NR341 CJE MedSurj II Review Qs

1. The nurse gathers supplies to perform an intermittent urinary catheterization on a client with urinary retention on a client from obstruction caused by an enlarged prostate. Which catheter shown in the image should the nurse use?

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Answer explanation

A coude-tip catheter has a curved tip designed to bypass the enlarged prostate and navigate the narrowed urethra often seen in BPH. It is the preferred first-line choice in men with known prostatic enlargement.

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  ❌ Opposing eyes – Standard Foley-type drainage eyes; not specific for BPH-related resistance.

• ❌ Pezzer catheter – Typically used for suprapubic placement, not urethral catheterization.

• ❌ Malecot catheter – Used for wound or nephrostomy drainage, not suitable for urethral insertion.

• ❌ Whistle tip – Used for irrigation in cases with hematuria or thick clots, not for prostatic obstruction.

1. A client receiving rifampin and isoniazid for TB experiences adverse effects of drug therapy. Which laboratory finding led the nurse to this conclusion?

• AST 64 U/mL

• ALP 38 U/mL

• A pCO2 of 44 on ABG results 

• ALT 28 U/mL

Answer explanation

✅ Correct Answer: AST 64 U/mL

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💡 Rationale:

• Isoniazid and rifampin are known to cause hepatotoxicity.

• AST (aspartate aminotransferase) is a liver enzyme that becomes elevated in liver injury or inflammation.

  • Normal ALT range: ~10–40 U/mL

  • AST of 64 U/mL = elevated, indicating possible liver injury.

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  ALP of 38 U/mL is within normal limits.

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  A pCO₂ of 44 mm Hg is normal on ABG; this does not indicate toxicity.

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  ALT 28 U/mL (another liver enzyme) is normal, not indicative of hepatotoxicity.

1. The nurse cares for five clients on the med-surg floor. Select the choices with the clients in proper order of priority as they should be seen by the nurse from first to last:

• A. A 42-yr-old female with UTI and a prescription to obtain a urine specimen

  B. 23-yr-old female with kidney stones stating 8/10 pain

  C. 65-yr-old male with BPH that is two days post op from TURP

  D. 76-yr-old male with BPH that has been unable to void for the past 2 hours 

  E. 72-yr-old male with AKI and a potassium of 5.8

• A. 72-yr-old male with AKI and a potassium of 5.8

  B. 76-yr-old male with BPH that has been unable to void for the past 2 hours 

  C. 23-yr-old female with kidney stones stating 8/10 pain

  D. 65-yr-old male with BPH that is two days post op from TURP

  E. A 42-yr-old female with UTI and a prescription to obtain a urine specimen

Answer explanation

🔢 Order of Priority (1 = First to be seen):

1. A.) 72-year-old male with AKI and a potassium of 5.8
   🔺 Rationale: Elevated potassium poses a life-threatening risk of cardiac dysrhythmias. This is an unstable lab value and requires immediate assessment/intervention.

2. B.) 76-year-old male with BPH who has been unable to void for 2 hours
   🔺 Rationale: Acute urinary retention can lead to bladder rupture or kidney damage. This is urgent and can cause severe discomfort and complications.

3. C.) 23-year-old female with kidney stones stating 8/10 pain
   🔺 Rationale: This patient is in severe pain and needs prompt pain management. However, she is stable, so she is seen after more acute physiological threats.

4. D.) 65-year-old male with BPH who is two days post-op from TURP
   🔸 Rationale: Post-op patient needs monitoring but is not showing signs of complications; stable for now.

5. E.) 42-year-old female with UTI and a prescription to obtain a urine specimen
   🔸 Rationale: Collecting a urine sample is important but not urgent. She is stable and has no reported distress.

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🧠 NCLEX Priority Principles Used:

• ABCs (airway, breathing, circulation)

• Unstable vs. stable

• Acute vs. chronic

• Potential for harm if delayed

1. A client is admitted with DKA. Upon assessment, the nurse finds the client with rapid, deep breathing. The nurse recognizes that because of the client’s diagnosis, the findings are probably due to the body compensating for the acidosis in what way?

• To increase oxygen levels to lower the pH

• To respond to increased renal metabolic demand

• To raise the pH by exerting more CO₂

• To decrease the amount of oxygen attached to hemoglobin

Answer explanation

CORRECT: To raise the pH by exerting more CO₂.

