MEDICAL SURGICAL NURSING Part 1
Abdominal cramps
1. Mrs. Chua a 78 year old client is
admitted with the
diagnosis of mild chronic heart failure. The
nurse expects
to hear when listening to client’s lungs
indicative of
chronic heart failure would be:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
2. Patrick who is hospitalized following a
myocardial
infarction asks the nurse why he is taking
morphine. The
nurse explains that morphine:
a. Decrease anxiety and restlessness
b. Prevents shock and relieves pain
c. Dilates coronary blood vessels
d. Helps prevent fibrillation of the heart
3. Which of the following should the nurse
teach the
client about the signs of digitalis toxicity?
a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing
yellow spots
4. Nurse Trisha teaches a client with heart
failure to take
oral Furosemide in the morning. The
reason for this is to
help…
a. Retard rapid drug absorption
b. Excrete excessive fluids accumulated at
night
c. Prevents sleep disturbances during night
d. Prevention of electrolyte imbalance
5. What would be the primary goal of
therapy for a client
with pulmonary edema and heart failure?
a. Enhance comfort
b. Increase cardiac output
c. Improve respiratory status
d. Peripheral edema decreased
6. Nurse Linda is caring for a client with
head injury and
monitoring the client with decerebrate
posturing. Which
of the following is a characteristic of this
type of
posturing?
a. Upper extremity flexion with lower
extremity flexion
b. Upper extremity flexion with lower
extremity
extension
c. Extension of the extremities after a
stimulus
d. Flexion of the extremities after stimulus
7. A female client is taking Cascara
Sagrada. Nurse Betty
informs the client that the following
maybe experienced
as side effects of this medication:
a. GI bleeding
b. Peptic ulcer disease
c.
d. Partial bowel obstruction
8. Dr. Marquez orders a continuous
intravenous
nitroglycerin infusion for the client
suffering from
myocardial infarction. Which of the
following is the most
essential nursing action?
a. Monitoring urine output frequently
b. Monitoring blood pressure every 4
hours
c. Obtaining serum potassium levels daily
d. Obtaining infusion pump for the
medication
9. During the second day of hospitalization
of the client
after a Myocardial Infarction. Which of the
following is
an expected outcome?
a. Able to perform self-care activities
without pain
b. Severe chest pain
c. Can recognize the risk factors of
Myocardial Infarction
d. Can Participate in cardiac rehabilitation
walking
program
10. A 68 year old client is diagnosed with a
right-sided
brain attack and is admitted to the
hospital. In caring for
this client, the nurse should plan to:
a. Application of elastic stockings to d. To measure oxygen content of different is an important measure. To promote
prevent flaccid by heart good dental care
muscle chambers in client with mitral stenosis in teaching
b. Use hand roll and extend the left upper 13. During the first several hours after a plan should
extremity on a cardiac include proper use of…
pillow to prevent contractions catheterization, it would be most essential a. Dental floss
c. Use a bed cradle to prevent dorsiflexion for nurse b. Electric toothbrush
of feet Cherry to… c. Manual toothbrush
d. Do passive range of motion exercise a. Elevate clients bed at 45ｰ d. Irrigation device
11. Nurse Liza is assigned to care for a 16. Among the following signs and
b. Instruct the client to cough and deep
client who has symptoms, which
breathe every 2
returned to the nursing unit after left would most likely be present in a client
hours
nephrectomy. c. Frequently monitor client’s apical pulse with mitral
Nurse Liza’s highest priority would be… and blood gurgitation?
a. Hourly urine output pressure a. Altered level of consciousness
b. Temperature b. Exceptional Dyspnea
476
c. Able to turn side to side c. Increase creatine phospholinase
476
d. Able to sips clear liquid concentration
d. Monitor clients temperature every hour
12. A 64 year old male client with a long d. Chest pain
14. Kate who has undergone mitral valve
history of 17. Kris with a history of chronic infection
replacement
cardiovascular problem including of the urinary
suddenly experiences continuous bleeding
hypertension and from the system complains of urinary frequency
angina is to be scheduled for cardiac surgical incision during postoperative and burning
catheterization. sensation. To figure out whether the
period. Which of
During pre cardiac catheterization the following pharmaceutical agents current problem is
teaching, Nurse in renal origin, the nurse should assess
should Nurse Aiza
Cherry should inform the client that the whether the
prepare to administer to Kate?
primary purpose client has discomfort or pain in the…
a. Protamine Sulfate
of the procedure is….. a. Urinary meatus
b. Quinidine Sulfate
a. To determine the existence of CHD b. Pain in the Labium
c. Vitamin C
b. To visualize the disease process in the c. Suprapubic area
d. Coumadin
coronary d. Right or left costovertebral angle
15. In reducing the risk of endocarditis,
arteries good dental care 18. Nurse Perry is evaluating the renal
c. To obtain the heart chambers pressure function of a male
client. After documenting urine volume Raynaud’s disease. Nurse Lilly realizes that 24. Nurse Donna is aware that the shift of
and the etiology body fluids
characteristics, Nurse Perry assesses which of the disease is unknown but it is associated with Intravenous
signs as the characterized by: administration of albumin
best indicator of renal function. a. Episodic vasospastic disorder of occurs in the process of:
a. Blood pressure capillaries a. Osmosis
b. Consciousness b. Episodic vasospastic disorder of small b. Diffusion
c. Distension of the bladder veins c. Active transport
d. Pulse rate c. Episodic vasospastic disorder of the d. Filtration
19. John suddenly experiences a seizure, aorta 25. Myrna a 52 year old client with a
and Nurse Gina d. Episodic vasospastic disorder of the fractured left tibia
notice that John exhibits uncontrollable small arteries has a long leg cast and she is using
jerking 22. Nurse Jamie should explain to male crutches to ambulate.
movements. Nurse Gina documents that client with Nurse Joy assesses for which sign and
John diabetes that self-monitoring of blood symptom that
experienced which type of seizure? glucose is indicates complication associated with
a. Tonic seizure preferred to urine glucose testing crutch walking?
b. Absence seizure because… a. Left leg discomfort
c. Myoclonic seizure a. More accurate b. Weak biceps brachii
d. Clonic seizure b. Can be done by the client c. Triceps muscle spasm
20. Smoking cessation is critical strategy c. It is easy to perform d. Forearm weakness
for the client d. It is not influenced by drugs 26. Which of the following statements
with Burgher’s disease, Nurse Jasmin 23. Jessie weighed 210 pounds on should the nurse
anticipates that the admission to the teach the neutropenic client and his family
male client will go home with a hospital. After 2 days of diuretic therapy, to avoid?
prescription for which Jessie weighs a. Performing oral hygiene after every
medication? 205.5 pounds. The nurse could estimate meal
a. Paracetamol the amount of b. Using suppositories or enemas
b. Ibuprofen fluid Jessie has lost… c. Performing perineal hygiene after each
c. Nitroglycerin a. 0.3 L bowel
d. Nicotine (Nicotrol) b. 1.5 L movement
21. Nurse Lilly has been assigned to a c. 2.0 L d. Using a filter mask
client with d. 3.5 L 27. A female client is experiencing painful
and rigid
abdomen and is diagnosed with
perforated peptic ulcer.
477
477
A surgery has been scheduled and a
nasogastric tube is
inserted. The nurse should place the client
before
surgery in
a. Sims position
b. Supine position
c. Semi-fowlers position
d. Dorsal recumbent position
28. Which nursing intervention ensures
adequate
ventilating exchange after surgery?
a. Remove the airway only when client is
fully conscious
b. Assess for hypoventilation by
auscultating the lungs
c. Position client laterally with the neck
extended
d. Maintain humidified oxygen via nasal
canula
29. George who has undergone thoracic
surgery has
chest tube connected to a water-seal
drainage system
attached to suction. Presence of excessive
bubbling is
identified in water-seal chamber, the
nurse should…
a. “Strip” the chest tube catheter
b. Check the system for air leaks
c. Recognize the system is functioning b. Incision site
correctly c. Airway
d. Decrease the amount of suction d. Level of consciousness
pressure 33. A client has 15% blood loss. Which of
30. A client who has been diagnosed of the following
hypertension is nursing assessment findings indicates
being taught to restrict intake of sodium. hypovolemic
The nurse shock?
would know that the teachings are a. Systolic blood pressure less than 90mm
effective if the client Hg
states that… b. Pupils unequally dilated
a. I can eat celery sticks and carrots c. Respiratory rate of 4 breath/min
b. I can eat broiled scallops d. Pulse rate less than 60bpm
c. I can eat shredded wheat cereal 34. Nurse Lucy is planning to give pre
d. I can eat spaghetti on rye bread operative teaching
31. A male client with a history of cirrhosis to a client who will be undergoing
and rhinoplasty. Which of
alcoholism is admitted with severe the following should be included?
dyspnea resulted to a. Results of the surgery will be
ascites. The nurse should be aware that immediately noticeable
the ascites is postoperatively
most likely the result of increased… b. Normal saline nose drops will need to
a. Pressure in the portal vein be administered
b. Production of serum albumin preoperatively
c. Secretion of bile salts c. After surgery, nasal packing will be in
d. Interstitial osmotic pressure place 8 to 10
32. A newly admitted client is diagnosed days
with Hodgkin’s d. Aspirin containing medications should
disease undergoes an excisional cervical not be taken 14
lymph node days before surgery
biopsy under local anesthesia. What does 35. Paul is admitted to the hospital due to
the nurse metabolic
assess first after the procedure? acidosis caused by Diabetic ketoacidosis
a. Vital signs (DKA). The
nurse prepares which of the following c. Increased GI motility b. Yellow urine
medications as an d. Difficulty in swallowing c. Nausea
initial treatment for this problem? 39. A client who has undergone a d. Clay- colored stools
a. Regular insulin cholecystectomy asks 41. Which of the following
b. Potassium the nurse whether there are any dietary antituberculosis drugs can
c. Sodium bicarbonate restrictions that damage the 8th cranial nerve?
