Medical Surgical Nursing

1. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication
was administered. The nurses best A. The patient is having an allergic reaction to the drug. B. The patient needs a higher dose of this drug C. This is normal side-effect of AtSO4 D. The patient is anxious about upcoming surgery 2. Anas postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question? A.Put the client in modified Trendelenbergs position. B. Administer oxygen at 100%. C. Monitor urine output every hour. D. Administer Demerol 50mg IM q4h

1.

A client is being evaluated for cancer of the colon. In preparing the

client for barium enema, the nurse should:

A. Give laxative the night before and a cleansing enema in the morning before the test B. Render an oil retention enema and give laxative the night before C. Instruct the client to swallow 6 radiopaque tablets the evening before the study D. Place the client on CBR a day before the study

2.

The client has a good understanding of the means to reduce the chances A. I will exercise daily. B. I will include more red meat in my diet. C. I will have an annual chest x-ray. D. I will include more fresh fruits and vegetables in my diet.

of colon cancer when he states:

5. Assessing the laboratory findings, which result would the nurse most

likely expect to find in a client with chronic renal failure?

A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased

serum calcium right upper and lower

The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the 1. extremities, as ordered by the physician. This medication will: A. Inhibit bacterial growth B. Relieve pain from the burn C. Prevent scar tissue formation D. Provide chemical debridement

Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12h. The drop factor of 2. the tubing is 10 gtt/ml. The nurse should set the flow to provide: A. 18 gtt/min B. 28 gtt/min C. 32 gtt/min D. 36 gtt/min 8. A client with head injury is confused, drowsy and has unequal A. altered level of cognitive function B. high risk for injury C. altered cerebral tissue perfusion D. sensory perceptual alteration 9. Which nursing diagnosis is of the highest priority when caring A. Pain B. High risk for injury related to muscle weakness C. Ineffective coping related to illness D. Ineffective airway clearance related to muscle weakness 10. The client has clear drainage from the nose and ears after a head injury. How can the nurse determine if the drainage is CSF? for a client with myasthenia gravis? pupils. Which of the following nursing diagnosis is most important at this time?

A. Measure the ph of the fluid B. Measure the specific gravity of the fluid C. Test for glucose D. Test for chlorides 11. The nurse includes the important measures for stump care in the be excluded from the teaching plan? A. Wash, dry, and inspect the stump daily. B. Treat superficial abrasions and blisters promptly. C. Apply a "shrinker" bandage with tighter arms around the D. Toughen the stump by pushing it against a progressively 12. Which is the most relevant knowledge about oxygen teaching plan for a client with an amputation. Which measure would

proximal end of the affected limb. harder substance (e.g., pillow on a foot-stool).

administration to a client with COPD? stimulus for medulla that breathing. makes the client breath.

A. Oxygen at 1-2L/min is given to maintain the hypoxic B. Hypoxia stimulates the central chemoreceptors in the C. Oxygen is administered best using a non-rebreathing mask D. Blood gases are monitored using a pulse oximeter.

1.

When suctioning mucus from a clients lungs, which nursing

action

would be least appropriate?

A. Lubricate the catheter tip with sterile saline before insertion. B. Use sterile technique with a two-gloved approach C. Suction until the client indicates to stop or no longer than 20 second D. Hyperoxygenate the client before and after suctioning

2.

An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:

A. Emptying the drainage bag frequently B. Collecting a weekly urine specimen C. Maintaining the ordered hydration D. Assessing urine specific gravity

3.

The nurse performs full range of motion on a bedridden clients extremities. When putting his ankle through range of motion, the nurse must perform:

A. Flexion, extension and left and right rotation B. Abduction, flexion, adduction and extension C. Pronation, supination, rotation, and extension D. Dorsiflexion, plantar flexion, eversion and inversion

ANSWERS 1. Answer: (C) This is normal side-effect of AtSO4. secretions and increases the heart rate. Atropine sulfate is a vagolytic drug that decreases oropharyngeal

2. Answer: (D) Administer Demerol 50mg IM q4h Administering Demerol, which is a narcotic analgesic, can depress respiratory and cardiac function and thus not given to a patient in shock. What is needed is promotion for adequate oxygenation and perfusion. All the other interventions can be expected to be done by the nurse. 3. Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema. 4. Answer: (D) I will include more fresh fruits and vegetables in my diet. Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.
1.

Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L

Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained.
2.

Answer: (A) Inhibit bacterial growth Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes.

7.

Answer: (B) 28 gtt/min This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes) 8. Answer: (C) altered cerebral tissue perfusion The observations made by the nurse clearly indicate a problem of decrease cerebral perfusion. Restoring cerebral perfusion is most important to maintain cerebral functioning and prevent further brain damage.

9. Answer: (D) Ineffective airway clearance related to muscle weakness Myasthenia gravis causes a failure in the transmission of nerve impulses at the neuromuscular junction which may be due to a weakening or decrease in acetylcholine receptor sites. This leads to sporadic, progressive weakness or abnormal fatigability of striated muscles that eventually causes loss of function. The respiratory muscles can become weak with decreased tidal volume and vital capacity making breathing and clearing the airway through coughing difficult. The respiratory muscle weakness may be severe enough to require and emergency airway and mechanical ventilation. 10. Answer: (C) Test for glucose The CSF contains a large amount of glucose which can be detected by using glucostix. A positive result with the drainage indicate CSF leakage. 11. Answer: (C) Apply a "shrinker" bandage with tighter arms around the proximal end of the affected limb. The shrinker bandage is applied to prevent swelling of the stump. It should be applied with the distal end with the tighter arms. Applying the tighter arms at the proximal end will impair circulation and cause swelling by reducing venous flow. 12. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the clients hypoxic drive. 13. Answer: (C) Suction until the client indicates to stop or no longer than 20 second One hazard encountered when suctioning a client is the development of hypoxia. Suctioning sucks not only the secretions but also the gases found in the airways. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning. 14. Answer: (C) Maintaining the ordered hydration Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection. 15. Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion These movements include all possible range of motion for the ankle joint