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Quiz Session - Attempts With Random Questions

ANCC MEDSURG-BC Exam Questions

Page 4 of 75

61.

Which of the following teaching points is most important for the nurse to cover when providing postoperative teaching to a patient who has recently undergone a partial cystectomy?

  • Ensuring the bladder does not become overextended

  • Enusing the drainage appliance is emptied regularly

  • Avoiding excessive intake of fluids

  • Avoiding lifting their arms above their head for six weeks

Correct answer: Ensuring the bladder does not become overextended

In a partial cystectomy, part of the bladder is removed. It is essential to avoid overdistension of the bladder, as this can cause stress on the surgical site and increase the risk of bladder rupture. A drainage appliance is not typically necessary for a partial cystectomy, but may be for a total cystectomy. Fluid intake should be encouraged, not discouraged. Patients who have had a pacemaker inserted should generally avoid lifting their arms above their head for six weeks, but this is not necessary following a partial cystectomy.

62.

Which of the following interventions is not indicated in a patient with paraplegia to help prevent pressure ulcers?

  • Encourage the patient to perform frequent active range of motion in all extremities

  • Avoid elevating the head of the bed beyond 30°

  • Encourage adequate hydration and nutrition

  • Use pillows to reduce pressure on bony prominences

Correct answer: Encourage the patient to perform frequent active range of motion in all extremities

The patient's care plan should be tailored to his specific and unique situation. A patient who is paraplegic will be unable to perform active range of motion in his lower extremities, and this intervention will not work for this patient. 

Avoiding elevating the head of the bed beyond 30° will help to avoid pressure and shear on the sacrum. Encouraging adequate hydration and nutrition will help to promote skin health and reduce the risk of pressure ulcers. Using pillows to reduce pressure on bony prominences will also reduce the risk of pressure ulcers.

63.

A patient admitted to the medical-surgical floor with pneumonia is receiving supplemental oxygen at 2 L/minute via nasal cannula. The patient’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). Because of these history findings, the nurse closely monitors the oxygen flow and the patient’s respiratory status.

Which of the following complications may arise if the patient receives a high oxygen concentration?

  • Apnea

  • Anginal pain

  • Respiratory alkalosis

  • Metabolic acidosis

Correct answer: Apnea

Hypoxia is the main breathing stimulus for a client with COPD. Supplemental oxygen is used for individuals with severe or progressive hypoxemia. Oxygen use is progressive (during exacerbations only, intermittently, at night, or continuously). Excessive oxygen administration may lead to apnea by removing that stimulus.

Anginal pain results from a reduced myocardial oxygen supply. A patient with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a patient with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations do not cause metabolic acidosis.

64.

Which of the following options is the best treatment to reverse the effects of polycystic kidney disease (PKD)?

  • Kidney transplant

  • Surgical drainage and removal of cysts as they develop

  • Furosemide (Lasix) 40 mg PO BID

  • Broad spectrum antibiotic therapy while cysts are present

Correct answer: Kidney transplant

PKD is a progressive, genetic, incurable condition in which normal kidney tissues are replaced with cysts. While surgical drainage of cysts may be indicated in some circumstances, this will not reverse the effects of PKD and will be more related to patient comfort. Lasix will not help with this condition. Antibiotic therapy will not reverse these cysts, as they are not caused by infection. Antibiotics may be needed to treat infections that develop, but do not reverse the effects of PKD. 

Ultimately, the effects of PKD cannot be reversed, and kidney transplant is the only way to eliminate the effects of this disease.

65.

A nurse is collaborating with a patient’s family and the palliative care team to manage the patient's end-of-life care. Which action by the nurse is MOST appropriate?

  • Facilitating discussions between the family and palliative care team

  • Allowing the patient’s family to make all decisions without any input or pressure from clinicians

  • Explaining the patient’s palliative care plan to them and their family

  • Encouraging the patient’s family to communicate all needs and concerns with the palliative care team

Correct answer: Facilitating discussions between the family and palliative care team

Facilitating discussions between the family and the palliative care team ensures the family is involved in the decision-making process and their concerns and preferences are communicated, promoting a collaborative approach to end-of-life care.