d. Calcium gluconate must be followed. Nurse Hilary would a. Isoniazid (INH)
36. Dr. Marquez tells a client that an recognize that the b. Paraoaminosalicylic acid (PAS)
increase intake of dietary teaching was well understood c. Ethambutol hydrochloride (myambutol)
foods that are rich in Vitamin E and beta- when the client d. Streptomycin
carotene are tells a family member that: 42. The client asks Nurse Annie the causes
important for healthier skin. The nurse a. “Most people need to eat a high protein of peptic
teaches the client diet for 12 ulcer. Nurse Annie responds that recent
that excellent food sources of both of months after surgery” research
these substances b. “I should not eat those foods that upset indicates that peptic ulcers are the result
are: me before the of which of the
a. Fish and fruit jam surgery” following:
b. Oranges and grapefruit c. “I should avoid fatty foods as long as I a. Genetic defect in gastric mucosa
c. Carrots and potatoes live” b. Stress
d. Spinach and mangoes 478 c. Diet high in fat
37. A client has Gastroesophageal Reflux 478 d. Helicobacter pylori infection
Disease (GERD). d. “Most people can tolerate regular diet 43. Ryan has undergone subtotal
The nurse should teach the client that after this type gastrectomy. The nurse
after every meals, of surgery” should expect that nasogastric tube
the client should… 40. Nurse Rachel teaches a client who has drainage will be
a. Rest in sitting position been recently what color for about 12 to 24 hours after
b. Take a short walk diagnosed with hepatitis A about surgery?
c. Drink plenty of water untoward signs and a. Bile green
d. Lie down at least 30 minutes symptoms related to Hepatitis that may b. Bright red
38. After gastroscopy, an adaptation that develop. The c. Cloudy white
indicates major one that should be reported immediately d. Dark brown
complication would be: to the 44. Nurse Joan is assigned to come for
a. Nausea and vomiting physician is: client who has
b. Abdominal distention a. Restlessness
just undergone eye surgery. Nurse Joan b. Warming the solution to room 50. Which of the following symptoms
plans to teach temperature during the icteric
the client activities that are permitted c. Pacing the tip of the dropper on the phase of viral hepatitis should the nurse
during the post edge of ear canal expect the
operative period. Which of the following is d. Placing client in side lying position client to inhibit?
best 47. Nurse Bea should instruct the male a. Watery stool
recommended for the client? client with an b. Yellow sclera
a. Watching circus ileostomy to report immediately which of c. Tarry stool
b. Bending over the following d. Shortness of breath
c. Watching TV symptom? ANSWERS and RATIONALES for
d. Lifting objects a. Absence of drainage from the ileostomy MEDICAL SURGICAL
45. A client suffered from a lower leg for 6 or more NURSING Part 1
injury and seeks hours 1. B. Left sided heart failure causes fluid
treatment in the emergency room. There b. Passage of liquid stool in the stoma accumulation in the capillary network of
is a prominent c. Occasional presence of undigested food the
deformity to the lower aspect of the leg, d. A temperature of 37.6 ｰC lung. Fluid eventually enters alveolar
and the injured spaces and
48. Jerry has diagnosed with appendicitis.
leg appears shorter that the other leg. The causes crackling sounds at the end of
He develops a
affected leg is inspiration.
fever, hypotension and tachycardia. The
painful, swollen and beginning to become 2. B. Morphine is a central nervous system
nurse suspects
ecchymotic. depressant used to relieve the pain
which of the following complications?
The nurse interprets that the client is associated
a. Intestinal obstruction
experiencing: with myocardial infarction, it also
b. Peritonitis
a. Fracture decreases
c. Bowel ischemia
b. Strain apprehension and prevents cardiogenic
d. Deficient fluid volume
c. Sprain shock.
49. Which of the following compilations
d. Contusion 3. D. Seeing yellow spots and colored
should the nurse
46. Nurse Jenny is instilling an otic solution vision are
carefully monitors a client with acute
into an adult common symptoms of digitalis toxicity
pancreatitis.
male client left ear. Nurse Jenny avoids 4. C. When diuretics are taken in the
a. Myocardial Infarction
doing which of morning,
b. Cirrhosis
the following as part of the procedure client will void frequently during daytime
c. Peptic ulcer
a. Pulling the auricle backward and and
d. Pneumonia
upward will not need to void frequently at night.
5. B. The primary goal of therapy for the
client with
pulmonary edema or heart failure is
increasing
cardiac output. Pulmonary edema is an
acute
medical emergency requiring immediate
intervention.
6. C. Decerebrate posturing is the
extension of the
extremities after a stimulus, which may
occur
with upper brain stem injury.
7. C. The most frequent side effects of
Cascara
Sagrada (Laxative) is abdominal cramps
and
nausea.
8. D. Administration of Intravenous
Nitroglycerin
infusion requires pump for accurate
control of
medication.
9. A. By the 2nd day of hospitalization after
suffering a Myocardial Infarction, Clients
are
able to perform care without chest pain
10. B. The left side of the body will be
affected in a
right-sided brain attack.
11. A. After nephrectomy, it is necessary
to measure
urine output hourly. This is done to assess
the
effectiveness of the remaining kidney also
to
detect renal failure early.
12. B. The lumen of the arteries can be
assessed by
cardiac catheterization. Angina is usually
caused
by narrowing of the coronary arteries.
13. C. Blood pressure is monitored to
detect
hypotension which may indicate shock or
hemorrhage. Apical pulse is taken to
detect
dysrhythmias related to cardiac irritability.
14. A. Protamine Sulfate is used to
prevent
continuous bleeding in client who has
undergone open heart surgery.
15. C. The use of electronic toothbrush,
irrigation
device or dental floss may cause bleeding
of
gums, allowing bacteria to enter and
increasing
the risk of endocarditis.
16. B. Weight gain due to retention of
fluids and
worsening heart failure causes exertional
dyspnea in clients with mitral
regurgitation.
17. D. Discomfort or pain is a problem that
originates in the kidney. It is felt at the
costovertebral angle on the affected side.
18. A. Perfusion can be best estimated by
blood
pressure, which is an indirect reflection of
the
adequacy of cardiac output.
19. C. Myoclonic seizure is characterized
by sudden
uncontrollable jerking movements of a
single or
multiple muscle group.
20. D. Nicotine (Nicotrol) is given in
controlled and
decreasing doses for the management of
nicotine withdrawal syndrome.
21. D. Raynaud’s disease is characterized
by
vasospasms of the small cutaneous
arteries that
involves fingers and toes.
22. A. Urine testing provides an indirect
measure
that maybe influenced by kidney function
while
blood glucose testing is a more direct and
accurate measure.
23. C. One liter of fluid approximately
weighs 2.2
pounds. A 4.5 pound weight loss equals to
approximately 2L.
24. A. Osmosis is the movement of fluid
from an
area of lesser solute concentration to an
area of
greater solute concentration.
25. D. Forearm muscle weakness is a
probable sign
of radial nerve injury caused by crutch
pressure
on the axillae.
26. B. Neutropenic client is at risk for
infection
especially bacterial infection of the
gastrointestinal and respiratory tract.
27. C. Semi-fowlers position will localize
the spilled
stomach contents in the lower part of the
abdominal cavity.
28. C. Positioning the client laterally with
the neck
extended does not obstruct the airway so
that
drainage of secretions and oxygen and
carbon
dioxide exchange can occur.
29. B. Excessive bubbling indicates an air
leak which
must be eliminated to permit lung
expansion.
30. C. Wheat cereal has a low sodium
content.
31. A. Enlarged cirrhotic liver impinges the
portal
system causing increased hydrostatic
pressure
resulting to ascites.
32. C. Assessing for an open airway is the
priority.
The procedure involves the neck, the green leafy vegetables. Food sources of
anesthesia betacarotene
may have affected the swallowing reflex include dark green vegetables, carrots,
or the mangoes and tomatoes.
480 37. A. Gravity speeds up digestion and
480 prevents
inflammation may have closed in on the reflux of stomach contents into the
airway esophagus.
leading to ineffective air exchange. 38. B. Abdominal distension may be
33. A. Typical signs and symptoms of associated with
hypovolemic pain, may indicate perforation, a
shock includes systolic blood pressure of complication
less that could lead to peritonitis.
than 90 mm Hg. 39. D. It may take 4 to 6 months to eat
34. D. Aspirin containing medications anything, but
should not be most people can eat anything they want.
taken 14 days before surgery to decrease 40. D. Clay colored stools are indicative of
the hepatic
risk of bleeding. obstruction
35. A. Metabolic acidosis is anaerobic 41. D. Streptomycin is an aminoglycoside
metabolism and
caused by lack of ability of the body to use damage on the 8th cranial nerve
circulating glucose. Administration of (ototoxicity) is a
insulin common side effect of aminoglycosides.
corrects this problem. 42. D. Most peptic ulcer is caused by
36. D. Beta-carotene and Vitamin E are Helicopter
antioxidants pylori which is a gram negative bacterium.
which help to inhibit oxidation. Vitamin E 43. D. 12 to 24 hours after subtotal
is gastrectomy
found in the following foods: wheat germ, gastric drainage is normally brown, which
corn, indicates digested food.
nuts, seeds, olives, spinach, asparagus 44. C. Watching TV is permissible because
and other the eye
does not need to move rapidly with this 481 4. Nurse Carol is assessing a client with
activity, MEDICAL SURGICAL NURSING Part 2 Parkinson’s
and it does not increase intraocular 1. A client is scheduled for insertion of an disease. The nurse recognize bradykinesia
pressure. inferior vena when the
45. A. Common signs and symptoms of cava (IVC) filter. Nurse Patricia consults client exhibits:
fracture the physician a. Intentional tremor
include pain, deformity, shortening of the about withholding which regularly b. Paralysis of limbs
extremity, crepitus and swelling. scheduled medication c. Muscle spasm
46. C. The dropper should not touch any on the day before the surgery? d. Lack of spontaneous movement
object or a. Potassium Chloride 5. A client who suffered from automobile
any part of the client’s ear. b. Warfarin Sodium accident
47. A. Sudden decrease in drainage or c. Furosemide complains of seeing frequent flashes of
onset of d. Docusate light. The nurse
severe abdominal pain should be reported 2. A nurse is planning to assess the corneal should expect:
immediately to the physician because it reflex on a. Myopia
could unconscious client. Which of the following b. Detached retina
mean that obstruction has been is the safest c. Glaucoma
developed. stimulus to touch the client’s cornea? d. Scleroderma
48. B. Complications of acute appendicitis a. Cotton buds 6. Kate with severe head injury is being
are b. Sterile glove monitored by the
peritonitis, perforation and abscess c. Sterile tongue depressor nurse for increasing intracranial pressure
development. d. Wisp of cotton (ICP). Which
49. D. A client with acute pancreatitis is 3. A female client develops an infection at finding should be most indicative sign of
prone to the catheter increasing
complications associated with respiratory insertion site. The nurse in charge uses the intracranial pressure?
system. term a. Intermittent tachycardia
50. B. Liver inflammation and obstruction “iatrogenic” when describing the infection b. Polydipsia
block the because it c. Tachypnea
normal flow of bile. Excess bilirubin turns resulted from: d. Increased restlessness
the a. Client’s developmental level 7. A hospitalized client had a tonic-clonic
skin and sclera yellow and the urine dark b. Therapeutic procedure seizure while
and c. Poor hygiene walking in the hall. During the seizure the
frothy. d. Inadequate dietary patterns nurse priority
481 should be:
a. Hold the clients arms and leg firmly 11. During the initial postoperative period 14. A female client has an acute
b. Place the client immediately to soft of the client’s pancreatitis. Which of
surface stoma. The nurse evaluates which of the the following signs and symptoms the
c. Protects the client’s head from injury following nurse would
d. Attempt to insert a tongue depressor observations should be reported expect to see?
between the immediately to the a. Constipation
client’s teeth physician? b. Hypertension
8. A client has undergone right a. Stoma is dark red to purple 482
pneumonectomy. When b. Stoma is oozes a small amount of blood 482
turning the client, the nurse should plan to c. Stoma is lightly edematous c. Ascites
position the d. Stoma does not expel stool d. Jaundice
client either: 12. Kate which has diagnosed with 15. A client is suspected to develop tetany
a. Right side-lying position or supine ulcerative colitis is after a
b. High fowlers following physician’s order for bed rest subtotal thyroidectomy. Which of the
c. Right or left side lying position with bathroom following
d. Low fowler’s position privileges. What is the rationale for this symptoms might indicate tetany?