💡 Rationale:

• In DKA, the body experiences metabolic acidosis due to excess ketones. The lungs compensate by increasing the respiratory rate and depth (Kussmaul respirations) to blow off CO₂, a respiratory acid. Removing CO₂ helps raise the blood pH and reduce acidosis.

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❌ Incorrect Options:

• To increase oxygen levels to lower the pH = Increasing oxygen does not directly correct acidosis or affect pH significantly.

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  To respond to increased renal metabolic demand = The lungs are compensating for metabolic acidosis, not renal metabolic demand.

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  To decrease the amount of oxygen attached to hemoglobin = Oxygen attached to hemoglobin does not influence pH compensation in DKA.

The nurse in the intensive care unit is precepting a new nurse in the care of a client diagnosed with acute respiratory distress recently placed on the ventilator. What action by the new nurse indicated an understanding of caring for a ventilated client? Select all that apply.

• Delivers the highest concentration of oxygen for SpO2 >99% and collect ABG 4 hours after ventilation

• Maintains cuff pressure between 20-25mm Hg.

• Suction clients to troubleshoot the high-pressure alarms.

• Checks for kinks in tubing with a lower-pressure alarm

• Sets tidal volume based on client’s weight

Answer explanation

✅ Correct Answers:

• → Maintains cuff pressure between 20–25 mm Hg
  → Suctions client to troubleshoot high pressure alarm
  → Checks for kinks in tubing with lower pressure alarm
  → Sets tidal volume based on client’s weight

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❌ Incorrect Answers:

• Delivers the highest concentration of oxygen for SpO₂ >99%
  → Incorrect. In ARDS, oxygen should be titrated to maintain SpO₂ 88–95%, not >99%, to prevent oxygen toxicity. FiO₂ should be kept as low as possible while maintaining adequate oxygenation.

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  Collect ABG 4 hours after ventilation
  → Incorrect. ABGs should typically be assessed within 30–60 minutes after initiation or major changes in ventilation to evaluate adequacy of gas exchange and support.

1. The nurse cares for a client with Cushing’s disease who had a tumor removed from the adrenal glands. The client receives IV corticosteroids, and the dosage is tapered based on the client’s clinical presentation. When the nurse assesses the client, which finding indicates that the client’s corticosteroid dosage is probably being tapered too quickly?

• Hypotension, weakness, and peeling of the skin

• Fluid overload and truncal edema

• Hypertension and rapid heart rate

• Decrease in heart rate from 90 to 68bpm

Answer explanation

Hypotension, weakness, and peeling of the skin

💡 Rationale:

• A rapid tapering of corticosteroids can lead to acute adrenal insufficiency, especially in clients previously dependent on exogenous steroids after adrenal surgery.

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❌ Incorrect Options:

• Fluid overload and truncal edema
  → This reflects excess corticosteroids (as in untreated Cushing’s), not rapid tapering.

• Hypertension and rapid heart rate
  → These are signs of Cushing’s syndrome or a stress response, not adrenal insufficiency.

• Decrease in heart rate from 90 to 68 bpm
  → A normal heart rate decline, not specific to corticosteroid tapering issues.

1. The nurse documents medication administration on the EMAR for a client with estrogen receptor-positive breast cancer and notes that one of the client’s medications has not been administered for the last three days. The nurse is concerned and queries the missing doses because, with this client’s cancer, the drug must be administered daily. Which missing drug does the nurse query? 

• Ondansetron

• Tamoxifen

• Raloxifene

• 1. Mineral oil enema 

Answer explanation

Correct

💡 Rationale:

• Tamoxifen is a selective estrogen receptor modulator (SERM) used as hormone therapy for ER+ breast cancer.

• It blocks estrogen receptors, slowing the growth of hormone-sensitive tumors.

• Daily administration is essential to maintain therapeutic levels and prevent cancer progression or recurrence.

• Missing multiple doses can reduce effectiveness and compromise cancer treatment.

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❌ Incorrect Options:

• Ondansetron → An antiemetic used as needed for nausea. Not critical if missed unless the client is symptomatic.

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  Naproxen → A nonsteroidal anti-inflammatory drug (NSAID) often used for pain; not critical to cancer control.

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  Mineral oil enema → A bowel regimen medication, used as needed; not related to cancer therapy.