Allowing the patient’s family to make all decisions without any input or pressure from clinicians is respectful; however, clinicians’ input is crucial for informed decision-making and providing appropriate care.

Explaining the patient’s palliative care plan to them and their family is important, but this task alone does not actively involve the family and palliative care team in a collaborative discussion.

Encouraging the patient’s family to communicate all needs and concerns with the palliative care team is passive and does not facilitate the necessary discussions and interactions for effective collaboration.

66.

In preparing a teaching plan for a patient with newly diagnosed hypertension, which lifestyle modification should the nurse prioritize?

  •  Increased aerobic exercise

  • Increased fluid intake

  • Daily weighing

  • Blood glucose monitoring

Correct answer: Increased aerobic exercise

Increased aerobic exercise helps reduce blood pressure, improves cardiovascular health, and is a key lifestyle modification for managing hypertension.

Increased fluid intake is not recommended for hypertension patients, as there is the potential it could contribute to increased blood pressure in some patients.

Daily weighing is important to monitor fluid levels if the patient has congestive heart failure; however, this is not indicated in the question.

Blood glucose monitoring is an essential component for diabetes management, not hypertension.

67.

You are performing an admission assessment on a patient being admitted for acute appendicitis when the patient says, "I have an insulin pump." Which of the following responses is most appropriate?

  • "I will have to ask the doctor if we will be letting you continue to use it or if we will take over managing your blood sugar levels."

  • "You will need to turn the pump off and I will have a nursing assistant check your blood sugar level."

  • "You can leave your pump on while you are here, but you will need to let us know how much insulin you are giving yourself."

  • "We will start you on IV insulin, so you will not need your pump while you are in the hospital."

Correct answer: "I will have to ask the doctor if we will be letting you continue to use it or if we will take over managing your blood sugar levels."

Patients who use insulin pumps may be permitted to continue using their pumps, but this will require an order from the doctor. Given the patient's possible need for surgery, the doctor may allow him to use his own pump until before surgery or may change the patient to a sliding scale insulin. 

The patient should not be told to turn his pump off until you have ascertained the doctor's intentions. The patient may not be allowed to leave his pump on, and the nurse should check with the doctor before making this guarantee. IV insulin is unlikely to be necessary during this patient's hospitalization.

68.

A nurse is working with a patient who has a different religious background. The patient requests time for prayer in the operating room immediately before their planned procedure. What should the nurse do?

  • Ask the surgical team to accommodate the patient's request

  • Inform the patient that there will be no time for prayer in the operating room

  • Suggest the patient pray before or after going to the operating room

  • Ask the surgical team to pray with the patient at some point before the surgery

Correct answer: Ask the surgical team to accommodate the patients’ request

Asking the surgical team to accommodate the patient's request for prayer respects the patient's religious beliefs and supports their emotional and spiritual needs. It demonstrates cultural competency and sensitivity, which are crucial in providing holistic patient care.

Informing the patient that there will be no time for prayer in the operating room dismisses their religious needs and can cause unnecessary distress, especially when this intervention is typically possible.

Suggesting the patient pray before or after going to the operating room does not address the patient’s specific request for prayer immediately before the procedure. Asking the surgical team to pray with the patient may not be appropriate as it involves the personal beliefs of the surgical team, which might not align with the patient’s beliefs.

69.

You are supervising a nursing student who is caring for a patient who has just been diagnosed with myasthenia gravis. Which statement made by the nursing student to the patient will require correcting?

  • "Myasthenia gravis symptoms are the worst the during morning."

  • "Myasthenia gravis happens because the muscles are not able to receive impulses from the nerves like they should."

  • "Myasthenia gravis is an autoimmune disease."

  • "Myasthenia gravis often makes eating harder."

Correct answer: "Myasthenia gravis symptoms are the worst during the morning."

Myasthenia gravis occurs because acetylcholine receptors are lost or blocked in neuromuscular junctions. Symptoms worsen with muscle use, making symptoms worse throughout the day. Symptoms will be least obtrusive in the morning and will worsen throughout the day. 

Telling the patient that myasthenia gravis occurs because the muscles are not able to receive impulses from the nerves like they should would be an accurate description of the pathology. Myasthenia gravis is an autoimmune disease. Myasthenia gravis often affects facial muscles, making eating more difficult.