9. Nurse Jenny should caution a female activity a. Tingling in the fingers
client who is restriction? b. Pain in hands and feet
sexually active in taking Isoniazid (INH) a. Prevent injury c. Tension on the suture lines
because the drug b. Promote rest and comfort d. Bleeding on the back of the dressing
has which of the following side effects? c. Reduce intestinal peristalsis 16. A 58 year old woman has newly
a. Prevents ovulation d. Conserve energy diagnosed with
b. Has a mutagenic effect on ova 13. Nurse KC should regularly assess the hypothyroidism. The nurse is aware that
c. Decreases the effectiveness of oral client’s ability to the signs and
contraceptives metabolize the total parenteral nutrition symptoms of hypothyroidism include:
d. Increases the risk of vaginal infection (TPN) solution a. Diarrhea
10. A client has undergone gastrectomy. adequately by monitoring the client for b. Vomiting
Nurse Jovy is which of the c. Tachycardia
aware that the best position for the client following signs: d. Weight gain
is: a. Hyperglycemia 17. A client has undergone for an ileal
a. Left side lying b. Hypoglycemia conduit, the nurse
b. Low fowler’s c. Hypertension in charge should closely monitor the client
c. Prone d. Elevate blood urea nitrogen for
d. Supine concentration
occurrence of which of the following c. Infection 24. A client has suffered from fall and
complications d. Platelet dysfunction sustained a leg
related to pelvic surgery? 21. Nurse Karen is caring for clients in the injury. Which appropriate question would
a. Ascites OR. The nurse the nurse ask
b. Thrombophlebitis is aware that the last physiologic function the client to help determine if the injury
c. Inguinal hernia that the client caused
d. Peritonitis loss during the induction of anesthesia is: fracture?
18. Dr. Marquez is about to defibrillate a a. Consciousness a. “Is the pain sharp and continuous?”
client in b. Gag reflex b. “Is the pain dull ache?”
ventricular fibrillation and says in a loud c. Respiratory movement c. “Does the discomfort feel like a cramp?”
voice “clear”. d. Corneal reflex d. “Does the pain feel like the muscle was
What should be the action of the nurse? 22. The nurse is assessing a client with stretched?”
a. Places conductive gel pads for pleural effusion. 25. The Nurse is assessing the client’s
defibrillation on the The nurse expect to find: casted extremity
client’s chest a. Deviation of the trachea towards the for signs of infection. Which of the
b. Turn off the mechanical ventilator involved side following findings is
c. Shuts off the client’s IV infusion b. Reduced or absent of breath sounds at indicative of infection?
d. Steps away from the bed and make sure the base of the a. Edema
all others lung b. Weak distal pulse
have done the same c. Moist crackles at the posterior of the c. Coolness of the skin
19. A client has been diagnosed with lungs d. Presence of “hot spot” on the cast
glomerulonephritis d. Increased resonance with percussion of 26. Nurse Rhia is performing an otoscopic
complains of thirst. The nurse should the involved examination
offer: area on a female client with a suspected
a. Juice 23. A client admitted with newly diagnosis of
b. Ginger ale diagnosed with mastoiditis. Nurse Rhia would expect to
c. Milk shake Hodgkin’s disease. Which of the following note which of
d. Hard candy would the the following if this disorder is present?
20. A client with acute renal failure is nurse expect the client to report? a. Transparent tympanic membrane
aware that the a. Lymph node pain b. Thick and immobile tympanic
most serious complication of this b. Weight gain membrane
condition is: c. Night sweats c. Pearly colored tympanic membrane
a. Constipation d. Headache d. Mobile tympanic membrane
b. Anemia
27. Nurse Jocelyn is caring for a client with 30. A 58 year old client is suffering from c. Use tongue depressor between teeth
nasogastric acute phase of d. Loosen restrictive clothing
tube that is attached to low suction. Nurse rheumatoid arthritis. Which of the 34. A client has undergone bone biopsy.
Jocelyn following would the Which nursing
assesses the client for symptoms of which nurse in charge identify as the lowest action should the nurse provide after the
acid-base priority of the plan procedure?
disorder? of care? a. Administer analgesics via IM
a. Respiratory alkalosis a. Prevent joint deformity b. Monitor vital signs
b. Respiratory acidosis b. Maintaining usual ways of c. Monitor the site for bleeding, swelling
c. Metabolic acidosis accomplishing task and hematoma
d. Metabolic alkalosis c. Relieving pain formation
28. A male adult client has undergone a d. Preserving joint function d. Keep area in neutral position
lumbar puncture 31. Among the following, which client is 35. A client is suffering from low back
to obtain cerebrospinal fluid (CSF) for autotransfusion pain. Which of the
analysis. Which of possible? following exercises will strengthen the
the following values should be negative if a. Client with AIDS lower back
the CSF is b. Client with ruptured bowel muscle of the client?
normal? c. Client who is in danger of cardiac arrest a. Tennis
a. Red blood cells d. Client with wound infection b. Basketball
b. White blood cells 32. Which of the following is not a sign of c. Diving
483 thromboembolism? d. Swimming
483 a. Edema 36. A client with peptic ulcer is being
c. Insulin b. Swelling assessed by the
d. Protein c. Redness nurse for gastrointestinal perforation. The
29. A client is suspected of developing d. Coolness nurse should
diabetes 33. Nurse Becky is caring for client who monitor for:
insipidus. Which of the following is the begins to a. (+) guaiac stool test
most effective experience seizure while in bed. Which b. Slow, strong pulse
assessment? action should the c. Sudden, severe abdominal pain
a. Taking vital signs every 4 hours nurse implement to prevent aspiration? d. Increased bowel sounds
b. Monitoring blood glucose a. Position the client on the side with head 37. A client has undergone surgery for
c. Assessing ABG values every other day flexed retinal
d. Measuring urine output hourly forward detachment. Which of the following goal
b. Elevate the head should be
prioritized?
a. Prevent an increase intraocular pressure
b. Alleviate pain
c. Maintain darkened room
d. Promote low-sodium diet
38. A Client with glaucoma has been
prescribed with
miotics. The nurse is aware that miotics is
for:
a. Constricting pupil
b. Relaxing ciliary muscle
c. Constricting intraocular vessel
d. Paralyzing ciliary muscle
39. When suctioning an unconscious
client, which
nursing intervention should the nurse
prioritize in
maintaining cerebral perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
d. Hyperoxygenate before and after
suctioning
40. When discussing breathing exercises
with a
postoperative client, Nurse Hazel should
include which
of the following teaching?
a. Short frequent breaths
b. Exhale with mouth open
c. Exercise twice a day
d. Place hand on the abdomen and feel it
rise
41. Louie, with burns over 35% of the
body, complains of
chilling. In promoting the client’s comfort,
the nurse
should:
a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees
42. Nurse Trish is aware that temporary
heterograft (pig
skin) is used to treat burns because this
graft will:
a. Relieve pain and promote rapid
epithelialization
b. Be sutured in place for better
adherence
c. Debride necrotic epithelium
d. Concurrently used with topical
antimicrobials
43. Mark has multiple abrasions and a
laceration to the
trunk and all four extremities says, “I can’t
eat all this
food”. The food that the nurse should
suggest to be
eaten first should be:
a. Meat loaf and coffee
484
484
b. Meat loaf and strawberries
c. Tomato soup and apple pie
d. Tomato soup and buttered bread
44. Tony returns form surgery with
permanent
colostomy. During the first 24 hours the
colostomy does
not drain. The nurse should be aware that:
a. Proper functioning of nasogastric
suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
45. When teaching a client about the signs
of colorectal
cancer, Nurse Trish stresses that the most
common
complaint of persons with colorectal
cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
46. Louis develops peritonitis and sepsis
after surgical
repair of ruptures diverticulum. The nurse
in charge
should expect an assessment of the client
to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds
47. Immediately after liver biopsy, the
client is placed on
the right side, the nurse is aware that that
this position
should be maintained because it will: 485 d. Inadequate dietary patterns
a. Help stop bleeding if any occurs 485 4. Nurse Carol is assessing a client with
b. Reduce the fluid trapped in the biliary MEDICAL SURGICAL NURSING Part 2 Parkinson’s
ducts 1. A client is scheduled for insertion of an disease. The nurse recognize bradykinesia
c. Position with greatest comfort inferior vena when the
d. Promote circulating blood volume cava (IVC) filter. Nurse Patricia consults client exhibits:
48. Tony has diagnosed with hepatitis A. the physician a. Intentional tremor
The information about withholding which regularly b. Paralysis of limbs
from the health history that is most likely scheduled c. Muscle spasm
linked to medication on the day before the surgery? d. Lack of spontaneous movement
hepatitis A is: a. Potassium Chloride 5. A client who suffered from automobile
a. Exposed with arsenic compounds at b. Warfarin Sodium accident
work c. Furosemide complains of seeing frequent flashes of
b. Working as local plumber d. Docusate light. The
c. Working at hemodialysis clinic 2. A nurse is planning to assess the corneal nurse should expect:
d. Dish washer in restaurants reflex on a. Myopia
49. Nurse Trish is aware that the unconscious client. Which of the following b. Detached retina
laboratory test result is the c. Glaucoma
that most likely would indicate acute safest stimulus to touch the client’s d. Scleroderma
pancreatitis is an cornea? 6. Kate with severe head injury is being
elevated: a. Cotton buds monitored by the
a. Serum bilirubin level b. Sterile glove nurse for increasing intracranial pressure
b. Serum amylase level c. Sterile tongue depressor (ICP).
