Nursing: Medical-Surgical Review Questions and Answers
Which method elicits the most accurate up and management.
information during a physical assessment of an
older adult?
A. use reliable assessment tools for older adults The nurse is caring for a client with HIV infection
B. Review the past medical record for who develops Mycobacterium avium complex
medications (MAC). what is the most significant desired
C. Ask the client to recount one's health history outcome for this client?
D. Obtain the client's information from a A. free from injury of drug side effects
caregiver - ANSWER -A. use reliable B. maintenance of intact perineal skin
assessment tools for older adults c. adequate oxygenation
D. return to pre-illness weight - ANSWER -
Specific assessment tools (D) for an older adult, D. return to pre-illness weight
such as Older Adult Resource Services Center
Instrument, mini-mental assessment, fall risk, MAC is an opportunistic infection that presents as
depression, or skin breakdown risk, consider a TB like pulmonary process. MAC is a major
age-related physiologic and psychosocial contributing factor to the development of wasting
changes related to aging and provide the most syndrome, so the most significant desired
accurate and complete information. A and B are outcome is the client's return to a pre-illness
subjective and may vary in reliability based on weight. drug schedules and side effects remain a
the client's memory and caregiver's current life-long management problem. Client outcomes
involvement. Although C is a good resource to for adequate oxygenation are often dependent on
identify polypharmacy, a written record may not management of anemia, maintenance of
be available or currently accurate. activities without fatigue, and supplemental
oxygen to prevent hypoxia. Skin integrity is
dependent upon resolution of diarrhea, which is
A client who has just tested positive for HIV does not as significant as optimal nutrition.
not appear to hear what the nurse is saying
during post-test counseling. Which information
should the nurse offer to facilitate the client's A client who had abdominal surgery two days
adjustment to HIV infection? ago has prescriptions for intravenous morphine
A. teach the client about the medications that are sulfate 4 mg every 2 hours and a clear liquid diet.
available for treatment the client complains of feeling distended and has
B. discuss retesting to verify the results, which sharp, cramping gas pains. What nursing
will ensure continuing contact intervention should be implemented?
C. identify the need to test others who have had A. assist the client to ambulate in the hall
risky contact with the client B. obtain a prescription for a laxative
D. inform the client how to protect sexual and C. administer the prescribed morphine sulfate
needle-sharing partners - ANSWER -B. D. withhold all oral fluid and food -
discuss retesting to verify results, which will ANSWER -a. assist the client to ambulate in
ensure continuing contact the hall
encouraging retesting supports hope and gives Post-operative abdominal distention is caused by
the client time to cope with the diagnosis. decreased peristalsis as a result of handling the
Although post-test counseling should include intestine during surgery, limited dietary intake
education about A, B, and C, retesting before and after surgery, and anesthetic and
encourages the client to maintain medical follow- analgesic agents. Peristalsis is stimulated and
,Nursing: Medical-Surgical Review Questions and Answers
distention minimized by implementing early and the nasal pharynx and oral pharynx are
frequent ambulation. Based on the client's status, anesthetized with local anesthetic spray prior to
laxatives or withholding dietary progression are bronchoscopy, and the bronchoscope is coated
not indicated at this time. although pain with lidocaine gel to inhibit the gag reflex and
management should be implemented, another prevent laryngeal spasm during insertion. The
analgesic prescription may be needed because client should be NPO until the client's gag reflex
morphine reduces intestinal motility and returns to prevent aspiration from any oral intake
contributes to the client's gas pains. or secretions. The others are not indicated after
bronchoscopy
A client with Meniere's disease is incapacitated
by vertigo and is lying in bed grasping the side The nurse is assessing a client with a cuffed
rails and staring at the television. Which nursing tracheostomy tube in place who is breathing
intervention should the nurse implement? spontaneously. to evaluate if the client can
A. keep the head of the bed elevated 30 degrees tolerate cuff deflation to promote speaking and
B. turn off the television and darken the room swallowing, what action should the nurse
c. encourage fluids to 3000 mL per day implement?
