Medical Surgical Nursing

Multiple ChoiceIdentify the choice that BEST completes the statement or answers the question.

____ 1. Ms. Baker has decided to have surgical correction of her stenosed valve at this time because her subjective complaints of dyspnea, hemoptysis, orthopnea, and paroxysmal nocturnal dyspnea have become unmanageable. These complaints are probably due to:

a.thickening of the pericardium

c.pulmonary hypertension

b.right heart failure

d.left ventricular hypertrophy

____ 2. SITUATION: Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking in midsentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA. Upper motor neuron disease may be manifested in WHICH of the following clinical signs?

a.spastic paralysis, hyperreflexia, presence of babinski reflex

b.flaccid paralysis, hyporeflexia

c.muscle atrophy, fasciculations

d.decreased or absent voluntary movement

____ 3. A thorough history reveals that hormonal changes associated with menstruation may have triggered Julie’s migraine attack. In investigating Julie’s history what factors would be LEAST significant in migraine?

a.seasonal ALLergies

c.family history of migraine

b.trigger foods such as alcohol, MSG, chocolate

d.warning sign of onset, or aura

____ 4. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one hour preoperatively. WHICH nursing actions follow the giving of the preop medication?

a.have her void soon after receiving the medication

b.ALLow her family to be with her before the medication takes effect

c.bring her valuables to the nursing station

d.reinforce preop teaching

____ 5. Mrs. Hogan returns to your clinical unit following discharge from the recovery room. Her vital signs are stable and her family is with her. Postoperative leg exercises SHOULD be inititated:

a.after the physician writes the order

c.if Mrs. Hogan will NOT be ambulated early

b.after the family leaves

d.stat

____ 6. If breath sounds are only heard on the right side after intubation:

a.Extubate, ventilate for 30 seconds then try again.

c.You have intubated the stomach.

b.The patient probably only has one lung, the right.

d.Pull the tube back and listen again.

____ 7. Diabetes insipidus involves a dysfunction of:a. Glucose c. Insulin productionb. ADH d. FSH

____ 8. The nurse is caring for a client who recently underwent a tracheostomy. The FIRST priority when caring for a client with a tracheostomy is:a. helping him communicate.b. keeping his airway patent.c. encouraging him to perform activities of daily living.d. preventing him from developing an infection.

____ 9. The nurse is caring for a client experiencing acute addisonian crisis. WHICH laboratory data would the nurse expect to find?a. Hyperkalemia c. Hypernatremiab. Reduced blood urea nitrogen (BUN) d. Hyperglycemia

____ 10. The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse SHOULD FIRST administer:a. I.M. or subcutaneous glucagon.b. an I.V. bolus of dextrose 50%.c. 15 to 20 g of a fast-acting carbohydrate such as orange juice.d. 10 U of fast-acting insulin.

____ 11. When a client is scheduled for a thyroid test, the nurse must determine if the client has taken any medication containing iodine, WHICH would alter test results. WHICH of the following medications contain iodine?a. Acetaminophen and aspirinb. Estrogen and amphetaminesc. Insulin and oral antidiabetic agentsd. Contrast media, topical antiseptics, and multivitamins

____ 12. One of these statements is true about the glomerulus?a. It can filter blood for approximately 125 cc/min.b. It reabsorbs filtrates.c. It receives blood from the renal arteries and later on returns it to the same blood vessel.d. ALL of the above

____ 13. A client has undergone subtotal thyroidectomy. Postoperatively, the nurse continues to assess for signs and symptoms of hypocalcemia. WHICH of the following are more indicative of tetany?a. Abdominal cramping and convulsions c. Positive Chvostek’s and Trousseau’s

signsb. Dyspnea and cyanosis d. Muscular flaccidity and hypotension

____ 14. A male client is diagnosed to have acute glomerulonephritis. WHICH of the following is the pathophysiologic alteration that occurs with this disease?a. CrystALLization in the distal tubules of the kidney due to an untoward effect of antipyretic

medication.b. Destruction of glomeruli due to the trapping of circulating antigen-antibody complexes.c. Inhibition of antibodies resulting from an invading microorganisms.d. Sensitivity of toxins resulting from an invading microorganisms.

____ 15. To control diabetes mellitus, proper treatment and diet SHOULD go hand in hand. The MOST important factor in the success of a diabetic diet is:a. the accuracy of the food exchange list to be given to the patientb. the appropriateness of the drug or insulin to be prescribed to the patientc. the patients willingness to adhere it consistentlyd. the age of the patient

____ 16. WHICH of the following disease processes is caused by an absence of insulin or inadequate amount of insulin, resulting in hyperglycemia and leading to a series of biochemical disorders?a. Diabetes insipidus c. Diabetic ketoacidosisb. Hyperaldosteronism d. HHNK syndrome

____ 17. Mrs. Cruise is to undergo laboratory examinations. The purpose of oral glucose tolerance test is:a. determine the amount of glucose in the blood when fastingb. measure the blood sugar following a mealc. determine person’s response to a measured dose of glucosed. any of these purposes.