c. Potassium level d. Wisp of cotton Which finding should be most indicative
d. Sodium level 3. A female client develops an infection at sign of
50. Dr. Marquez orders serum the catheter increasing intracranial pressure?
electrolytes. To determine insertion site. The nurse in charge uses the a. Intermittent tachycardia
the effect of persistent vomiting, Nurse term b. Polydipsia
Trish should be “iatrogenic” when describing the infection c. Tachypnea
most concerned with monitoring the: because it d. Increased restlessness
a. Chloride and sodium levels resulted from: 7. A hospitalized client had a tonic-clonic
b. Phosphate and calcium levels a. Client’s developmental level seizure while
c. Protein and magnesium levels b. Therapeutic procedure walking in the hall. During the seizure the
d. Sulfate and bicarbonate levels c. Poor hygiene nurse
priority should be: c. Prone d. Elevate blood urea nitrogen
a. Hold the clients arms and leg firmly d. Supine concentration
b. Place the client immediately to soft 11. During the initial postoperative period 14. A female client has an acute
surface of the client’s pancreatitis. Which of
c. Protects the client’s head from injury stoma. The nurse evaluates which of the the following signs and symptoms the
d. Attempt to insert a tongue depressor following nurse would
between observations should be reported expect to see?
the client’s teeth immediately to the a. Constipation
8. A client has undergone right physician? 486
pneumonectomy. When a. Stoma is dark red to purple 486
turning the client, the nurse should plan to b. Stoma is oozes a small amount of blood b. Hypertension
position c. Stoma is lightly edematous c. Ascites
the client either: d. Stoma does not expel stool d. Jaundice
a. Right side-lying position or supine 12. Kate which has diagnosed with 15. A client is suspected to develop tetany
b. High fowlers ulcerative colitis is after a
c. Right or left side lying position following physician’s order for bed rest subtotal thyroidectomy. Which of the
d. Low fowler’s position with following
9. Nurse Jenny should caution a female bathroom privileges. What is the rationale symptoms might indicate tetany?
client who is for this a. Tingling in the fingers
sexually active in taking Isoniazid (INH) activity restriction? b. Pain in hands and feet
because the a. Prevent injury c. Tension on the suture lines
drug has which of the following side b. Promote rest and comfort d. Bleeding on the back of the dressing
effects? c. Reduce intestinal peristalsis 16. A 58 year old woman has newly
a. Prevents ovulation d. Conserve energy diagnosed with
b. Has a mutagenic effect on ova 13. Nurse KC should regularly assess the hypothyroidism. The nurse is aware that
c. Decreases the effectiveness of oral client’s ability to the signs
contraceptives metabolize the total parenteral nutrition and symptoms of hypothyroidism include:
d. Increases the risk of vaginal infection (TPN) a. Diarrhea
10. A client has undergone gastrectomy. solution adequately by monitoring the b. Vomiting
Nurse Jovy is client for c. Tachycardia
aware that the best position for the client which of the following signs: d. Weight gain
is: a. Hyperglycemia 17. A client has undergone for an ileal
a. Left side lying b. Hypoglycemia conduit, the nurse
b. Low fowler’s c. Hypertension
in charge should closely monitor the client most serious complication of this nurse expect the client to report?
for condition is: a. Lymph node pain
occurrence of which of the following a. Constipation b. Weight gain
complications b. Anemia c. Night sweats
related to pelvic surgery? c. Infection d. Headache
a. Ascites d. Platelet dysfunction 24. A client has suffered from fall and
b. Thrombophlebitis 21. Nurse Karen is caring for clients in the sustained a leg
c. Inguinal hernia OR. The nurse injury. Which appropriate question would
d. Peritonitis is aware that the last physiologic function the nurse
18. Dr. Marquez is about to defibrillate a that the ask the client to help determine if the
client in client loss during the induction of injury caused
ventricular fibrillation and says in a loud anesthesia is: fracture?
voice a. Consciousness a. “Is the pain sharp and continuous?”
“clear”. What should be the action of the b. Gag reflex b. “Is the pain dull ache?”
nurse? c. Respiratory movement c. “Does the discomfort feel like a cramp?”
a. Places conductive gel pads for d. Corneal reflex d. “Does the pain feel like the muscle was
defibrillation on 22. The nurse is assessing a client with stretched?”
the client’s chest pleural effusion. 25. The Nurse is assessing the client’s
b. Turn off the mechanical ventilator The nurse expect to find: casted extremity
c. Shuts off the client’s IV infusion a. Deviation of the trachea towards the for signs of infection. Which of the
d. Steps away from the bed and make sure involved following findings
all side is indicative of infection?
others have done the same b. Reduced or absent of breath sounds at a. Edema
19. A client has been diagnosed with the b. Weak distal pulse
glomerulonephritis base of the lung c. Coolness of the skin
complains of thirst. The nurse should c. Moist crackles at the posterior of the d. Presence of “hot spot” on the cast
offer: lungs 26. Nurse Rhia is performing an otoscopic
a. Juice d. Increased resonance with percussion of examination
b. Ginger ale the on a female client with a suspected
c. Milk shake involved area diagnosis of
d. Hard candy 23. A client admitted with newly mastoiditis. Nurse Rhia would expect to
20. A client with acute renal failure is diagnosed with note which
aware that the Hodgkin’s disease. Which of the following of the following if this disorder is present?
would the a. Transparent tympanic membrane
b. Thick and immobile tympanic b. Monitoring blood glucose a. Position the client on the side with head
membrane c. Assessing ABG values every other day flexed forward
c. Pearly colored tympanic membrane d. Measuring urine output hourly b. Elevate the head
d. Mobile tympanic membrane 30. A 58 year old client is suffering from c. Use tongue depressor between teeth
27. Nurse Jocelyn is caring for a client with acute phase of d. Loosen restrictive clothing
nasogastric rheumatoid arthritis. Which of the 34. A client has undergone bone biopsy.
tube that is attached to low suction. Nurse following would Which nursing
Jocelyn the nurse in charge identify as the lowest action should the nurse provide after the
assesses the client for symptoms of which priority of procedure?
acid-base the plan of care? a. Administer analgesics via IM
disorder? a. Prevent joint deformity b. Monitor vital signs
a. Respiratory alkalosis b. Maintaining usual ways of c. Monitor the site for bleeding, swelling
b. Respiratory acidosis accomplishing task and
c. Metabolic acidosis c. Relieving pain hematoma formation
d. Metabolic alkalosis d. Preserving joint function d. Keep area in neutral position
28. A male adult client has undergone a 31. Among the following, which client is 35. A client is suffering from low back
lumbar puncture autotransfusion pain. Which of the
to obtain cerebrospinal fluid (CSF) for possible? following exercises will strengthen the
analysis. a. Client with AIDS lower back
487 b. Client with ruptured bowel muscle of the client?
487 c. Client who is in danger of cardiac arrest a. Tennis
Which of the following values should be d. Client with wound infection b. Basketball
negative if 32. Which of the following is not a sign of c. Diving
the CSF is normal? thromboembolism? d. Swimming
a. Red blood cells a. Edema 36. A client with peptic ulcer is being
b. White blood cells b. Swelling assessed by the
c. Insulin c. Redness nurse for gastrointestinal perforation. The
d. Protein d. Coolness nurse
29. A client is suspected of developing 33. Nurse Becky is caring for client who should monitor for:
diabetes begins to a. (+) guaiac stool test
insipidus. Which of the following is the experience seizure while in bed. Which b. Slow, strong pulse
most action should c. Sudden, severe abdominal pain
effective assessment? the nurse implement to prevent d. Increased bowel sounds
a. Taking vital signs every 4 hours aspiration?
37. A client has undergone surgery for
retinal
detachment. Which of the following goal
should be
prioritized?
a. Prevent an increase intraocular pressure
b. Alleviate pain
c. Maintain darkened room
d. Promote low-sodium diet
38. A Client with glaucoma has been
prescribed with
miotics. The nurse is aware that miotics is
for:
a. Constricting pupil
b. Relaxing ciliary muscle
c. Constricting intraocular vessel
d. Paralyzing ciliary muscle
39. When suctioning an unconscious
client, which
nursing intervention should the nurse
prioritize in
maintaining cerebral perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
d. Hyperoxygenate before and after
suctioning
40. When discussing breathing exercises
with a
postoperative client, Nurse Hazel should
include
which of the following teaching?
a. Short frequent breaths
b. Exhale with mouth open
c. Exercise twice a day
d. Place hand on the abdomen and feel it
rise
41. Louie, with burns over 35% of the
body, complains of
chilling. In promoting the client’s comfort,
the nurse
should:
a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees
42. Nurse Trish is aware that temporary
heterograft (pig
skin) is used to treat burns because this
graft will:
a. Relieve pain and promote rapid
epithelialization
b. Be sutured in place for better
adherence
c. Debride necrotic epithelium
d. Concurrently used with topical
antimicrobials
488
488
43. Mark has multiple abrasions and a
laceration to the
trunk and all four extremities says, “I can’t
eat all this
food”. The food that the nurse should
suggest to be
eaten first should be:
a. Meat loaf and coffee
b. Meat loaf and strawberries
c. Tomato soup and apple pie
d. Tomato soup and buttered bread
44. Tony returns form surgery with
permanent
colostomy. During the first 24 hours the
colostomy
does not drain. The nurse should be aware
that:
a. Proper functioning of nasogastric
suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
45. When teaching a client about the signs
of colorectal
cancer, Nurse Trish stresses that the most
common
complaint of persons with colorectal
cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
46. Louis develops peritonitis and sepsis
after surgical
repair of ruptures diverticulum. The nurse
in charge
should expect an assessment of the client
to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds
47. Immediately after liver biopsy, the
client is placed on
the right side, the nurse is aware that that
this
position should be maintained because it
will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary
ducts
c. Position with greatest comfort
d. Promote circulating blood volume
48. Tony has diagnosed with hepatitis A.
The information
from the health history that is most likely
linked to
hepatitis A is:
a. Exposed with arsenic compounds at
work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
49. Nurse Trish is aware that the
laboratory test result
that most likely would indicate acute
pancreatitis is
an elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level
50. Dr. Marquez orders serum
electrolytes. To determine
the effect of persistent vomiting, Nurse
Trish should
be most concerned with monitoring the:
a. Chloride and sodium levels
b. Phosphate and calcium levels
c. Protein and magnesium levels
d. Sulfate and bicarbonate levels
489
489
ANSWERS and RATIONALES for
MEDICAL SURGICAL
NURSING Part 2
1. B. In preoperative period, the nurse
should consult
with the physician about withholding
Warfarin
Sodium to avoid occurrence of
hemorrhage.