D. change the client's position every two hours - A. observe the client for coughing colored sputum
ANSWER -B. turn off the television and after drinking a small amount of colored water
darken the room B. ask the client to try to speak
C. auscultate for pulmonary crackles after the
to decrease the client's vertigo during an acute client drinks a small amount of clear water
attack of Meniere's disease, any visual stimuli or D. assess for respiratory distress -
rotational movement, such as sudden head ANSWER -A. observe the client four
movements or position changes, should be coughing colored sputum after drinking a small
minimized. Turning off the television and amount of colored water
darkening the room minimize fluorescent lights,
flickering television lights, and distracting sound. to evaluate the risk for aspiration after the cuff is
The other are ineffective in managing the client's deflated, the client should be instructed to
symptoms. swallow a small amount of colored water, then be
observed for coughing up colored sputum, or the
tracheostomy should be suctioned for the
a client who has a chronic cough with blood- presence of colored water.
tinged sputum returns to the unit after a
bronchoscopy. What nursing interventions should
be implemented in the immediate post- What assessment finding should the nurse
procedural period? identify that indicates a client with an acute
A. check vital signs every 15 minutes for 2 hours asthma exacerbation is beginning to improve
B. allow the client nothing by mouth until the gag after treatment?
reflex returns A. vesicular breath sounds decrease
C. encourage fluid intake to promote elimination B. wheezing becomes louder
of the contrast media C. bronchodilators stimulate coughing
D. keep the client on bed rest for 8 hours - D. cough remains unproductive -
ANSWER -B. allow the client nothing by ANSWER -B. wheezing becomes louder
mouth until the gag reflex returns
In an acute asthma attack, air flow may be so
, Nursing: Medical-Surgical Review Questions and Answers
significantly restricted that wheezing is for occult bleeding in the emesis, sputum, feces,
diminished. If the client is successfully urine, nasogastric secretions, or wounds.
responding to bronchodilators and respiratory
treatments, wheezing becomes louder as air flow
increases in the airways. As the airways open A client is admitted for complaints of chest pain
and mucous is mobilized in response to and aching for the past 4 days. the results for
treatment, the cough becomes more productive. serum creatine kinase-MB (CK-MB) and troponin
vesicular sounds are soft, low-pitched, gentle, are obtained. What rationale should the nurse
rustling sounds heard over lung fields. use to evaluate the laboratory findings?
A. serum myoglobin levels are needed to confirm
myocardial damage
A client with sickle cell anemia is admitted with B. myocardial damage that occurred several days
severe abdominal pain and the diagnosis is earlier is best validated by serum troponin levels
sickle cell crisis. What is the most important C. the most reliable indicator of myocardial
nursing action to implement? necrosis is serum CK-MB
A. limit the client's intake of oral fluids D. serum cardiac markers are inconclusive in
B. teach the client about prevention of crises determining myocardial injury after waiting
C. evaluate the effectiveness of narcotic several days - ANSWER -B. myocardial
analgesics damage that occurred several days earlier is best
D. encourage the client to ambulate as tolerated validated by serum troponin levels
- ANSWER -C. evaluate the effectiveness
of narcotic analgesics Serum CK-MB and troponin are the two most
important serum cardiac markers for confirming
Pain management is the priority for a client myocardial infarction. CK-MB begins to rise in the
during sickle cell crisis. Continuous narcotic first 3 to 12 hours after the myocardial infarction,
analgesics are the mainstay of pain control, peaks in 24 hours, and returns to normal in 2 to 3
which should be evaluated frequently to days. the troponin level rises as quickly but
determine if the client's pain is adequately remains elevated for 2 weeks.
controlled.
Three weeks after discharge fro an acute
The nurse is caring for a client with non- myocardial infarction (MI), a client returns to the
Hodgkin's lymphoma who is receiving cardiac center for follow-up. When the nurse asks
chemotherapy. Laboratory results reveal a about sleep patterns, the client tells the nurse
platelet count of 10,000/mL. What action should that he sleeps fine but that his wife moved into
the nurse implement? the spare bedroom to sleep when he returned
A. provide oral hygiene every 2 hours home. He states "I guess we will never have sex
B. check for fever every 4 hours again after this." Which response is best for the
C. encourage fluids to 3000 mL/day nurse to provide?
D. check stools for occult blood - A. sexual activity can be resumed whenever you
ANSWER -D. check stools for occult blod and you wife feel like it because the sexual
response is more emotional rather than physical
Platelet counts less than 100,000/mm3 are B. you should discuss your questions about your
indicative of thrombocytopenia, a common side sexual activity with your healthcare provider
effect of chemotherapy. A client with because sexual activity may be limited by your
thrombocytopenia should be assessed frequently heart damage
Which method elicits the most accurate up and management.
information during a physical assessment of an
older adult?