____ 18. If fluid intake is limited in a client with diabetes insipidus, WHICH of the following complications will he be at risk for developing?a. Hypertension and bradycardia c. Glucosuria and weight gainb. Peripheral edema and weight gain d. Severe dehydration and hypernatremia

____ 19. WHICH of the following statements would the nurse identify as the BEST indication of a 50-year-old client's developmental concerns at

this time in his life?a. It is time to reevaluate life's goalsb. selection of a career is importantc. Leisure-time activities are a center of focusd. Stress associated with illness precipitates a need to "settle down

____ 20. When developing a teaching plan for a sexuality class at a community center about human immunodeficiency virus (HIV) transmission, the nurse would include WHICH of the following behaviors as a measure to greatly reduce the risk of transmission?a. Avoiding inhalant drugsb. Avoiding prolonged sexc. Using latex condoms with sexual intercoursed. Douching before and after sexual intercourse

____ 21. When developing the plan of care for a client with aplastic anemia, WHICH of the following goals would be MOST appropriate to include?a. Perform activities of daily living without excessive fatigue or dyspneab. Learn how to administer weekly vitamin B injectionsc. Correctly demonstrate how to take prescribed anticoagulant drug therapyd. Describe self-care behaviors to prevent the transmission to family members

____ 22. When developing the plan of care for a client with full-thickness burns over 35% of his body, the nurse would anticipate WHICH of thefollowing?a. Using oral analgesics because full-thickness burns are painless owing to nerve

destruction.b. Relying on nonpharmacologic measures to avoid respiratory depression

c. Sedating the client to an unconscious state to decrease awareness of paind. Administering intravenous opioid analgesics such as morphine

____ 23. The nurse performs a cardiovascular assessment on an elderly client, WHICH reveals a BP of 162/86. The nurse’s assessment finding is MOST likely a result of a. Less muscle mass c. Dehydrationb. Calcification of the arteries d. Impaired lung capacity

____ 24. WHICH nursing care measure is NOT appropriate for client with deep vein thrombosis? a. Careful leg massages c. Elevating the legsb. Elastic stockings d. Leg exercises

____ 25. A client has thrombophlebitis. Heparin SC Q 8hr is prescribed. Nursing interventions related to the administration of heparin include: a. Monitoring the client’s UO c. Checking the client’s Ecchymosisb. Checking the client’s INR before administration d. Informing the client that NSAIODS may be taken for

discomfort

____ 26. The nurse is caring for patients on the medical unit. A patient is admitted with a diagnosis of deep vein thrombosis (DVT). Admission orders include heparin 2,000 units per hour in 5% dextrose in water. The nurse SHOULD have WHICH of the following available?a. Propanolol (Inderal) c. Protamine sulfateb. Protamine zinc d. Vitamin K

____ 27. The nurse observes a nursing assistant positioning the client’s leg on a pillow. The client is diagnosed with arterial insufficiency of the lower extremities. The nurse SHOULD:a. Go to the client’s room and remove the pillow from

the client’s leg immediatelyc. Go into the client’s room and demonstrate proper

positioning in front of the nursing assistantb. CALL the nursing assistant’s attention and explain

the position is wrongd. Ignore the nursing assistant’s action

____ 28. WHICH of the following is a cardinal symptom of a patient with peripheral arterial occlusive disease? a. Thrombophlebitis c. Edema and painb. Positive human sign d. Intermittent claudication

____ 29. If a patient develops a pyrogenic reaction to a blood transfusion, the patient would MOST likely have WHICH of the following symptoms? a. Pounding headache c. Chill and feverb. Urticaria d. Flank pain

____ 30. WHICH of these observations of a patient who has pernicious anemia would indicate that the goal of care has been achieved?a. The patient’s skin has no petechiae c. The patient has no dependent edemab. The patient’s tongue has lost its beefy red color d. The patient has good appetite

____ 31. An 88-year old female patient is on IV therapy dehydration. The nurse would assess the effectiveness of this treatment by: a. Pinching the skin over the sternum c. Checking the patient’s tongueb. Pinching the skin over the hand d. Looking at the patient’s conjunctiva

____ 32. A patient scheduled for surgery asks the nurse “How long before surgery SHOULD I stop taking aspirin? The nurse’s BEST response would be:a. 24 hours c. 8 hoursb. 48 hours d. 3 days

____ 33. A 24-year-old patient has a long-leg cast applied to the left leg following a fracture sustained in an accident. WHICH of these measures would be MOST important to include in the patient’s care plan initiALLy? a. Maintaining the leg in external rotation c. Determining the capillary refill in the toes

of the affected legb. Monitoring the femoral pulses d. Encouraging exercise of the unaffected

leg

____ 34. An 80 years old female who sustained an unstable fracture of hip when she fell from a kitchen ladder is brought to the ER. WHICH of the following clinical findings would be MOST significant in the initial assessment of the patient? a. Deformity c. Localized swellingb. Ecchymoses d. Pain