70.

You are establishing priorities for morning assessments of your patients. Which of the following patients should you assess first?

  • The newly admitted patient with acute abdominal pain

  • The sleeping patient who received pain medication 1 hour ago

  • The patient receiving continuous tube feedings who needs the residual checked

  • The patient who needs an abdominal dressing changed (postoperative day 3)

Correct answer: The newly admitted patient with acute abdominal pain

You should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable.

You should then change the abdominal dressing for the postoperative patient or measure feeding tube residual in the patient with continuous tube feedings. Do not disturb the sleeping patient who recently received pain medication.

71.

Which of the following is not a goal of quality and performance improvement initiatives in the emergency department setting?

  • Identification of poor-performing healthcare institutions

  • Improving the patient care experience

  • Improving population health

  • Reducing healthcare costs

Correct answer: Identification of poor-performing healthcare institutions 

"Quality" in healthcare has been defined as the "degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." The implementation of quality and performance initiatives is aimed to improve overall patient care while also improving cost-efficient patient care.

While poorly performing healthcare institutions can impact reimbursement for services, this is not a major goal of these initiatives.

72.

The nurse suspects a patient of having meningitis. Which of the following interventions would best help the nurse assess for this condition?

  • Flex the patient's neck

  • Raise the patient's arms to a 90-degree angle from their body

  • Have the patient rapidly touch their finger to their nose, then the nurse's finger and back

  • Administer Tylenol and monitor the patient's response

Correct answer: Flex the patient's neck

Flexing the patient's neck and observing for flexion in the hips and knees is how Brudzinski's sign is assessed. Positive flexion of the hips and knees indicates irritation of the meningitis and indicates that meningitis may be present. Raising the patient's arms to a 90-degree angle from their body and observing for drift is a method of assessing for stroke. Having the patient rapidly touch their finger to their nose, then the nurse's finger and back is a method of assessing for ataxia, but this is not an ideal assessment to determine the presence of meningeal irritation. Administering Tylenol and monitoring the patient's response will not help assess for meningitis.

73.

You are working at the hospital when a patient's family member pulls out a handgun at the nurse's station and randomly begins shooting staff and patients. The only exit is down the hall past the shooter. Which of the following actions should you take?

  • Find a room to hide in

  • Run past the shooter to get to the exit and escape

  • Charge the shooter and attempt to disarm them

  • Play dead, hoping that the shooter will ignore you

Correct answer: Find a room to hide in

In the event of a mass shooting, you should run if possible, hide if running is not possible, and fight as a last resort.

As the only exit is beyond the shooter, running is not an option. Therefore, you should hide the best you can. Barricading the room can make it more difficult for the shooter to enter and enhance the safety of a hiding location. Charging the shooter and attempting to fight is not recommended if hiding is an option. Pretending to be dead is not a good strategy.

74.

You are caring for a patient with chronic pyelonephritis. Which of the following statements by the patient indicates there is a need for additional teaching? 

  • "This might eventually go away and I won't have kidney problems anymore."

  • "This might be caused by frequent UTIs."

  • "I might need to be on antibiotics for several weeks."

  • "I might need dialysis eventually."

Correct answer: "This might eventually go away and I won't have kidney problems anymore."

Chronic pyelonephritis is a gradual, progressive disease that causes permanent scarring to the kidneys. Chronic pyelonephritis will not spontaneously resolve. 

Chronic pyelonephritis can be caused by frequent UTIs, prolonged antibiotic treatment may be necessary, and patients who have severe chronic pyelonephritis may eventually require dialysis.

75.

You are caring for a patient with a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following nursing interventions is appropriate for this patient?

  • Restricting fluids

  • Infusing IV fluids rapidly as ordered

  • Encouraging increased oral intake

  • Administering glucose-containing IV fluids as ordered

Correct answer: Restricting fluids

Syndrome of inappropriate antidiuretic hormone (SIADH) results from hypersecretion of antidiuretic hormone (ADH) from the posterior pituitary gland and is characterized by hyponatremia, in which the plasma sodium levels are lowered, and total body fluid is increased. Although the sodium level is low, SIADH is brought about by an excess of water, rather than a deficit of sodium. To reduce water retention in the patient with SIADH, the nurse should restrict fluids.