2. D. A client who is unconscious is at
greater risk for
corneal abrasion. For this reason, the
safest way to
test the cornel reflex is by touching the
cornea
lightly with a wisp of cotton.
3. B. Iatrogenic infection is caused by the
heath care
provider or is induced inadvertently by
medical
treatment or procedures.
4. D. Bradykinesia is slowing down from
the initiation
and execution of movement.
5. B. This symptom is caused by
stimulation of retinal
cells by ocular movement.
6. D. Restlessness indicates a lack of
oxygen to the brain
stem which impairs the reticular activating
system.
7. C. Rhythmic contraction and relaxation
associated
with tonic-clonic seizure can cause
repeated banging
of head.
8. A. Right side lying position or supine
position permits
ventilation of the remaining lung and
prevent fluid
from draining into sutured bronchial
stump.
9. C. Isoniazid (INH) interferes in the
effectiveness of oral
contraceptives and clients of childbearing
age should
be counseled to use an alternative form of
birth
control while taking this drug.
10. B. A client who has had abdominal
surgery is best
placed in a low fowler’s position. This
relaxes
abdominal muscles and provides
maximum
respiratory and cardiovascular function.
11. A. Dark red to purple stoma indicates
inadequate
blood supply.
12. C. The rationale for activity restriction
is to help
reduce the hypermotility of the colon.
13. A. During Total Parenteral Nutrition
(TPN)
administration, the client should be
monitored
regularly for hyperglycemia.
14. D. Jaundice may be present in acute
pancreatitis
owing to obstruction of the biliary duct.
15. A. Tetany may occur after
thyroidectomy if the
parathyroid glands are accidentally injured
or
removed.
16. D. Typical signs of hypothyroidism
includes weight
gain, fatigue, decreased energy, apathy,
brittle nails,
dry skin, cold intolerance, constipation
and
numbness.
17. B. After a pelvic surgery, there is an
increased chance
of thrombophlebitits owing to the pelvic
manipulation that can interfere with
circulation and
promote venous stasis.
18. D. For the safety of all personnel, if the
defibrillator
paddles are being discharged, all
personnel must
stand back and be clear of all the contact
with the
client or the client’s bed.
19. D. Hard candy will relieve thirst and presence of “hot spot” which are areas on
increase the cast
carbohydrates but does not supply extra that are warmer than the others.
fluid. 26. B. Otoscopic examnation in a client
20. C. Infection is responsible for one third with mastoiditis
of the reveals a dull, red, thick and immobile
traumatic or surgically induced death of tymphanic
clients with membrane with or without perforation.
renal failure as well as medical induced 27. D. Loss of gastric fluid via nasogastric
acute renal suction or
failure (ARF) vomiting causes metabolic alkalosis
21. C. There is no respiratory movement because of the
in stage 4 of loss of hydrochloric acid which is a potent
anesthesia, prior to this stage, respiration acid in the
is body.
depressed but present. 28. A. The adult with normal
22. B. Compression of the lung by fluid cerebrospinal fluid has no
that accumulates red blood cells.
at the base of the lungs reduces expansion 29. D. Measuring the urine output to
and air detect excess
exchange. amount and checking the specific gravity
23. C. Assessment of a client with of urine
Hodgkin’s disease samples to determine urine concentration
most often reveals enlarged, painless are
lymph node, appropriate measures to determine the
fever, malaise and night sweats. onset of
24. A. Fractured pain is generally diabetes insipidus.
described as sharp, 30. B. The nurse should focus more on
continuous, and increasing in frequency. developing less
25. D. Signs and symptoms of infection stressful ways of accomplishing routine
under a casted task.
area include odor or purulent drainage 31. C. Autotransfusion is acceptable for
and the the client who is
in danger of cardiac arrest.
32. D. The client with thromboembolism 38. A. Miotic agent constricts the pupil alternating with diarrhea are the most
does not have and contracts common
coolness. ciliary muscle. These effects widen the symptoms of colorectal cancer.
33. A. Positioning the client on one side filtration 46. B. With increased intraabdominal
with head flexed angle and permit increased out flow of pressure, the
forward allows the tongue to fall forward aqueous abdominal wall will become tender and
and humor. rigid.
facilitates drainage secretions therefore 39. D. It is a priority to hyperoxygenate 47. A. Pressure applied in the puncture
prevents the client before site indicates
aspiration. and after suctioning to prevent hypoxia that a biliary vessel was puncture which is
490 and to a common
490 maintain cerebral perfusion. complication after liver biopsy.
34. C. Nursing care after bone biopsy 40. D. Abdominal breathing improves 48. B. Hepatitis A is primarily spread via
includes close lungs expansion fecal-oral route.
monitoring of the punctured site for 41. C. A Client with burns is very sensitive Sewage polluted water may harbor the
bleeding, to virus.
swelling and hematoma formation. temperature changes because heat is loss 49. B. Amylase concentration is high in the
35. D. Walking and swimming are very in the pancreas and
helpful in burn areas. is elevated in the serum when the
strengthening back muscles for the client 42. A. The graft covers the nerve endings, pancreas becomes
suffering which reduces acutely inflamed and also it distinguishes
from lower back pain. pain and provides framework for pancreatitis from other acute abdominal
36. C. Sudden, severe abdominal pain is granulation problems.
the most 43. B. Meat provides proteins and the 50. A. Sodium, which is concerned with
indicative sign of perforation. When fruit proteins the regulation of
perforation of vitamin C that both promote wound extracellular fluid volume, it is lost with
an ulcer occurs, the nurse maybe unable healing. vomiting.
to hear 44. C. This is primarily caused by the Chloride, which balances cations in the
bowel sounds at all. trauma of intestinal extracellular
37. A. After surgery to correct a detached manipulation and the depressive effects compartments, is also lost with vomiting,
retina, anesthetics because
prevention of increased intraocular and analgesics. sodium and chloride are parallel
pressure is the 45. D. Constipation, diarrhea, and/or electrolytes,
priority goal. constipation hyponatremia will accompany.
491 d. Evidence of extreme weight loss and c. Perineal edema
491 high d. Urethral discharge
MEDICAL SURGICAL NURSING Part 3 fever 7. A client has undergone with penile
1. Marco who was diagnosed with brain 4. Nurse Maureen is aware that a client implant. After 24
tumor was who has been hrs of surgery, the client’s scrotum was
scheduled for craniotomy. In preventing diagnosed with chronic renal failure edematous
the recognizes an and painful. The nurse should:
development of cerebral edema after adequate amount of high-biologic-value a. Assist the client with sitz bath
surgery, the protein b. Apply war soaks in the scrotum
nurse should expect the use of: when the food the client selected from the c. Elevate the scrotum using a soft support
a. Diuretics menu d. Prepare for a possible incision and
b. Antihypertensive was: drainage.
c. Steroids a. Raw carrots 8. Nurse hazel receives emergency
d. Anticonvulsants b. Apple juice laboratory results for
2. Halfway through the administration of c. Whole wheat bread a client with chest pain and immediately
blood, the d. Cottage cheese informs the
female client complains of lumbar pain. 5. Kenneth who has diagnosed with physician. An increased myoglobin level
After uremic syndrome suggests
stopping the infusion Nurse Hazel should: has the potential to develop which of the following?
a. Increase the flow of normal saline complications. Which a. Liver disease
b. Assess the pain further among the following complications should b. Myocardial damage
c. Notify the blood bank the nurse c. Hypertension
d. Obtain vital signs. anticipates: d. Cancer
3. Nurse Maureen knows that the positive a. Flapping hand tremors 9. Nurse Maureen would expect the a
diagnosis for b. An elevated hematocrit level client with mitral
HIV infection is made based on which of c. Hypotension stenosis would demonstrate symptoms
the d. Hypokalemia associated
following: 6. A client is admitted to the hospital with with congestion in the:
a. A history of high risk sexual behaviors. benign a. Right atrium
b. Positive ELISA and western blot tests prostatic hyperplasia, the nurse most b. Superior vena cava
c. Identification of an associated relevant c. Aorta
opportunistic assessment would be: d. Pulmonary
infection a. Flank pain radiating in the groin 10. A client has been diagnosed with
b. Distention of the lower abdomen hypertension. The
nurse priority nursing diagnosis would be: 492 c. 40 to 50 years
a. Ineffective health maintenance 492 d. 60 60 70 years
b. Impaired skin integrity 14. Nurse Josie should instruct the client 18. Marie with acute lymphocytic
c. Deficient fluid volume to eat which of leukemia suffers from
d. Pain the following foods to obtain the best nausea and headache. These clinical
11. Nurse Hazel teaches the client with supply of manifestations
angina about Vitamin B12? may indicate all of the following except
common expected side effects of a. dairy products a. effects of radiation
nitroglycerin b. vegetables b. chemotherapy side effects
including: c. Grains c. meningeal irritation
a. high blood pressure d. Broccoli d. gastric distension
b. stomach cramps 15. Karen has been diagnosed with 19. A client has been diagnosed with
c. headache aplastic anemia. The Disseminated
d. shortness of breath nurse monitors for changes in which of the Intravascular Coagulation (DIC). Which of
12. The following are lipid abnormalities. following the
Which of the physiologic functions? following is contraindicated with the
following is a risk factor for the a. Bowel function client?
development of b. Peripheral sensation a. Administering Heparin
atherosclerosis and PVD? c. Bleeding tendencies b. Administering Coumadin
a. High levels of low density lipid (LDL) d. Intake and out put c. Treating the underlying cause
cholesterol 16. Lydia is scheduled for elective d. Replacing depleted blood products
b. High levels of high density lipid (HDL) splenectomy. Before 20. Which of the following findings is the
cholesterol the clients goes to surgery, the nurse in best indication
c. Low concentration triglycerides charge final that fluid replacement for the client with
d. Low levels of LDL cholesterol. assessment would be: hypovolemic shock is adequate?
