1|Page
Nursing: Medical-Surgical Review
Questions & Answers
Which method elicits the most accurate information during a physical assessment
of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health history
D. Obtain the client's information from a caregiver - correct-answer -A. use
reliable assessment tools for older adults
Specific assessment tools (D) for an older adult, such as Older Adult Resource
Services Center Instrument, mini-mental assessment, fall risk, depression, or skin
breakdown risk, consider age-related physiologic and psychosocial changes related
to aging and provide the most accurate and complete information. A and B are
subjective and may vary in reliability based on the client's memory and caregiver's
current involvement. Although C is a good resource to identify polypharmacy, a
written record may not be available or currently accurate.
A client who has just tested positive for HIV does not appear to hear what the
nurse is saying during post-test counseling. Which information should the nurse
offer to facilitate the client's adjustment to HIV infection?
A. teach the client about the medications that are available for treatment
,2|Page
B. discuss retesting to verify the results, which will ensure continuing contact
C. identify the need to test others who have had risky contact with the client
D. inform the client how to protect sexual and needle-sharing partners - correct-
answer -B. discuss retesting to verify results, which will ensure continuing contact
encouraging retesting supports hope and gives the client time to cope with the
diagnosis. Although post-test counseling should include education about A, B, and
C, retesting encourages the client to maintain medical follow-up and
management.
The nurse is caring for a client with HIV infection who develops Mycobacterium
avium complex (MAC). what is the most significant desired outcome for this
client?
A. free from injury of drug side effects
B. maintenance of intact perineal skin
c. adequate oxygenation
D. return to pre-illness weight - correct-answer -D. return to pre-illness weight
MAC is an opportunistic infection that presents as a TB like pulmonary process.
MAC is a major contributing factor to the development of wasting syndrome, so
the most significant desired outcome is the client's return to a pre-illness weight.
drug schedules and side effects remain a life-long management problem. Client
outcomes for adequate oxygenation are often dependent on management of
anemia, maintenance of activities without fatigue, and supplemental oxygen to
prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is
not as significant as optimal nutrition.
,3|Page
A client who had abdominal surgery two days ago has prescriptions for
intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. the client
complains of feeling distended and has sharp, cramping gas pains. What nursing
intervention should be implemented?
A. assist the client to ambulate in the hall
B. obtain a prescription for a laxative
C. administer the prescribed morphine sulfate
D. withhold all oral fluid and food - correct-answer -a. assist the client to ambulate
in the hall
Post-operative abdominal distention is caused by decreased peristalsis as a result
of handling the intestine during surgery, limited dietary intake before and after
surgery, and anesthetic and analgesic agents. Peristalsis is stimulated and
distention minimized by implementing early and frequent ambulation. Based on
the client's status, laxatives or withholding dietary progression are not indicated at
this time. although pain management should be implemented, another analgesic
prescription may be needed because morphine reduces intestinal motility and
contributes to the client's gas pains.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed
grasping the side rails and staring at the television. Which nursing intervention
should the nurse implement?
A. keep the head of the bed elevated 30 degrees
B. turn off the television and darken the room
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c. encourage fluids to 3000 mL per day
D. change the client's position every two hours - correct-answer -B. turn off the
television and darken the room
to decrease the client's vertigo during an acute attack of Meniere's disease, any
visual stimuli or rotational movement, such as sudden head movements or
position changes, should be minimized. Turning off the television and darkening
the room minimize fluorescent lights, flickering television lights, and distracting
sound. The other are ineffective in managing the client's symptoms.
a client who has a chronic cough with blood-tinged sputum returns to the unit
after a bronchoscopy. What nursing interventions should be implemented in the
immediate post-procedural period?
