Medical-Surgical Nursing Exam 3

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1. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults the physician about withholding which regularly scheduled medication on the day before the surgery?

  1. Potassium Chloride
  2. Warfarin Sodium
  3. Furosemide
  4. Docusate

2. A nurse is planning to assess the corneal reflex on unconscious client. Which of the following is the safest stimulus to touch the client’s cornea?

  1. Cotton buds
  2. Sterile glove
  3. Sterile tongue depressor
  4. Wisp of cotton

3. A female client develops an infection at the catheter insertion site. The nurse in charge uses the term “iatrogenic” when describing the infection because it resulted from:

  1. Client’s developmental level
  2. Therapeutic procedure
  3. Poor hygiene
  4. Inadequate dietary patterns

4. Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognize bradykinesia when the client exhibits:

  1. Intentional tremor
  2. Paralysis of limbs
  3. Muscle spasm
  4. Lack of spontaneous movement

5. A client who suffered from automobile accident complains of seeing frequent flashes of light. The nurse should expect:

  1. Myopia
  2. Detached retina
  3. Glaucoma
  4. Scleroderma

6. Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure?

  1. Intermittent tachycardia
  2. Polydipsia
  3. Tachypnea
  4. Increased restlessness

7. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be:

  1. Hold the clients arms and leg firmly
  2. Place the client immediately to soft surface
  3. Protects the client’s head from injury
  4. Attempt to insert a tongue depressor between the client’s teeth

8. A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either:

  1. Right side-lying position or supine
  2. High fowlers
  3. Right or left side lying position
  4. Low fowler’s position

9. Nurse Jenny should caution a female client who is sexually active in taking Isoniazid (INH) because the drug has which of the following side effects?

  1. Prevents ovulation
  2. Has a mutagenic effect on ova
  3. Decreases the effectiveness of oral contraceptives
  4. Increases the risk of vaginal infection

10. A client has undergone gastrectomy. Nurse Jovy is aware that the best position for the client is:

  1. Left side lying
  2. Low fowler’s
  3. Prone
  4. Supine

11. During the initial postoperative period of the client’s stoma. The nurse evaluates which of the following observations should be reported immediately to thephysician?

  1. Stoma is dark red to purple
  2. Stoma is oozes a small amount of blood
  3. Stoma is lightly edematous
  4. Stoma does not expel stool

12. Kate which has diagnosed with ulcerative colitis is following physician’s order for bed rest with bathroom privileges. What is the rationale for this activity restriction?

  1. Prevent injury
  2. Promote rest and comfort
  3. Reduce intestinal peristalsis
  4. Conserve energy

13. Nurse KC should regularly assess the client’s ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the client for which of the following signs:

  1. Hyperglycemia
  2. Hypoglycemia
  3. Hypertension
  4. Elevate blood urea nitrogen concentration

14. A female client has an acute pancreatitis. Which of the following signs and symptoms the nurse would expect to see?

  1. Constipation
  2. Hypertension
  3. Ascites
  4. Jaundice

15. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms might indicate tetany?

  1. Tingling in the fingers
  2. Pain in hands and feet
  3. Tension on the suture lines
  4. Bleeding on the back of the dressing

16. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include:

  1. Diarrhea
  2. Vomiting
  3. Tachycardia
  4. Weight gain

17. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the client for occurrence of which of the following complications related to pelvic surgery?

  1. Ascites
  2. Thrombophlebitis
  3. Inguinal hernia
  4. Peritonitis

18. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice “clear”. What should be the action of the nurse?

  1. Places conductive gel pads for defibrillation on the client’s chest
  2. Turn off the mechanical ventilator
  3. Shuts off the client’s IV infusion
  4. Steps away from the bed and make sure all others have done the same

19. A client has been diagnosed with glomerulonephritis complains of thirst. The nurse should offer:

  1. Juice
  2. Ginger ale
  3. Milk shake
  4. Hard candy

20. A client with acute renal failure is aware that the most serious complication of this condition is:

  1. Constipation
  2. Anemia
  3. Infection
  4. Platelet dysfunction

21. Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is:

  1. Consciousness
  2. Gag reflex
  3. Respiratory movement
  4. Corneal reflex

22. The nurse is assessing a client with pleural effusion. The nurse expect to find:

  1. Deviation of the trachea towards the involved side
  2. Reduced or absent of breath sounds at the base of the lung
  3. Moist crackles at the posterior of the lungs
  4. Increased resonance with percussion of the involved area

23. A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would the nurse expect the client to report?

  1. Lymph node pain
  2. Weight gain
  3. Night sweats
  4. Headache

24. A client has suffered from fall and sustained a leg injury. Which appropriate question would the nurse ask the client to help determine if the injury caused fracture?

  1. “Is the pain sharp and continuous?”
  2. “Is the pain dull ache?”
  3. “Does the discomfort feel like a cramp?”
  4. “Does the pain feel like the muscle was stretched?”

25. The Nurse is assessing the client’s casted extremity for signs of infection. Which of the following findings is indicative of infection?

  1. Edema
  2. Weak distal pulse
  3. Coolness of the skin
  4. Presence of “hot spot” on the cast

26. Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this disorder is present?