13. Which of the following represents a a. signed consent a. Urine output greater than 30ml/hr
significant risk b. vital signs b. Respiratory rate of 21 breaths/minute
immediately after surgery for repair of c. name band c. Diastolic blood pressure greater than 90
aortic d. empty bladder mmhg
aneurysm? 17. What is the peak age range in d. Systolic blood pressure greater than 110
a. Potential wound infection acquiring acute mmhg
b. Potential ineffective coping lymphocytic leukemia (ALL)? 21. Which of the following signs and
c. Potential electrolyte balance a. 4 to 12 years. symptoms would
d. Potential alteration in renal perfusion b. 20 to 30 years
Nurse Maureen include in teaching plan as 24. Patricia a 20 year old college student b. Put leg through full range of motion
an early with diabetes twice
manifestation of laryngeal cancer? mellitus requests additional information daily
a. Stomatitis about the c. Report any discomfort or stiffness to the
b. Airway obstruction advantages of using a pen like insulin physician
c. Hoarseness delivery 493
d. Dysphagia devices. The nurse explains that the 493
22. Karina a client with myasthenia gravis advantages of d. Elevate the leg when sitting for long
is to receive these devices over syringes includes: periods of
immunosuppressive therapy. The nurse a. Accurate dose delivery time.
understands b. Shorter injection time 27. While performing a physical
that this therapy is effective because it: c. Lower cost with reusable insulin assessment of a male
a. Promotes the removal of antibodies cartridges client with gout of the great toe, Nurse
that d. Use of smaller gauge needle. Vivian should
impair the transmission of impulses 25. A male client’s left tibia was fractured assess for additional tophi (urate deposits)
b. Stimulates the production of in an on the:
acetylcholine at automobile accident, and a cast is applied. a. Buttocks
the neuromuscular junction. To assess b. Ears
c. Decreases the production of for damage to major blood vessels from c. Face
autoantibodies the fracture d. Abdomen
that attack the acetylcholine receptors. tibia, the nurse in charge should monitor 28. Nurse Katrina would recognize that the
d. Inhibits the breakdown of acetylcholine the client demonstration of crutch walking with
at the for: tripod gait was
neuromuscular junction. a. Swelling of the left thigh understood when the client places weight
23. A female client is receiving IV b. Increased skin temperature of the foot on the:
Mannitol. An c. Prolonged reperfusion of the toes after a. Palms of the hands and axillary regions
assessment specific to safe administration blanching b. Palms of the hand
of the d. Increased blood pressure c. Axillary regions
said drug is: 26. After a long leg cast is removed, the d. Feet, which are set apart
a. Vital signs q4h male client 29. Mang Jose with rheumatoid arthritis
b. Weighing daily should: states, “the only
c. Urine output hourly a. Cleanse the leg by scrubbing with a brisk time I am without pain is when I lie in bed
d. Level of consciousness q4h motion perfectly
still”. During the convalescent stage, the the following tests differentiates mucus sclerosis for discharge from the hospital to
nurse in from home.
charge with Mang Jose should encourage: cerebrospinal fluid (CSF)? Which of the following instruction is most
a. Active joint flexion and extension a. Protein appropriate?
b. Continued immobility until pain b. Specific gravity a. “Practice using the mechanical aids that
subsides c. Glucose you
c. Range of motion exercises twice daily d. Microorganism will need when future disabilities arise”.
d. Flexion exercises three times daily 33. A 22 year old client suffered from his b. “Follow good health habits to change
30. A male client has undergone spinal first tonicclonic the
surgery, the seizure. Upon awakening the client asks course of the disease”.
nurse should: the c. “Keep active, use stress reduction
a. Observe the client’s bowel movement nurse, “What caused me to have a strategies,
and seizure? Which of and avoid fatigue.
voiding patterns the following would the nurse include in d. “You will need to accept the necessity
b. Log-roll the client to prone position the primary for a
c. Assess the client’s feet for sensation and cause of tonic clonic seizures in adults quiet and inactive lifestyle”.
circulation more the 20 36. The nurse is aware the early indicator
d. Encourage client to drink plenty of fluids years? of hypoxia in
31. Marina with acute renal failure moves a. Electrolyte imbalance the unconscious client is:
into the b. Head trauma a. Cyanosis
diuretic phase after one week of therapy. c. Epilepsy b. Increased respirations
During this d. Congenital defect c. Hypertension
phase the client must be assessed for signs 34. What is the priority nursing d. Restlessness
of assessment in the first 24 37. A client is experiencing spinal shock.
developing: hours after admission of the client with Nurse Myrna
a. Hypovolemia thrombotic should expect the function of the bladder
b. renal failure CVA? to be
c. metabolic acidosis a. Pupil size and papillary response which of the following?
d. hyperkalemia b. cholesterol level a. Normal
32. Nurse Judith obtains a specimen of c. Echocardiogram b. Atonic
clear nasal d. Bowel sounds c. Spastic
drainage from a client with a head injury. 35. Nurse Linda is preparing a client with d. Uncontrolled
Which of multiple 38. Which of the following stage the
carcinogen is
irreversible? high risk for potential hazards from the 46. Nurse Faith should recognize that fluid
a. Progression stage surgical shift in an
b. Initiation stage experience? client with burn injury results from
c. Regression stage a. 67-year-old client increase in the:
d. Promotion stage b. 49-year-old client a. Total volume of circulating whole blood
39. Among the following components c. 33-year-old client b. Total volume of intravascular plasma
thorough pain d. 15-year-old client c. Permeability of capillary walls
assessment, which is the most significant? 43. Nurse Jon assesses vital signs on a d. Permeability of kidney tubules
a. Effect client undergone 47. An 83-year-old woman has several
b. Cause epidural anesthesia. Which of the ecchymotic areas
c. Causing factors following would on her right arm. The bruises are probably
d. Intensity the nurse assess next? caused
494 a. Headache by:
494 b. Bladder distension a. increased capillary fragility and
40. A 65 year old female is experiencing c. Dizziness permeability
flare up of d. Ability to move legs b. increased blood supply to the skin
pruritus. Which of the client’s action could 44. Nurse Katrina should anticipate that all c. self inflicted injury
aggravate of the d. elder abuse
the cause of flare ups? following drugs may be used in the 48. Nurse Anna is aware that early
a. Sleeping in cool and humidified attempt to adaptation of client
environment control the symptoms of Meniere’s with renal carcinoma is:
b. Daily baths with fragrant soap disease except: a. Nausea and vomiting
c. Using clothes made from 100% cotton a. Antiemetics b. flank pain
d. Increasing fluid intake b. Diuretics c. weight gain
41. Atropine sulfate (Atropine) is c. Antihistamines d. intermittent hematuria
contraindicated in all d. Glucocorticoids 49. A male client with tuberculosis asks
but one of the following client? 45. Which of the following complications Nurse Brian how
a. A client with high blood associated with long the chemotherapy must be
b. A client with bowel obstruction tracheostomy tube? continued. Nurse
c. A client with glaucoma a. Increased cardiac output Brian’s accurate reply would be:
d. A client with U.T.I b. Acute respiratory distress syndrome a. 1 to 3 weeks
42. Among the following clients, which (ARDS) b. 6 to 12 months
among them is c. Increased blood pressure c. 3 to 5 months
d. Damage to laryngeal nerves d. 3 years and more
50. A client has undergone laryngectomy. amino acids essential for life. nature of hypertension that makes it so
The immediate 5. A. Elevation of uremic waste products difficult to
nursing priority would be: causes irritation treat.
a. Keep trachea free of secretions of the nerves, resulting in flapping hand 11. C. Because of its widespread
b. Monitor for signs of infection tremors. vasodilating effects,
c. Provide emotional support 6. B. This indicates that the bladder is nitroglycerin often produces side effects
d. Promote means of communication distended with such as
495 urine, therefore palpable. headache, hypotension and dizziness.
495 7. C. Elevation increases lymphatic 12. A. An increased in LDL cholesterol
ANSWERS and RATIONALES for drainage, reducing concentration has
MEDICAL SURGICAL edema and pain. been documented at risk factor for the
NURSING Part 3 8. B. Detection of myoglobin is a development
1. C. Glucocorticoids (steroids) are used diagnostic tool to of atherosclerosis. LDL cholesterol is not
for their antiinflammatory determine whether myocardial damage broken
action, which decreases the has down into the liver but is deposited into
development of edema. occurred. the wall of
2. A. The blood must be stopped at once, 9. D. When mitral stenosis is present, the the blood vessels.
and then left atrium has 13. D. There is a potential alteration in
normal saline should be infused to keep difficulty emptying its contents into the renal perfusion
the line left ventricle manifested by decreased urine output.
patent and maintain blood volume. because there is no valve to prevent back The altered
3. B. These tests confirm the presence of ward flow renal perfusion may be related to renal
HIV antibodies into the pulmonary vein, the pulmonary artery
that occur in response to the presence of circulation is embolism, prolonged hypotension, or
the human under pressure. prolonged
immunodeficiency virus (HIV). 10. A. Managing hypertension is the aortic cross-clamping during the surgery.
4. D. One cup of cottage cheese contains priority for the 14. A. Good source of vitamin B12 are
approximately client with hypertension. Clients with dairy products
225 calories, 27 g of protein, 9 g of fat, 30 hypertension and meats.
mg frequently do not experience pain, 15. C. Aplastic anemia decreases the bone
cholesterol, and 6 g of carbohydrate. deficient volume, marrow
Proteins of or impaired skin integrity. It is the production of RBC’s, white blood cells, and
high biologic value (HBV) contain optimal asymptomatic platelets.
levels of
The client is at risk for bruising and hypovolemic shock. Urine output should circulatory perfusion of the toes, this
bleeding be would indicate
tendencies. consistently greater than 30 to 35 mL/hr. the lack of blood supply to the extremity.
16. B. An elective procedure is scheduled 21. C. Early warning signs of laryngeal 26. D. Elevation will help control the
in advance so cancer can vary edema that usually
that all preparations can be completed depending on tumor location. Hoarseness occurs.
ahead of lasting 2 27. B. Uric acid has a low solubility, it
time. The vital signs are the final check weeks should be evaluated because it is tends to
that must be one of the precipitate and form deposits at various
completed before the client leaves the most common warning signs. sites where
room so that 22. C. Steroids decrease the body’s blood flow is least active, including
continuity of care and assessment is immune response cartilaginous
provided for. thus decreasing the production of tissue such as the ears.
