gastrointestinal Diseases NCLEX Review Questions Part 1 Answers and Rationale Share this on Facebook Tweet This! Email this via...
Gastrointestinal Diseases NCLEX Review Questions Part 2 Answers and Rationale Share this on Facebook Tweet This! Email this via...