A. check vital signs every 15 minutes for 2 hours
B. allow the client nothing by mouth until the gag reflex returns
C. encourage fluid intake to promote elimination of the contrast media
D. keep the client on bed rest for 8 hours - correct-answer -B. allow the client
nothing by mouth until the gag reflex returns
the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray
prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to
inhibit the gag reflex and prevent laryngeal spasm during insertion. The client
should be NPO until the client's gag reflex returns to prevent aspiration from any
oral intake or secretions. The others are not indicated after bronchoscopy
Nursing: Medical-Surgical Review
Questions & Answers
Which method elicits the most accurate information during a physical assessment
of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health history
D. Obtain the client's information from a caregiver - correct-answer -A. use
reliable assessment tools for older adults
Specific assessment tools (D) for an older adult, such as Older Adult Resource
Services Center Instrument, mini-mental assessment, fall risk, depression, or skin
breakdown risk, consider age-related physiologic and psychosocial changes related
to aging and provide the most accurate and complete information. A and B are
subjective and may vary in reliability based on the client's memory and caregiver's
current involvement. Although C is a good resource to identify polypharmacy, a
written record may not be available or currently accurate.
A client who has just tested positive for HIV does not appear to hear what the
nurse is saying during post-test counseling. Which information should the nurse
offer to facilitate the client's adjustment to HIV infection?
A. teach the client about the medications that are available for treatment
,2|Page
B. discuss retesting to verify the results, which will ensure continuing contact
C. identify the need to test others who have had risky contact with the client
D. inform the client how to protect sexual and needle-sharing partners - correct-
answer -B. discuss retesting to verify results, which will ensure continuing contact
encouraging retesting supports hope and gives the client time to cope with the
diagnosis. Although post-test counseling should include education about A, B, and
C, retesting encourages the client to maintain medical follow-up and
management.
The nurse is caring for a client with HIV infection who develops Mycobacterium
avium complex (MAC). what is the most significant desired outcome for this
client?
A. free from injury of drug side effects
B. maintenance of intact perineal skin
c. adequate oxygenation
D. return to pre-illness weight - correct-answer -D. return to pre-illness weight
MAC is an opportunistic infection that presents as a TB like pulmonary process.
MAC is a major contributing factor to the development of wasting syndrome, so
the most significant desired outcome is the client's return to a pre-illness weight.
drug schedules and side effects remain a life-long management problem. Client
outcomes for adequate oxygenation are often dependent on management of
anemia, maintenance of activities without fatigue, and supplemental oxygen to
prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is
not as significant as optimal nutrition.
,3|Page
A client who had abdominal surgery two days ago has prescriptions for
intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. the client
complains of feeling distended and has sharp, cramping gas pains. What nursing
intervention should be implemented?
A. assist the client to ambulate in the hall
B. obtain a prescription for a laxative
C. administer the prescribed morphine sulfate
D. withhold all oral fluid and food - correct-answer -a. assist the client to ambulate
in the hall
Post-operative abdominal distention is caused by decreased peristalsis as a result
of handling the intestine during surgery, limited dietary intake before and after
surgery, and anesthetic and analgesic agents. Peristalsis is stimulated and
distention minimized by implementing early and frequent ambulation. Based on
the client's status, laxatives or withholding dietary progression are not indicated at
this time. although pain management should be implemented, another analgesic
prescription may be needed because morphine reduces intestinal motility and
contributes to the client's gas pains.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed
grasping the side rails and staring at the television. Which nursing intervention
should the nurse implement?
A. keep the head of the bed elevated 30 degrees
B. turn off the television and darken the room
, 4|Page
c. encourage fluids to 3000 mL per day
D. change the client's position every two hours - correct-answer -B. turn off the
television and darken the room
to decrease the client's vertigo during an acute attack of Meniere's disease, any
visual stimuli or rotational movement, such as sudden head movements or
position changes, should be minimized. Turning off the television and darkening
the room minimize fluorescent lights, flickering television lights, and distracting
sound. The other are ineffective in managing the client's symptoms.
a client who has a chronic cough with blood-tinged sputum returns to the unit
after a bronchoscopy. What nursing interventions should be implemented in the
immediate post-procedural period?
A. check vital signs every 15 minutes for 2 hours
B. allow the client nothing by mouth until the gag reflex returns
C. encourage fluid intake to promote elimination of the contrast media
D. keep the client on bed rest for 8 hours - correct-answer -B. allow the client
nothing by mouth until the gag reflex returns
the nasal pharynx and oral pharynx are anesthetized with local anesthetic spray
prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to
inhibit the gag reflex and prevent laryngeal spasm during insertion. The client
should be NPO until the client's gag reflex returns to prevent aspiration from any
oral intake or secretions. The others are not indicated after bronchoscopy