17. A. The peak incidence of Acute antibodies that 28. B. The palms should bear the client’s
Lymphocytic attack the acetylcholine receptors at the weight to avoid
Leukemia (ALL) is 4 years of age. It is neuromuscular junction damage to the nerves in the axilla.
uncommon 23. C. The osmotic diuretic mannitol is 496
after 15 years of age. contraindicated in 496
18. D. Acute Lymphocytic Leukemia (ALL) the presence of inadequate renal function 29. A. Active exercises, alternating
does not cause or heart extension, flexion,
gastric distention. It does invade the failure because it increases the abduction, and adduction, mobilize
central nervous intravascular volume exudates in the
system, and clients experience headaches that must be filtered and excreted by the joints relieves stiffness and pain.
and kidney. 30. C. Alteration in sensation and
vomiting from meningeal irritation. 24. A. These devices are more accurate circulation indicates
19. B. Disseminated Intravascular because they are damage to the spinal cord, if these occurs
Coagulation (DIC) has easily to used and have improved notify
not been found to respond to oral adherence in physician immediately.
anticoagulants insulin regimens by young people because 31. A. In the diuretic phase fluid retained
such as Coumadin. the during the
20. A. Urine output provides the most medication can be administered oliguric phase is excreted and may reach 3
sensitive discreetly. to 5 liters
indication of the client’s response to 25. C. Damage to blood vessels may daily, hypovolemia may occur and fluids
therapy for decrease the should be
replaced. nurse should suspect hypoxia in area, and the nurse in charge should
32. C. The constituents of CSF are similar unconscious client monitor the
to those of who suddenly becomes restless. client for distended bladder.
blood plasma. An examination for glucose 37. B. In spinal shock, the bladder 44. D. Glucocorticoids play no significant
content is becomes completely role in disease
done to determine whether a body fluid is atonic and will continue to fill unless the treatment.
a mucus client is 45. D. Tracheostomy tube has several
or a CSF. A CSF normally contains glucose. catheterized. potential
33. B. Trauma is one of the primary cause 38. A. Progression stage is the change of complications including bleeding, infection
of brain tumor from the and
damage and seizure activity in adults. preneoplastic state or low degree of laryngeal nerve damage.
Other malignancy to a 46. C. In burn, the capillaries and small
common causes of seizure activity in fast growing tumor that cannot be vessels dilate,
adults include reversed. and cell damage cause the release of a
neoplasms, withdrawal from drugs and 39. D. Intensity is the major indicative of histaminelike
alcohol, and severity of pain substance. The substance causes the
vascular disease. and it is important for the evaluation of capillary
34. A. It is crucial to monitor the pupil size the walls to become more permeable and
and papillary treatment. significant
response to indicate changes around the 40. B. The use of fragrant soap is very quantities of fluid are lost.
cranial drying to skin 47. A. Aging process involves increased
nerves. hence causing the pruritus. capillary fragility
35. C. The nurse most positive approach is 41. C. Atropine sulfate is contraindicated and permeability. Older adults have a
to encourage with glaucoma decreased
the client with multiple sclerosis to stay patients because it increases intraocular amount of subcutaneous fat and cause an
active, use pressure. increased
stress reduction techniques and avoid 42. A. A 67 year old client is greater risk incidence of bruise like lesions caused by
fatigue because the collection
because it is important to support the older adult client is more likely to have a of extravascular blood in loosely
immune lesseffective structured dermis.
system while remaining active. immune system. 48. D. Intermittent pain is the classic sign
36. D. Restlessness is an early indicator of 43. B. The last area to return sensation is of renal
hypoxia. The in the perineal carcinoma. It is primarily due to capillary
erosion by
the cancerous growth. b. Assess the pain further
49. B. Tubercle bacillus is a drug resistant c. Notify the blood bank
organism and d. Obtain vital signs.
takes a long time to be eradicated. Usually 3. Nurse Maureen knows that the positive
a diagnosis for HIV infection is made based
combination of three drugs is used for on
minimum of 6 which of the following:
months and at least six months beyond a. A history of high risk sexual behaviors.
culture b. Positive ELISA and western blot tests
conversion. c. Identification of an associated
50. A. Patent airway is the most priority; opportunistic infection
therefore d. Evidence of extreme weight loss and
removal of secretions is necessary. high fever
4. Nurse Maureen is aware that a client
who has
MEDSURG ALL been diagnosed with chronic renal failure
recognizes an adequate amount of high-
MEDICAL SURGICAL NURSING biologicvalue
1. Marco who was diagnosed with brain protein when the food the client selected
tumor was from the menu was:
scheduled for craniotomy. In preventing a. Raw carrots
the b. Apple juice
development of cerebral edema after c. Whole wheat bread
surgery, d. Cottage cheese
the nurse should expect the use of: 5. Kenneth who has diagnosed with
a. Diuretics uremic
b. Antihypertensive syndrome has the potential to develop
c. Steroids complications. Which among the following
d. Anticonvulsants complications should the nurse
2. Halfway through the administration of anticipates:
blood, a. Flapping hand tremors
the female client complains of lumbar b. An elevated hematocrit level
pain. After c. Hypotension
stopping the infusion Nurse Hazel should: d. Hypokalemia
a. Increase the flow of normal saline
6. A client is admitted to the hospital with
benign
prostatic hyperplasia, the nurse most
relevant
assessment would be:
a. Flank pain radiating in the groin
b. Distention of the lower abdomen
c. Perineal edema
d. Urethral discharge
7. A client has undergone with penile
implant.
After 24 hrs of surgery, the client’s
scrotum was
edematous and painful. The nurse should:
a. Assist the client with sitz bath
b. Apply war soaks in the scrotum
c. Elevate the scrotum using a soft support
d. Prepare for a possible incision and
drainage.
8. Nurse hazel receives emergency
laboratory
results for a client with chest pain and
immediately informs the physician. An
increased
myoglobin level suggests which of the
following?
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer
9. Nurse Maureen would expect the client
with
mitral stenosis would demonstrate
symptoms
associated with congestion in the: 13. Which of the following represents a c. name band
a. Right atrium significant d. empty bladder
b. Superior vena cava risk immediately after surgery for repair of 17. What is the peak age range in
c. Aorta aortic acquiring acute
d. Pulmonary aneurysm? lymphocytic leukemia (ALL)?
10. A client has been diagnosed with a. Potential wound infection a. 4 to 12 years.
hypertension. b. Potential ineffective coping b. 20 to 30 years
The nurse priority nursing diagnosis would c. Potential electrolyte balance c. 40 to 50 years
be: d. Potential alteration in renal perfusion d. 60 60 70 years
a. Ineffective health maintenance 14. Nurse Josie should instruct the client 18. Marie with acute lymphocytic
b. Impaired skin integrity to eat leukemia suffers
c. Deficient fluid volume which of the following foods to obtain the from nausea and headache. These clinical
d. Pain best manifestations may indicate all of the
11. Nurse Hazel teaches the client with supply of Vitamin B12? following
angina about a. dairy products except
common expected side effects of b. vegetables a. effects of radiation
nitroglycerin c. Grains b. chemotherapy side effects
including: d. Broccoli c. meningeal irritation
a. high blood pressure 15. Karen has been diagnosed with d. gastric distension
b. stomach cramps aplastic anemia. 19. A client has been diagnosed with
c. headache The nurse monitors for changes in which Disseminated
d. shortness of breath of the Intravascular Coagulation (DIC). Which of
12. The following are lipid abnormalities. following physiologic functions? the
Which of a. Bowel function following is contraindicated with the
the following is a risk factor for the b. Peripheral sensation client?
development c. Bleeding tendencies a. Administering Heparin
of atherosclerosis and PVD? d. Intake and out put b. Administering Coumadin
a. High levels of low density lipid (LDL) 16. Lydia is scheduled for elective c. Treating the underlying cause
cholesterol splenectomy. d. Replacing depleted blood products
b. High levels of high density lipid (HDL) Before the clients goes to surgery, the 20. Which of the following findings is the
cholesterol nurse in best
c. Low concentration triglycerides charge final assessment would be: indication that fluid replacement for the
d. Low levels of LDL cholesterol. a. signed consent client
174 b. vital signs with hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr 23. A female client is receiving IV b. Increased skin temperature of the foot
b. Respiratory rate of 21 breaths/minute Mannitol. An c. Prolonged reperfusion of the toes after
c. Diastolic blood pressure greater than 90 assessment specific to safe administration blanching
mmhg of the d. Increased blood pressure
d. Systolic blood pressure greater than 110 said drug is: 26. After a long leg cast is removed, the
mmhg a. Vital signs q4h male client
21. Which of the following signs and b. Weighing daily should:
symptoms c. Urine output hourly a. Cleanse the leg by scrubbing with a brisk
would Nurse Maureen include in teaching d. Level of consciousness q4h motion
plan 24. Patricia a 20 year old college student b. Put leg through full range of motion
as an early manifestation of laryngeal with twice daily
cancer? diabetes mellitus requests additional c. Report any discomfort or stiffness to the
a. Stomatitis information about the advantages of using physician
b. Airway obstruction a pen d. Elevate the leg when sitting for long
c. Hoarseness like insulin delivery devices. The nurse periods of time.
d. Dysphagia explains 27. While performing a physical
22. Karina a client with myasthenia gravis that the advantages of these devices over assessment of a
is to syringes include: male client with gout of the great toe,
receive immunosuppressive therapy. The a. Accurate dose delivery NurseVivian should assess for additional
nurse b. Shorter injection time tophi
understands that this therapy is effective 175 (urate deposits) on the:
because it: c. Lower cost with reusable insulin a. Buttocks
a. Promotes the removal of antibodies cartridges b. Ears
that d. Use of smaller gauge needle. c. Face
impair the transmission of impulses 25. A male client’s left tibia is fractures in d. Abdomen
b. Stimulates the production of an 28. Nurse Katrina would recognize that the
acetylcholine at the neuromuscular automobile accident, and a cast is applied. demonstration of crutch walking with
junction. To tripod gait
c. Decreases the production of assess for damage to major blood vessels was understood when the client places
autoantibodies that attack the from weight
acetylcholine receptors. the fracture tibia, the nurse in charge on the:
d. Inhibits the breakdown of acetylcholine should a. Palms of the hands and axillary regions
at the neuromuscular junction. monitor the client for: b. Palms of the hand
a. Swelling of the left thigh c. Axillary regions
d. Feet, which are set apart 32. Nurse Judith obtains a specimen of 35. Nurse Linda is preparing a client with
29. Mang Jose with rheumatoid arthritis clear nasal multiple
states, “the drainage from a client with a head injury. sclerosis for discharge from the hospital to
only time I am without pain is when I lie in Which home. Which of the following instruction
bed of the following tests differentiates mucus is most
perfectly still”. During the convalescent from appropriate?
stage, cerebrospinal fluid (CSF)? 176
the nurse in charge with Mang Jose should a. Protein a. “Practice using the mechanical aids that
encourage: b. Specific gravity you will need when future disabilities
a. Active joint flexion and extension c. Glucose arise”.
b. Continued immobility until pain d. Microorganism b. “Follow good health habits to change
subsides 33. A 22 year old client suffered from his the course of the disease”.
c. Range of motion exercises twice daily first tonicclonic c. “Keep active, use stress reduction
d. Flexion exercises three times daily seizure. Upon awakening the client asks strategies, and avoid fatigue.