____ 35. The nurse is evaluating the care given to a client who has had a total hip replacement. WHICH position indicates the client has been position appropriately a. The affected leg is abducted and externALLy

rotatedc. The affected leg is abducted and internALLy

rotatedb. The affected leg is adducted and externALLy

rotatedd. The affected leg is adducted and internALLy

rotated

____ 36. The client with a spinal cord injury at the level of C5 has a weakened respiratory effort, ineffective cough, and is using accessory neck muscles in breathing. The nurse carefully monitors the client and formulates WHICH of the following diagnosis? a. Ineffective breathing pattern c. Risk for aspirationb. Impaired gas exchange d. Risk for injury

____ 37. A swimmer sustains a spinal cord injury at the level of C6-C7 following a diving accident. WHICH of the following would be the MOST important for the nurse to have readily available at the bedside? a. A lumbar puncture tray c. A chest tube insertion trayb. A tracheostomy set d. A gastric lavage/suction kit

____ 38. WHICH of the following nursing diagnosis would have the highest priority for a patient with diagnosis of Guillain-Barre syndrome? a. Potential for impaired physical mobility c. Potential for ineffective breathing patternsb. Potential for altered nutrition d. Potential for altered elimination;

bowel/bladder____ 39. A nurse is caring for a client with Guillain-Barre syndrome. WHICH of the following strategies is of MOST

importance in the plan of care? a. Range of motion exercises three to four times per

dayc. Use of artificial tears

b. Frequent measurement of vital capacity d. Starting an enteral feeding

____ 40. A client has been diagnosed with Bell’s palsy (cranial nerve 7 disorder). One of the instructions the nurse needs to review with the client is: a. Chew foods on affected side to strengthen facial

musclesc. Massaged effected side of the face vigorously

b. Perform simple exercises such as blinking the eye d. Apply protective eye shield over affected eye

____ 41. The client has dysfunction of the cochlear division of the vestibulcochlear cochlear nerve (cranial nerve VIII). The nurse evaluates that the client is adequately adapting to this problem if the client states a plan to obtain a a. Hearing aid c. Pair of eye glassesb. Walker d. Bath thermometer

____ 42. The client is admitted with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of

a. Hypertension c. Heart failureb. Chronic obstructive pulmonary disease d. Prosthetic valve replacement

____ 43. The nurse is caring for a patient 4 hours after intracranial surgery. WHICH of the following actions SHOULD the nurse take immediately? a. Turn. Cough, and deep-breathe the

patientc. Perform passive range of motion exercise

b. Place the patient with the neck flexed and head turned to the side

d. Move the client to the head of the bed using a turning sheet

____ 44. Patient has right-sided CVA. What does the nurse need to do when feeding this patient? a. Give the patient sips of water between each bite c. Avoid thickened fluids and food with textureb. Place the food in the left side of the patient’s

mouthd. Position patient upright with the head tilted slightly

forward

____ 45. A client has had a cerebral vascular accident (CVA). The nurse establishes a nursing diagnosis of alteration in nutrition related to dysphagia. WHICH of the following actions might make swallowing easier for the client? a. Stroking the posterior neck to promote

swALLowingc. Positioning the client upright with the head and

neck positioned forward and flexedb. Feeding the client thin liquids, such as clear

soups, coffee, and tead. Placing about one teaspoonful of liquid in the front

of the mouth

____ 46. The client with CVA has residual dysphagia. When a diet order is initiated, the nurse avoids doing WHICH of the following? a. Giving the client thin liquids c. Placing the food on the unaffected side of the

mouthb. Thickening liquids to the consistency of oatmeal d. ALLowing plenty of time for chewing and

swALLowing

____ 47. A tracheostomy was performed and mechanical ventilation instituted on an adult. Tracheal suctioning by the nurse SHOULD include a. Wearing clean gloves, goggles, and a mask c. Hyperoxygenating the client with 100% O2 only

after the procedure is completedb. Applying a constant suction while inserting the

catheterd. Applying intermittent suction and rotating the

catheter as the suction catheter is drawn from the tracheostomy tube

____ 48. You are caring for the patient with water sealed drainage. WHICH of the following is NOT a proper intervention or observation?

a. Do NOT clamp the tubing during transport or ambulation

c. Keep the drainage equipment below the level of the patient’s chest

b. Observe the water fluctuate with inspiration and expiration

d. Observe that continuous bubbling occurs in the fluid where the water seal is maintained

____ 49. WHICH assessment is MOST useful in assessing the adequacy of O2 therapy of patient with COPD? a. Respiratory rate c. Pulmonary function testsb. Color mucous membranes d. Arterial blood gases

____ 50. A client is on a ventilator. The ventilator alarm goes off. The nurse assesses the patient and observes increased respiratory rate, use of accessory muscles, and agitation. The nurse’s BEST initial action is to a. Remove the client from the ventilator and ambu

bag the patient, while continuing to assess to determine the cause of the client’s distress

c. notify the physician

b. CALL the respiratory therapy to check the ventilator

d. Turn off the alarm