1. A young child has a rare form of kidney cancer and is actively dying in a hospice unit. The parent, who is with the child every day, is very difficult. Staff provides exceptional care to the client, but the parent finds something to complain about daily. Today the unlicensed assistive personnel (UAP) observes the parent trying to feel the client soup and the client is coughing weekly. The UAP reports this to the nurse. Which statement by the nurse to the parent is appropriate? SATA 

• “I understand you think your child is hungry, but at this stage, hunger is not experienced”

• 1. “If you cause your child to choke, it will be on your head and not ours.”

• 1. “We ask that you do not feed you child as doing so can cause choking”

• “We told you before not to feed your child. Do you think you know better than us?”

• 1. “We provide the best care for your child, but you never seem to be satisfied.” 

Answer explanation

Correct:

• “I understand you think your child is hungry, but at this stage, hunger is not experienced.” = Therapeutic and informative. Gently informs the parent in a compassionate, nonjudgmental way about the child’s reduced physiological need for food at the end of life.

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  “We ask that you do not feed your child as doing so can cause choking.”

• Clear and safety-focused. Directs the parent not to feed the child due to the high risk of aspiration and choking, which is common in the actively dying phase.

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Incorrect

• ❌ “If you cause your child to choke, it will be on your head and not ours.” = Judgmental and threatening. Blames the parent, which is not therapeutic or supportive.

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• ❌ “We told you before not to feed your child. Do you think you know better than us?” = Condescending and confrontational. Dismisses the parent’s concerns and creates conflict.

• ❌ “We provide the best care for your child, but you never seem to be satisfied.” = Defensive and unprofessional. Shifts focus away from the child’s needs and escalates the emotional tension.

1. The nurse assesses a client and notes fatigue, nausea, muscle weakness, and cardiac irregularities. Which prescription should the nurse anticipate for the client?

• 1. Arrange for dialysis 

• 1. Administer diuretics

• 1. Administer normal saline fluid bolus 

• 1. Give glucose and insulin 

Answer explanation

✅ Correct Answer: Give glucose and insulin

• → The signs and symptoms — fatigue, nausea, muscle weakness, and cardiac irregularities — suggest hyperkalemia (elevated serum potassium). This is a life-threatening electrolyte imbalance that can cause cardiac dysrhythmias.

• Glucose and insulin are used together to drive potassium into the cells, lowering serum potassium quickly. This is a first-line emergency intervention for moderate to severe hyperkalemia.

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❌ Other Options Explained:

• Arrange for dialysis
  → Used in severe or unresponsive hyperkalemia, particularly in clients with renal failure. It's appropriate but not the first anticipated action unless potassium is extremely elevated or the patient is anuric.

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  Administer diuretics
  → May help in mild hyperkalemia, but not fast-acting enough for acute symptoms and less effective if renal function is impaired.

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  Administer normal saline fluid bolus
  → Not indicated in hyperkalemia and could worsen fluid overload or have no effect on potassium levels.

The UAP performs hygiene care on a client receiving chemotherapy and external radiation for cancer. When the client calls the nurse into the room to report that the UAP is not providing appropriate care to the radiation site, which assessment finding supports the client’s report?

• 1. Rinsing skin on radiation site and patting dry with a washcloth 

• Washing broken skin to radiation site and applying a perfumed lotion

• Using normal saline to clean broken skin to the radiation site

• Using unscented soap to cleanse the skin to the radiation site

Answer explanation

✅ Correct Answer: Washing broken skin to radiation site and applying a perfumed lotion = it is incorrect and unsafe care. Applying perfumed lotions to broken or irradiated skin is contraindicated. Fragrances and additives can irritate the skin, delay healing, and increase the risk of infection, especially when the skin is compromised from radiation.

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❌ Correct and Safe Practices (All the other options):

• →Rinsing skin on radiation site and patting dry with a washcloth = Gently rinsing and patting dry the area is appropriate to minimize trauma to the fragile skin.

• → Using normal saline to clean broken skin to the radiation site = Using normal saline is safe for cleaning broken or sensitive skin, especially in radiation areas.

• → Using unscented soap to cleanse the skin to the radiation site = Unscented, mild soap is appropriate for gentle cleansing as long as the skin is not broken.

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🧠 NCLEX Tip:

For external radiation sites:

• → Avoid lotions, perfumes, deodorants, or powders unless prescribed.

• → Use lukewarm water, no scrubbing, and no heat/cold applications.

• → Protect the skin from sunlight and friction.