30. A male client has undergone spinal the nurse, “What caused me to have a d. “You will need to accept the necessity
surgery, the seizure? for a quiet and inactive lifestyle”.
nurse should: Which of the following would the nurse 36. The nurse is aware the early indicator
a. Observe the client’s bowel movement include of hypoxia
and voiding patterns in the primary cause of tonic-clonic in the unconscious client is:
b. Log-roll the client to prone position seizures in a. Cyanosis
c. Assess the client’s feet for sensation and adults more the 20 years? b. Increased respirations
circulation a. Electrolyte imbalance c. Hypertension
d. Encourage client to drink plenty of fluids b. Head trauma d. Restlessness
31. Marina with acute renal failure moves c. Epilepsy 37. A client is experiencing spinal shock.
into the d. Congenital defect Nurse
diuretic phase after one week of therapy. 34. What is the priority nursing Myrna should expect the function of the
During assessment in the bladder
this phase the client must be assessed for first 24 hours after admission of the client to be which of the following?
signs with a. Normal
of developing: thrombotic CVA? b. Atonic
a. Hypovolemia a. Pupil size and papillary response c. Spastic
b. renal failure b. cholesterol level d. Uncontrolled
c. metabolic acidosis c. Echocardiogram 38. Which of the following stage the
d. hyperkalemia d. Bowel sounds carcinogen is
irreversible? c. 33-year-old client client with burn injury results from
a. Progression stage d. 15-year-old client increase in
b. Initiation stage 43. Nurse Jon assesses vital signs on a the:
c. Regression stage client a. Total volume of circulating whole blood
d. Promotion stage undergone epidural anesthesia. b. Total volume of intravascular plasma
39. Among the following components 44. Which of the following would the c. Permeability of capillary walls
thorough pain nurse assess d. Permeability of kidney tubules
assessment, which is the most significant? next? 48. An 83-year-old woman has several
a. Effect a. Headache ecchymotic
b. Cause b. Bladder distension areas on her right arm. The bruises are
c. Causing factors c. Dizziness probably
d. Intensity d. Ability to move legs caused by:
40. A 65 year old female is experiencing 45. Nurse Katrina should anticipate that all a. increased capillary fragility and
flare up of of the permeability
pruritus. Which of the client’s action could following drugs may be used in the b. increased blood supply to the skin
aggravate the cause of flare ups? attempt to c. self-inflicted injury
a. Sleeping in cool and humidified control the symptoms of Meniere's d. elder abuse
environment disease 177
b. Daily baths with fragrant soap except: 49. Nurse Anna is aware that early
c. Using clothes made from 100% cotton a. Antiemetics adaptation of
d. Increasing fluid intake b. Diuretics client with renal carcinoma is:
41. Atropine sulfate (Atropine) is c. Antihistamines a. Nausea and vomiting
contraindicated in d. Glucocorticoids b. flank pain
all but one of the following client? 46. Which of the following complications c. weight gain
a. A client with high blood associated d. intermittent hematuria
b. A client with bowel obstruction with tracheostomy tube? 50. A male client with tuberculosis asks
c. A client with glaucoma a. Increased cardiac output Nurse Brian
d. A client with U.T.I b. Acute respiratory distress syndrome how long the chemotherapy must be
42. Among the following clients, which (ARDS) continued.
among them c. Increased blood pressure Nurse Brian’s accurate reply would be:
is high risk for potential hazards from the d. Damage to laryngeal nerves a. 1 to 3 weeks
surgical experience? 47. Nurse Faith should recognize that fluid b. 6 to 12 months
a. 67-year-old client shift in a c. 3 to 5 months
b. 49-year-old client d. 3 years and more
51. A client has undergone laryngectomy.
The
immediate nursing priority would be:
a. Keep trachea free of secretions
b. Monitor for signs of infection
c. Provide emotional support
d. Promote means of communication
178
ANSWERS AND RATIONALE –
MEDICAL SURGICAL
NURSING
1. C. Glucocorticoids (steroids) are used
for their
anti-inflammatory action, which decreases
the
development of edema.
2. A. The blood must be stopped at once,
and then
normal saline should be infused to keep
the line
patent and maintain blood volume.
3. B. These tests confirm the presence of
HIV
antibodies that occur in response to the
presence of the human immunodeficiency
virus
(HIV).
4. D. One cup of cottage cheese contains
approximately 225 calories, 27g of protein,
9g of
fat, 30mg cholesterol, and 6g of
carbohydrate.
Proteins of high biologic value (HBV)
contain
optimal levels of amino acids essential for
life.
5. A. Elevation of uremic waste products
causes
irritation of the nerves, resulting in
flapping
hand tremors.
6. B. This indicates that the bladder is
distended
with urine, therefore palpable.
7. C. Elevation increases lymphatic
drainage,
reducing edema and pain.
8. B. Detection of myoglobin is a
diagnostic tool to
determine whether myocardial damage
has
occurred.
9. D. When mitral stenosis is present, the
left
atrium has difficulty emptying its contents
into
the left ventricle because there is no valve
to
prevent back ward flow into the
pulmonary vein,
the pulmonary circulation is under
pressure.
10. A. Managing hypertension is the
priority for the
client with hypertension. Clients with
hypertension frequently do not experience
pain,
deficient volume, or impaired skin
integrity. It is
the asymptomatic nature of hypertension
that
makes it so difficult to treat.
11. C. Because of its widespread
vasodilating effects,
nitroglycerin often produces side effects
such as
headache, hypotension and dizziness.
12. A. An increased in LDL cholesterol
concentration
has been documented at risk factor for the
development of atherosclerosis. LDL
cholesterol
is not broken down into the liver but is
deposited into the wall of the blood
vessels.
13. D. There is a potential alteration in
renal
perfusion manifested by decreased urine
output.
The altered renal perfusion may be related
to
renal artery embolism, prolonged
hypotension,
or prolonged aortic cross-clamping during
the
surgery.
14. A. Good source of vitamin B12 are
dairy
products and meats.
15. C. Aplastic anemia decreases the bone
marrow
production of RBC’s, white blood cells, and
platelets. The client is at risk for bruising
and
bleeding tendencies.
16. B. An elective procedure is scheduled
in advance
so that all preparations can be completed
ahead
of time. The vital signs are the final check
that
must be completed before the client
leaves the
room so that continuity of care and
assessment
is provided for.
17. A. The peak incidence of Acute
Lymphocytic
Leukemia (ALL) is 4 years of age. It is
uncommon
after 15 years of age.
18. D. Acute Lymphocytic Leukemia (ALL)
does not
cause gastric distention. It does invade the
central nervous system, and clients
experience
headaches and vomiting from meningeal
irritation.
19. B. Disseminated Intravascular
Coagulation (DIC)
has not been found to respond to oral
anticoagulants such as Coumadin.
20. A. Urine output provides the most
sensitive
indication of the client’s response to
therapy for
hypovolemic shock. Urine output should
be
consistently greater than 30 to 35 mL/hr.
21. C. Early warning signs of laryngeal
cancer can
vary depending on tumor location.
Hoarseness
lasting 2 weeks should be evaluated
because it is
one of the most common warning signs.
22. C. Steroids decrease the body’s
immune
response thus decreasing the production
of
antibodies that attack the acetylcholine
receptors at the neuromuscular junction
23. C. The osmotic diuretic mannitol is
contraindicated in the presence of
inadequate
renal function or heart failure because it
increases the intravascular volume that
must be
filtered and excreted by the kidney.
24. A. These devices are more accurate
because
they are easily to used and have improved
adherence in insulin regimens by young
people
because the medication can be
administered
discreetly.
25. C. Damage to blood vessels may
decrease the
circulatory perfusion of the toes, this
would
indicate the lack of blood supply to the
extremity.
26. D. Elevation will help control the
edema that
usually occurs.
27. B. Uric acid has a low solubility, it
tends to
precipitate and form deposits at various
sites
179
where blood flow is least active, including
cartilaginous tissue such as the ears.
28. B. The palms should bear the client’s
weight to
avoid damage to the nerves in the axilla.
29. A. Active exercises, alternating
extension,
flexion, abduction, and adduction,
mobilize
exudates in the joints relieves stiffness and
pain.
30. C. Alteration in sensation and
circulation
indicates damage to the spinal cord, if
these
occurs notify physician immediately.
31. A. In the diuretic phase fluid retained
during the
oliguric phase is excreted and may reach 3
to 5
liters daily, hypovolemia may occur and the immune system while remaining
fluids active.
should be replaced. 36. D. Restlessness is an early indicator of
32. C. The constituents of CSF are similar hypoxia.
to those of The nurse should suspect hypoxia in
blood plasma. An examination for glucose unconscious
content is done to determine whether a client who suddenly becomes restless.
body 37. B. In spinal shock, the bladder
fluid is a mucus or a CSF. A CSF normally becomes
contains completely atonic and will continue to fill
glucose. unless
33. B. Trauma is one of the primary the client is catheterized.
causes of brain 38. A. Progression stage is the change of
damage and seizure activity in adults. tumor from
Other the preneoplastic state or low degree of
common causes of seizure activity in malignancy to a fast growing tumor that
adults cannot
include neoplasms, withdrawal from drugs be reversed.
and 39. D. Intensity is the major indicative of
alcohol, and vascular disease. severity of
34. A. It is crucial to monitor the pupil size pain and it is important for the evaluation
and of the
papillary response to indicate changes treatment.
around 40. B. The use of fragrant soap is very
the cranial nerves. drying to skin
35. C. The nurse most positive approach is hence causing the pruritus.
to 41. C. Atropine sulfate is contraindicated
encourage the client with multiple with
sclerosis to glaucoma patients because it increases
stay active, use stress reduction intraocular pressure.
techniques and 42. A. A 67 year old client is greater risk
avoid fatigue because it is important to because the
support older adult client is more likely to have a
lesseffective
immune system.
43. B. The last area to return sensation is
in the
perineal area, and the nurse in charge
should
monitor the client for distended bladder.
44. D. Glucocorticoids play no significant
role in
disease treatment.
45. D. Tracheostomy tube has several
potential
complications including bleeding, infection
and
laryngeal nerve damage.
46. C. In burn, the capillaries and small
vessels
dilate, and cell damage cause the release
of a
histamine-like substance. The substance
causes
the capillary walls to become more
permeable
and significant quantities of fluid are lost.
47. A. Aging process involves increased
capillary
fragility and permeability. Older adults
have a
decreased amount of subcutaneous fat
and
cause an increased incidence of bruise like
lesions caused by collection of
extravascular
blood in loosely structured dermis.
48. D. Intermittent pain is the classic sign
of renal
carcinoma. It is primarily due to capillary
erosion
by the cancerous growth.
49. B. Tubercle bacillus is a drug resistant
organism
and takes a long time to be eradicated.
Usually a
combination of three drugs is used for
minimum
of 6 months and at least six months
beyond
culture conversion.
50. A. Patent airway is the most priority;
therefore
removal of secretions is necessary