A. use reliable assessment tools for older adults The nurse is caring for a client with HIV infection
B. Review the past medical record for who develops Mycobacterium avium complex
medications (MAC). what is the most significant desired
C. Ask the client to recount one's health history outcome for this client?
D. Obtain the client's information from a A. free from injury of drug side effects
caregiver - ANSWER -A. use reliable B. maintenance of intact perineal skin
assessment tools for older adults c. adequate oxygenation
D. return to pre-illness weight - ANSWER -
Specific assessment tools (D) for an older adult, D. return to pre-illness weight
such as Older Adult Resource Services Center
Instrument, mini-mental assessment, fall risk, MAC is an opportunistic infection that presents as
depression, or skin breakdown risk, consider a TB like pulmonary process. MAC is a major
age-related physiologic and psychosocial contributing factor to the development of wasting
changes related to aging and provide the most syndrome, so the most significant desired
accurate and complete information. A and B are outcome is the client's return to a pre-illness
subjective and may vary in reliability based on weight. drug schedules and side effects remain a
the client's memory and caregiver's current life-long management problem. Client outcomes
involvement. Although C is a good resource to for adequate oxygenation are often dependent on
identify polypharmacy, a written record may not management of anemia, maintenance of
be available or currently accurate. activities without fatigue, and supplemental
oxygen to prevent hypoxia. Skin integrity is
dependent upon resolution of diarrhea, which is
A client who has just tested positive for HIV does not as significant as optimal nutrition.
not appear to hear what the nurse is saying
during post-test counseling. Which information
should the nurse offer to facilitate the client's A client who had abdominal surgery two days
adjustment to HIV infection? ago has prescriptions for intravenous morphine
A. teach the client about the medications that are sulfate 4 mg every 2 hours and a clear liquid diet.
available for treatment the client complains of feeling distended and has
B. discuss retesting to verify the results, which sharp, cramping gas pains. What nursing
will ensure continuing contact intervention should be implemented?
C. identify the need to test others who have had A. assist the client to ambulate in the hall
risky contact with the client B. obtain a prescription for a laxative
D. inform the client how to protect sexual and C. administer the prescribed morphine sulfate
needle-sharing partners - ANSWER -B. D. withhold all oral fluid and food -
discuss retesting to verify results, which will ANSWER -a. assist the client to ambulate in
ensure continuing contact the hall
encouraging retesting supports hope and gives Post-operative abdominal distention is caused by
the client time to cope with the diagnosis. decreased peristalsis as a result of handling the
Although post-test counseling should include intestine during surgery, limited dietary intake
education about A, B, and C, retesting before and after surgery, and anesthetic and
encourages the client to maintain medical follow- analgesic agents. Peristalsis is stimulated and
,Nursing: Medical-Surgical Review Questions and Answers
distention minimized by implementing early and the nasal pharynx and oral pharynx are
frequent ambulation. Based on the client's status, anesthetized with local anesthetic spray prior to
laxatives or withholding dietary progression are bronchoscopy, and the bronchoscope is coated
not indicated at this time. although pain with lidocaine gel to inhibit the gag reflex and
management should be implemented, another prevent laryngeal spasm during insertion. The
analgesic prescription may be needed because client should be NPO until the client's gag reflex
morphine reduces intestinal motility and returns to prevent aspiration from any oral intake
contributes to the client's gas pains. or secretions. The others are not indicated after
bronchoscopy
A client with Meniere's disease is incapacitated
by vertigo and is lying in bed grasping the side The nurse is assessing a client with a cuffed
rails and staring at the television. Which nursing tracheostomy tube in place who is breathing
intervention should the nurse implement? spontaneously. to evaluate if the client can
A. keep the head of the bed elevated 30 degrees tolerate cuff deflation to promote speaking and
B. turn off the television and darken the room swallowing, what action should the nurse
c. encourage fluids to 3000 mL per day implement?
