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Quiz Session - Attempts With Random Questions

ANCC MEDSURG-BC Exam Questions

Page 10 of 75

181.

A patient is admitted to your unit with extreme weakness, pallor, and confusion. He is expectorating bright red blood, and the physician suspects he has a Mallory-Weiss tear. You begin taking a patient history from the patient's wife, who has accompanied him.

Which of the following questions demonstrates your understanding of a Mallory-Weiss tear?

  • "Tell me about your husband's alcohol usage."

  • "Is your husband being treated for tuberculosis?"

  • "Has your husband recently fallen or injured his chest?"

  • "Describe the spices your husband uses on his foods."

Correct answer: "Tell me about your husband's alcohol usage."

A Mallory-Weiss tear, or esophageal tear, is associated with massive bleeding from a tear at the junction of the esophagus and the stomach; there is a strong correlation with alcohol and aspirin abuse, with resultant vomiting.

The bleeding originates from the stomach, not from the lungs as would be the case with tuberculosis. It does not occur due to chest injuries and is not associated with eating spicy foods.

182.

Which of the following interventions will help to enhance mobility and recovery in a patient who has just had a total hip arthroplasty?

  • The patient should begin ambulating as soon as possible once they return from the surgery

  • The patient will need continuous passive motion (CMP) to help maintain range of motion

  • The patient should exercise by moving the leg side to side as far as it will go each way

  • The patient should try to move the hip for as little as possible for the first 48 hours until the swelling at the surgical site has decreased

Correct answer: The patient should begin ambulating as soon as possible once they return from the surgery

Early mobilization of the joint is recommended to promote an earlier and more complete recovery. 

CPM is used for patients who have had a knee replacement, not a hip replacement. Patients who have recently had a hip replacement should not allow the surgical leg to cross the midline, as this increases the risk of dislocating the joint. Limiting mobility of the joint is not recommended following a total hip arthroplasty.

183.

You are assessing a patient's lung sounds and note bronchovesicular wheezing on expiration. Which of the following conditions is this type of breath sound most likely to be associated with?

  • Asthma

  • Heart failure

  • Pneumonia 

  • Anaphylaxis

Correct answer: Asthma

Asthma causes wheezing in the bronchovesicular areas that is primarily present on expiration. This is due to constriction or edema in the small airways. 

Heart failure causes coarse crackles that may be present on both inspiration and expiration, but are more often associated with inspiration and are almost always vesicular and dependent. Pneumonia is also likely to cause coarse or fine crackles, but these are typically limited to the affected lobe and are normally more vesicular in nature. Anaphylaxis does cause wheezing from airway contractions. This wheezing primarily affects the upper airways and would be more bronchial, while bronchovesicular wheezing would be more likely with asthma.

184.

During a community health fair, a nurse is educating attendees about healthy lifestyle modifications. Which of the following recommendations is MOST effective in reducing the risk of cardiovascular disease?

  • Engaging in regular physical activity

  • Maintaining a stable salt intake

  • Monitoring blood glucose levels regularly

  • Increasing water consumption

Correct answer: Engaging in regular physical activity

Regular physical activity is proven to reduce the risk of cardiovascular disease by improving cardiovascular fitness, lowering blood pressure, and helping maintain a healthy weight.

A stable salt intake and a low salt intake are not equivalent. Maintaining a low salt intake is important, but it does not have as much impact as regular physical activity on reducing cardiovascular disease risk.

Monitoring blood glucose levels is important for diabetes management, but the need for diabetic management is not indicated for this patient. Increasing water consumption is generally a healthy choice, but it does not have a significant, direct impact on reducing cardiovascular disease risk like regular physical activity does.

185.

A nurse is preparing to use a piece of medical equipment on a patient. Which step is MOST important to ensure patient safety?