Administering fluids by any route would further increase the patient's already heightened fluid load.

76.

You are caring for a patient who suddenly develops unilateral weakness. Which of the following interventions should be performed first?

  • CT scan

  • Administer tPA

  • Assess the patient's NIH stroke scale

  • Check the patient's blood glucose level

Correct answer: CT scan

In evaluating a patient with sudden onset of unilateral weakness, stroke should be suspected. A CT of the head will be necessary to evaluate if the stroke is hemorrhagic or ischemic, allowing for better understanding of how to treat the stroke. 

Administering tPA may be necessary, but can only be done on a patient with ischemic stroke, and a head CT is needed first. Assessing the patient's NIH stroke scale will provide helpful information, but will not determine treatment like a CT will, making the CT more necessary. Assessing the patient's blood glucose level will be necessary; however, sudden onset of unilateral weakness is more indicative of a stroke than hypoglycemia, and a CT of the head should be performed first.

77.

During a discharge planning session, a patient seems unsure about how to manage their medications at home. What should the nurse do?

  • Provide a detailed written medication schedule and review it with the patient

  • Recognize the patient may need time to figure it out once they are home

  • Tell the patient to call if they have any questions and provide contact information

  • Schedule a patient consultation with the pharmacist

Correct answer: Provide a detailed written medication schedule and review it with the patient

Providing a detailed written medication schedule and reviewing it ensures the patient understands how to manage their medications, which is crucial for adherence and safety.

Assuming the patient will figure it out at home without guidance can lead to medication errors and adverse outcomes. Simply telling the patient to call if they have questions is insufficient without providing clear instructions beforehand, as it may lead to confusion and non-adherence.

Scheduling a consultation with a pharmacist can be helpful, but the nurse should still provide immediate education and review the medication plan to ensure patient understanding before discharge.

78.

A nurse is working with a patient who is non-verbal due to a recent stroke. What communication strategy should the nurse use?

  • Assess potential non-verbal methods to engage with the patient

  • Recognize that trying to communicate will frustrate the patient and focus on physical care

  • Focus communication efforts on the patient's family

  • Recognize that communication will be one-way until the patient can speak again

Correct answer: Assess potential non-verbal methods to engage with the patient

Assessing potential non-verbal methods helps the nurse understand which methods of engaging with the patient will be most effective and therapeutic. This approach will facilitate engaged teaching with the patient.

Recognizing that trying to communicate will frustrate the patient and focusing on physical care is incorrect, as the nurse is responsible for facilitating communication using the method that works best for the patient.

Focusing communication efforts on the patient's family is only appropriate if there is no way to communicate with the patient; assessing the patient's ability to communicate is a better initial intervention.

Recognizing that communication will be one-way until the patient can speak again is not correct, as speaking is not absolutely necessary for communication.

79.

The therapeutic drug level of phenytoin (Dilantin) is:

  • 10-20 mcg/mL

  • 0.5-1 mcg/mL

  • 50-100 mcg/mL

  • 5-10 mcg/mL

Correct answer: 10-20 mcg/mL

Phenytoin is a sodium channel blocker used in the prevention of seizure activity; it stabilizes neuronal membranes. It may be administered orally or per intravenous route. Adverse effects include constipation, nausea, vomiting, drowsiness, dizziness, hirsutism, bone marrow suppression, dysrhythmias, and gingival hyperplasia. 

Levels must be closely monitored in patients taking this drug; therapeutic level is within 10-20 mcg/mL.

80.

A patient is concerned about having a myocardial infarction (MI) because their father passed away from an MI. Which of the following is NOT a modifiable risk factor for having an MI?

  • Family history of MI

  • Smoking

  • A sedentary job

  • Employment related stress

Correct answer: Family history of MI

All the answers are risk factors for having an MI, however, only three are modifiable. Modifiable risk factors describe risk factors that are under the patient's control. Smoking, a sedentary lifestyle, and stress are all modifiable, although employment related modifiable risks may cause a greater cost to the patient to actually modify. A family history of MI is not in the patient's control.

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