  1. Transparent tympanic membrane
  2. Thick and immobile tympanic membrane
  3. Pearly colored tympanic membrane
  4. Mobile tympanic membrane

27. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses the client for symptoms of which acid-base disorder?

  1. Respiratory alkalosis
  2. Respiratory acidosis
  3. Metabolic acidosis
  4. Metabolic alkalosis

28. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal?

  1. Red blood cells
  2. White blood cells
  3. Insulin
  4. Protein

29. A client is suspected of developing diabetes insipidus. Which of the following is the most effective assessment?

  1. Taking vital signs every 4 hours
  2. Monitoring blood glucose
  3. Assessing ABG values every other day
  4. Measuring urine output hourly

30. A 58 year old client is suffering from acute phase of rheumatoid arthritis. Which of the following would the nurse in charge identify as the lowest priority of the plan of care?

  1. Prevent joint deformity
  2. Maintaining usual ways of accomplishing task
  3. Relieving pain
  4. Preserving joint function

31. Among the following, which client is autotransfusion possible?

  1. Client with AIDS
  2. Client with ruptured bowel
  3. Client who is in danger of cardiac arrest
  4. Client with wound infection

32. Which of the following is not a sign of thromboembolism?

  1. Edema
  2. Swelling
  3. Redness
  4. Coolness

33. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration?

  1. Position the client on the side with head flexed forward
  2. Elevate the head
  3. Use tongue depressor between teeth
  4. Loosen restrictive clothing

34. A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure?

  1. Administer analgesics via IM
  2. Monitor vital signs
  3. Monitor the site for bleeding, swelling and hematoma formation
  4. Keep area in neutral position

35. A client is suffering from low back pain. Which of the following exercises will strengthen the lower back muscle of the client?

  1. Tennis
  2. Basketball
  3. Diving
  4. Swimming

36. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for:

  1. (+) guaiac stool test
  2. Slow, strong pulse
  3. Sudden, severe abdominal pain
  4. Increased bowel sounds

37. A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized?

  1. Prevent an increase intraocular pressure
  2. Alleviate pain
  3. Maintain darkened room
  4. Promote low-sodium diet

38. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for:

  1. Constricting pupil
  2. Relaxing ciliary muscle
  3. Constricting intraocular vessel
  4. Paralyzing ciliary muscle

39. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion?

  1. Administer diuretics
  2. Administer analgesics
  3. Provide hygiene
  4. Hyperoxygenate before and after suctioning

40. When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching?

  1. Short frequent breaths
  2. Exhale with mouth open
  3. Exercise twice a day
  4. 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:

  1. Maintain room humidity below 40%
  2. Place top sheet on the client
  3. Limit the occurrence of drafts
  4. 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:

  1. Relieve pain and promote rapid epithelialization
  2. Be sutured in place for better adherence
  3. Debride necrotic epithelium
  4. 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:

  1. Meat loaf and coffee
  2. Meat loaf and strawberries
  3. Tomato soup and apple pie
  4. 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:

  1. Proper functioning of nasogastric suction
  2. Presurgical decrease in fluid intake
  3. Absence of gastrointestinal motility
  4. 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:

  1. Abdominal pain
  2. Hemorrhoids
  3. Change in caliber of stools
  4. 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:

  1. Tachycardia
  2. Abdominal rigidity
  3. Bradycardia
  4. 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:

  1. Help stop bleeding if any occurs
  2. Reduce the fluid trapped in the biliary ducts
  3. Position with greatest comfort
  4. 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:

  1. Exposed with arsenic compounds at work
  2. Working as local plumber
  3. Working at hemodialysis clinic
  4. Dish washer in restaurants

49. Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated:

  1. Serum bilirubin level
  2. Serum amylase level
  3. Potassium level
  4. Sodium level

50. Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse Trish should be most concerned with monitoring the:

  1. Chloride and sodium levels
  2. Phosphate and calcium levels
  3. Protein and magnesium levels
  4. Sulfate and bicarbonate levels
Answers and Rationales
  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 increase carbohydrates but does not supply extra fluid.
  20. C. Infection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as medical induced acute renal failure (ARF)
  21. C. There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present.
  22. B. Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
  23. C. Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever, malaise and night sweats.
  24. A. Fractured pain is generally described as sharp, continuous, and increasing in frequency.
  25. D. Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of “hot spot” which are areas on the cast that are warmer than the others.
  26. B. Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or without perforation.
  27. D. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid in the body.
  28. A. The adult with normal cerebrospinal fluid has no red blood cells.
  29. D. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus.
  30. B. The nurse should focus more on developing less stressful ways of accomplishing routine task.
  31. C. Autotransfusion is acceptable for the client who is in danger of cardiac arrest.
  32. D. The client with thromboembolism does not have coolness.
  33. A. Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.
  34. C. Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma formation.
  35. D. Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain.
  36. C. Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.
  37. A. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.
  38. A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of aqueous humor.
  39. D. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.
  40. D. Abdominal breathing improves lungs expansion
  41. C. A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.
  42. A. The graft covers the nerve endings, which reduces pain and provides framework for granulation
  43. B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.
  44. C. This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.
  45. D. Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal cancer.
  46. B. With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
  47. A. Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy.
  48. B. Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.
  49. B. Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems.
  50. A. Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will accompany.