  • Checking the equipment for cleanliness and function

  • Ensuring the equipment is plugged in

  • Asking maintenance to check the condition of the equipment’s circuitry

  • Documenting the equipment used in the patient's chart

Correct answer: Checking the equipment for cleanliness and function

Checking the equipment for cleanliness and function is essential to ensure it is safe and operational, thereby preventing infections and ensuring effective use. This step ensures the equipment is in proper working order and sanitary for patient use.

Ensuring the equipment is plugged in is important for functionality but does not address its overall safety.

Asking maintenance to check the condition of the equipment’s circuitry can be appropriate if there is a specific question, but it is not the responsibility of the nurse before routine use.

Documenting the equipment used in the patient's chart is part of record-keeping but does not directly ensure patient safety.

186.

All of the following statements related to enteral nutrition are true except:

  • It is indicated for complete intestinal obstruction

  • It maintains the mucosal barrier of the GI tract

  • It is associated with fewer complications than parenteral nutrition

  • It maintains gastrointestinal structure and function by maintaining villi height and number and enzyme activity

Correct answer: It is indicated for complete intestinal obstruction

Enteral nutrition (tube feeding) is the administration of liquid formula via tube directly into the GI tract. Benefits of enteral feeding include: it maintains the mucosal barrier of the GI tract, potentially reducing the incidence of stress ulcers and infections, is associated with fewer complications than parenteral nutrition (administering nutrients intravenously), and maintains gastrointestinal structure and function by maintaining villi height and number and enzyme activity. Also, it is less expensive than parenteral nutrition.

Enteral nutrition is contraindicated in situations where there is complete intestinal obstruction, prohibiting use of the bowel; parenteral nutrition is indicated in these instances.

187.

A patient with nephrotic syndrome asks their nurse why they have developed swelling in their legs. Which of the following answers is most correct?

  • This happens because your blood is unable to keep fluid in your veins, making the fluid build up in your soft tissues.

  • This edema is not due to your nephrotic syndrome.

  • This swelling is caused because your kidneys are creating less urine, causing fluid to build up in your body.

  • This swelling is due to the effects nephrotic syndrome causes on your heart.

Correct answer: This happens because your blood is unable to keep fluid in your veins, making the fluid build up in your soft tissues. 

Nephrotic syndrome causes increased permeability in the glomeruli, allowing proteins such as albumin to cross into the urine. The deficiency in albumin causes hypoalbuminemia, leading to tissues leaking out of the vascular space into the interstitial space. The interstitial edema is not caused by fluid retention or due to heart failure,

188.

You are assessing a patient who has complaints of a lymph node abnormality. Which of the following findings is most concerning?

  • The lymph node is painless

  • The lymph node is well marginated

  • The lymph node is smooth

  • The lymph node is not movable

Correct answer: The lymph node is painless

Painless lymph nodes are more consistent with a cancerous etiology than they are with inflammatory lymphadenopathy. 

Lymph nodes that are well marginated, smooth, and are not movable are not associated with lymphoma.

189.

When assessing a male patient with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

  • Tachycardia

  • A fasting blood glucose of 60 mg/dL

  • A supine blood pressure of 100/55

  • Weight gain

Correct answer: Tachycardia

Pheochromocytomas, rare tumors of the adrenal medulla (chromaffin tissue) that secrete excessive amounts of catecholamines (mostly norepinephrine), cause headaches, hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. Sweating, nervousness, anxiety, chest or abdominal pain, nausea, weakness, and orthostatic hypotension are also common.

190.

Which of the following is true regarding the risk of diabetes in patients who have pancreatitis?

  • Patients with chronic pancreatitis will develop diabetes mellitus late in the disease process.

  • Pancreatitis is separate from diabetes and will not cause diabetes.

  • Acute pancreatitis will not always cause diabetes, but significantly raises the risk this will occur.

  • Pancreatitis may cause diabetes insipidus, but will not cause diabetes mellitus.

Correct answer: Patients with chronic pancreatitis will develop diabetes mellitus late in the disease process.

