Question 1

Ms. Margaret Shawn, a 45-year-old librarian, was ordered by her physician to undergo an oral cholecystography. Which nursing action is inappropriate in preparing Ms. Shawn for this procedure?

Accepted Answer

A)  Administering a fat-free diet the evening before the test
B)  Administering Telepaque (iopanoic acid)  tablets in 5-minute intervals 1 hour after supper
C)  Administering at least 6 oz. of water with each Telepaque (iopanoic acid)  tablet
D)  Allowing the client, after ingesting the tablets, to drink water until midnight, then NPO C

Question 2

Mr. Rodriguez is to undergo a vasectomy the next day. The nurse discussed with him important points after the operation is done. Which of the following instructions should the nurse include in her health teaching?

Accepted Answer

A)  No sexual activity for 2 weeks
B)  Application of ice for pain or swelling
C)  Bed rest for several days
D)  Returning for suture removal in 1 week B

Question 3

Mikaela, 25 years old, is scheduled for a skin biopsy and asks the nurse how painful the procedure is. The appropriate response by the nurse is:

Accepted Answer

A)  "There is no pain associated with this procedure."
B)  "The local anesthetic may cause a burning or stinging sensation."
C)  "A preoperative medication will be given so you will be sleeping and will not feel any pain."
D)  "There is some pain, but the physician will prescribe an opioid analgesic following the procedure." B

Question 4

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in:

Accepted Answer

A)  A fall and further injury
B)  Injury to the brachia plexus nerves
C)  Skin breakdown in the area of the axilla
D)  Impaired range of motion while the client ambulates

Question 5

Two hours ago the client had a left thoracotomy with a lobe resection. The sanguineous drainage in the chest tube collection chamber is 325 mL. The nurse recognizes that this is:

Accepted Answer

A)  Normal chest tube drainage
B)  Indicative of a pneumothorax
C)  Chyle drainage
D)  A sign of hemorrhage

Question 6

One potential complication of an abdominal hysterectomy is abdominal distention. Postoperative nursing measures designed to avoid abdominal distention are:

Accepted Answer

A)  Auscultation of the abdomen for bowel sounds
B)  Abdominal massage and bed rest
C)  Insertion of nasogastric and rectal tubes and ambulation, as ordered
D)  Progression of postoperative diet

Question 7

The client is admitted with metabolic acidosis secondary to diabetic ketoacidosis (DKA). Understanding metabolic acidosis, the nurse should choose which of the following as the priority nursing diagnosis?

Accepted Answer

A)  Decreased urinary elimination related to reduced output and muscle function.
B)  Decreased cardiac output related to fluid and electrolyte imbalance.
C)  Ineffective breathing pattern related to hyperventilation.
D)  Anxiety related to fears of long-term outcomes and discomfort.

Question 8

Lisa, the nurse on duty, is preparing to discharge a client newly diagnosed with diabetes mellitus. The client states, " I should eat a candy bar or cup of ice cream every time I feel shaky, hungry, or nauseated." Which of the following is Lisa's best response?

Accepted Answer

A)  "Yes. A candy bar or cup of ice cream is needed to treat the hypoglycemia."
B)  "Yes. You should eat the snack and then have a meal as soon as possible."
C)  "No. You should quickly eat a meal; the candy will cause hyperglycemia."
D)  "No. These have too much sugar and fat, 5 Lifesavers candies or skim milk is better."

Question 9

Mr. HP recently undergone a colostomy. During his first day post-operative, the nurse does not find any measurable fecal drainage from the colostomy. What should the nurse do?

Accepted Answer

A)  Continue the current plan of care
B)  Call the doctor immediately
C)  Irrigate the stoma
D)  Encourage the patient to increase fluid intake

Question 10

A client newly diagnosed with trigeminal neuralgia asks the nurse to explain why it hurts so much when an episode occurs. The nurse would explain that the pain of trigeminal neuralgia is the result of which of the following?

Accepted Answer

A)  Stimulation of the nerve by temperature or pressure
B)  Irritation due to cellular effects of hypoglycemia
C)  Release of epinephrine during the fight-or-flight response
D)  An immune system reaction to cold and influenza

Question 11

Which assessment finding by the nurse has the most serious implication for a 70-year-old client with emphysema?

Accepted Answer

A)  Increased anterior-posterior diameter of the chest
B)  Bilateral crackles throughout the lung fields
C)  Pursed-lip breathing
D)  Circumoral cyanosis

Question 12

The physician has ordered a 24-hour urine specimen collection. After explaining the procedure to the client, the nurse collects the first specimen. She is doing the right thing if she ________.

Accepted Answer

A)  Discards the first specimen, and then starts the collection
B)  Saves this specimen as part of the 24-hour collection
C)  Tests the specimen, and then discards it
D)  Places this specimen in a separate container and later adds to the collection

Question 13

Mr. Tuxen, a 66-year-old black American, was brought by his wife to the Emergency Department because he is increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver. While assessing Mr. Tuxen, the nurse understands that the correct technique when doing abdominal assessment is:

Accepted Answer

A)  Palpate the most painful area progressing to the least painful parts
B)  Begin with inspection and end with palpation
C)  Follow the sequence of auscultation, inspection, percussion, and palpation
D)  Auscultate the bowel sound first then perform palpation and percussion

Question 14

Luis, 32 years old, obtained a third-degree circumferential arm burn after a pot of boiling oil was accidentally turned over. Escharotomy procedure was ordered for Luis. The nurse understands that the anticipated therapeutic outcome of the escharotomy is:

Accepted Answer

A)  Return of distal pulses
B)  Brisk bleeding from the site
C)  Decreasing edema formation
D)  Formation of granulation tissue

Question 15

In a client with right lung pneumonia, the nurse should encourage which position to facilitate optimal oxygenation?

Accepted Answer

A)  Prone position
B)  Supine position with head elevated at 30 degrees
C)  Positioned with the right side dependent
D)  Positioned with the left side dependent

Question 16

Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:

Accepted Answer

A)  Facilitate his verbal communication
B)  Maintain sterility of the ventilation system
C)  Assess his response to the equipment
D)  Prepare him for emergency surgery

Question 17

The non-insulin-dependent diabetic who is obese is best controlled by weight loss because obesity:

Accepted Answer

A)  Reduces the number of insulin receptors
B)  Causes pancreatic islet cell exhaustion
C)  Reduces insulin binding at receptor sites
D)  Reduces pancreatic insulin production

Question 18

Mr. Chandler has trouble remembering to rotate his sites for insulin injections. In the past week he has self-injected into the right abdomen, left abdomen, right upper arm, left thigh, and right thigh. Into which site should he self-inject his insulin next?

Accepted Answer

A)  Left ankle
B)  Right abdomen
C)  Left midback
D)  Left upper arm

Question 19

Arnold Swanson, who had a myocardial infarction 2 days ago, has been complaining to the nurse about issues related to his hospital stay. The best initial nursing response would be to:

Accepted Answer

A)  Allow him to release his feelings and then leave him alone to allow him to regain his composure.
B)  Refocus the conversation on his fears, frustrations, and anger about his condition.
C)  Explain how his being upset dangerously disturbs his need for rest.
D)  Attempt to explain the purpose of different hospital routines.

Question 20

The client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which of the following actions would the nurse include in the client's postoperative plan of care?

Accepted Answer

A)  Position the client on the affected side
B)  Irrigating the Penrose drain using sterile procedure
C)  Changing dressings frequently around the Penrose drain
D)  Weighing dressings and adding the amount to the output

Exam 1: Medical Surgical