A patient with chronic pancreatitis will develop diabetes mellitus later in the disease process due to malfunction of the islets of Langerhans. Chronic pancreatitis will eventually cause diabetes mellitus, but is not associated with diabetes insipidus. Acute pancreatitis does not normally involve the islets of Langerhans. While it may raise the risk of diabetes mellitus developing, this risk is not significant.

191.

A patient who had an ileostomy two days ago has scant bleeding and edema at the stoma site. Which of the following interventions is most important for the nurse to take?

  • Continue to monitor the stoma.

  • Contact the doctor and prepare the patient for a potential return to the operating room.

  • Change the ileostomy bag and provide stoma care.

  • Apply a pressure dressing to the stoma until the edema subsides.

Correct answer: Continue to monitor the stoma.

Edema and scant bleeding from a stoma that was formed two days ago is normal. Bleeding can occur for a few days postsurgically and edema may last for up to a week. Preparing to return to the OR is not necessary. Changing the ileostomy bag and providing stoma care is not an incorrect intervention, but is not a necessary response to the nurses' findings. A pressure dressing should not be applied to the stoma, as this could obstruct stool from exiting the stoma and could cause necrosis of the stomal mucosa.

192.

The syndrome of inappropriate antidiuretic hormone (SIADH) is:

  • Characterized by excessive release of antidiuretic hormone

  • Characterized by the suppression of antidiuretic hormone

  • Characterized by hypernatremia

  • Characterized by decreased renal responsiveness to antidiuretic hormone

Correct answer: Characterized by excessive release of antidiuretic hormone

Syndrome of inappropriate antidiuretic hormone (SIADH) results from hypersecretion (not suppression) of antidiuretic hormone (ADH) and is characterized by hyponatremia (not hypernatremia) and increased urinary hyperosmolality caused by the sustained release of ADH in the absence of osmotic and nonosmotic stimuli. Water retention progresses to water intoxication.

Nephrogenic diabetes insipidus (not SIADH) is characterized by decreased renal responsiveness to ADH.

193.

You are caring for a patient with chronic kidney disease (CKD) and his recent lab work reveals he has a serum potassium level of 6.8 mEq/L. What should you assess first?

  • Pulse

  • Temperature

  • Respirations

  • Blood pressure

Correct answer: Pulse

An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse.

The patient’s blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these are not affected by the serum potassium level.

194.

A nurse discovers a medication error that has not caused harm to the patient. Utilizing utilitarian ethics, what should the nurse's next step be?

  • Report the error to prevent future harm to other patients

  • Correct the error without reporting it to avoid any potential consequences

  • Determine the intentions of the person who committed the error

  • Discuss the error with the healthcare team privately

Correct answer: Report the error to prevent future harm to other patients

Utilitarian ethics would guide the nurse to report the medication error to prevent future harm to other patients. This approach focuses on maximizing overall benefit and minimizing harm, ensuring that corrective actions are taken to improve patient safety.

Correcting the error without reporting it avoids immediate consequences but fails to prevent potential future harm, which is contrary to utilitarian principles.

Determining the intentions of the person who committed the error focuses on moral intent rather than the utilitarian outcome.

Discussing the error privately may not lead to systemic changes necessary to prevent future errors and is not consistent with utilitarian ethics.

195.

You are performing preoperative teaching with a patient who has ulcerative colitis (UC) and needs a total colectomy with an ileoanal reservoir. Which information do you include?

  • The surgery usually occurs in two stages

  • A reservoir is created that exits through the abdominal wall

  • A permanent ileostomy is created

  • Continence is not possible after this surgery

Correct answer: The surgery usually occurs in two stages

An ileoanal reservoir is usually created in two stages.

First, diseased intestines are removed, and a temporary loop ileostomy is created. Second, the loop ileostomy is closed, and stool goes to the reservoir and out through the anal sphincter, maintaining bowel control and eliminating the need for a permanent ileostomy.

196.

For a patient with suspected increased intracranial pressure (ICP), the most appropriate respiratory goal is:

  • Promote carbon dioxide elimination

  • Lower arterial pH

  • Maintain partial pressure of oxygen (PO2) below 60 mm Hg

  • Prevent respiratory alkalosis

Correct answer: Promote carbon dioxide elimination

In increased ICP, CO2 levels increase, PO2 levels decrease, and pH decreases. The goal of treatment is to prevent acidemia by eliminating carbon dioxide; an acidic environment in the brain causes cerebral vasodilation and increased cerebral blood flow.

Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It is necessary to maintain a PO2 of 80-100 mm Hg; below 60 mm Hg will not adequately oxygenate the patient.

197.

You are caring for a patient who presents with an area of edema on their lower left leg where the skin is warm to the touch, erythemic, and tender with palpation. Which of the following should you suspect is most likely the cause of the patient's symptoms?

  • Cellulitis

  • Right sided heart failure

  • Lymphedema

  • Venous insufficiency

Correct answer: Cellulitis

Right sided heart failure and venous insufficiency typically present with bilateral edema, not unilateral edema as described in this scenario. These conditions will also not typically cause erythema or warmth over the edematous area. While lymphedema can cause unilateral edema, this edema is also not typically associated with erythema or warmth. Both erythema and warmth are suggestive of an infectious etiology, which would be most consistent with cellulitis.

198.

A nurse finds that a colleague has posted about a patient’s condition on social media. What is the nurse’s responsibility?

  • Report the post to the colleague's manager

  • Talk to the colleague about the need to maintain patient confidentiality

  • Recognize that any interaction outside of work is not the nurse’s concern

  • Report the post to the social media provider as a breach of their terms of service

Correct answer: Report the post to the colleague's manager

Reporting the post to the colleague’s manager is the appropriate action to address the breach of patient confidentiality and to follow institutional protocols. This ensures the situation is handled formally and prevents further breaches of confidentiality.

Discussing the need to maintain patient confidentiality with the colleague does not ensure formal resolution and might not prevent future incidents.

Viewing interactions outside of work as not a concern is incorrect because patient confidentiality is a continuous professional responsibility.

Reporting the post to the social media provider does not address the breach of professional standards and does not ensure appropriate follow-up within the healthcare environment.

199.

A patient with polycystic kidney disease is preparing to undergo a percutaneous cyst puncture. The nurse understands that which of the following is correct regarding this procedure?

  • It is to provide palliative relief.

  • It is normally contraindicated in patients with polycystic kidney disease.

  • It may enable the kidneys to heal and return to normal.

  • It can stop the progression of the disease, but will not restore function that has already been lost.

Correct answer: It is to provide palliative relief.

Percutaneous cyst puncture may be used in patients with polycystic kidney disease; however, this procedure is solely used to provide relief from the pain that the cysts cause. This procedure will not arrest the progression of the disease nor help to restore the health of the kidney.

200.

A nurse is evaluating a new wound care product. Which action represents evidence-based practice?

  • Reviewing clinical studies that compare its effectiveness to current products

  • Choosing the product by balancing its cost and effectiveness

  • Selecting the product based on evidence provided by the company

  • Using the product because colleagues report it is safe and effective

Correct answer: Reviewing clinical studies that compare its effectiveness to current products

Reviewing clinical studies that compare the new product's effectiveness to current products is a key aspect of evidence-based practice. This approach involves evaluating research to make informed decisions and ensuring the chosen product has been proven to be effective.

While practical, choosing the product by balancing cost and effectiveness doesn't embody prioritizing evidence from clinical studies. Relying on evidence provided by the company can introduce bias and may not reflect independent, rigorous research. Using the product based on colleagues' reports relies on anecdotal evidence rather than scientific evaluation.

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