D. change the client's position every two hours - A. observe the client for coughing colored sputum
ANSWER -B. turn off the television and after drinking a small amount of colored water
darken the room B. ask the client to try to speak
C. auscultate for pulmonary crackles after the
to decrease the client's vertigo during an acute client drinks a small amount of clear water
attack of Meniere's disease, any visual stimuli or D. assess for respiratory distress -
rotational movement, such as sudden head ANSWER -A. observe the client four
movements or position changes, should be coughing colored sputum after drinking a small
minimized. Turning off the television and amount of colored water
darkening the room minimize fluorescent lights,
flickering television lights, and distracting sound. to evaluate the risk for aspiration after the cuff is
The other are ineffective in managing the client's deflated, the client should be instructed to
symptoms. swallow a small amount of colored water, then be
observed for coughing up colored sputum, or the
tracheostomy should be suctioned for the
a client who has a chronic cough with blood- presence of colored water.
tinged sputum returns to the unit after a
bronchoscopy. What nursing interventions should
be implemented in the immediate post- What assessment finding should the nurse
procedural period? identify that indicates a client with an acute
A. check vital signs every 15 minutes for 2 hours asthma exacerbation is beginning to improve
B. allow the client nothing by mouth until the gag after treatment?
reflex returns A. vesicular breath sounds decrease
C. encourage fluid intake to promote elimination B. wheezing becomes louder
of the contrast media C. bronchodilators stimulate coughing
D. keep the client on bed rest for 8 hours - D. cough remains unproductive -
ANSWER -B. allow the client nothing by ANSWER -B. wheezing becomes louder
mouth until the gag reflex returns
In an acute asthma attack, air flow may be so
, Nursing: Medical-Surgical Review Questions and Answers
significantly restricted that wheezing is for occult bleeding in the emesis, sputum, feces,
diminished. If the client is successfully urine, nasogastric secretions, or wounds.
responding to bronchodilators and respiratory
treatments, wheezing becomes louder as air flow
increases in the airways. As the airways open A client is admitted for complaints of chest pain
and mucous is mobilized in response to and aching for the past 4 days. the results for
treatment, the cough becomes more productive. serum creatine kinase-MB (CK-MB) and troponin
vesicular sounds are soft, low-pitched, gentle, are obtained. What rationale should the nurse
rustling sounds heard over lung fields. use to evaluate the laboratory findings?
A. serum myoglobin levels are needed to confirm
myocardial damage
A client with sickle cell anemia is admitted with B. myocardial damage that occurred several days
severe abdominal pain and the diagnosis is earlier is best validated by serum troponin levels
sickle cell crisis. What is the most important C. the most reliable indicator of myocardial
nursing action to implement? necrosis is serum CK-MB
A. limit the client's intake of oral fluids D. serum cardiac markers are inconclusive in
B. teach the client about prevention of crises determining myocardial injury after waiting
C. evaluate the effectiveness of narcotic several days - ANSWER -B. myocardial
analgesics damage that occurred several days earlier is best
D. encourage the client to ambulate as tolerated validated by serum troponin levels
- ANSWER -C. evaluate the effectiveness
of narcotic analgesics Serum CK-MB and troponin are the two most
important serum cardiac markers for confirming
Pain management is the priority for a client myocardial infarction. CK-MB begins to rise in the
during sickle cell crisis. Continuous narcotic first 3 to 12 hours after the myocardial infarction,
analgesics are the mainstay of pain control, peaks in 24 hours, and returns to normal in 2 to 3
which should be evaluated frequently to days. the troponin level rises as quickly but
determine if the client's pain is adequately remains elevated for 2 weeks.
controlled.
Three weeks after discharge fro an acute
The nurse is caring for a client with non- myocardial infarction (MI), a client returns to the
Hodgkin's lymphoma who is receiving cardiac center for follow-up. When the nurse asks
chemotherapy. Laboratory results reveal a about sleep patterns, the client tells the nurse
platelet count of 10,000/mL. What action should that he sleeps fine but that his wife moved into
the nurse implement? the spare bedroom to sleep when he returned
A. provide oral hygiene every 2 hours home. He states "I guess we will never have sex
B. check for fever every 4 hours again after this." Which response is best for the
C. encourage fluids to 3000 mL/day nurse to provide?
D. check stools for occult blood - A. sexual activity can be resumed whenever you
ANSWER -D. check stools for occult blod and you wife feel like it because the sexual
response is more emotional rather than physical
Platelet counts less than 100,000/mm3 are B. you should discuss your questions about your
indicative of thrombocytopenia, a common side sexual activity with your healthcare provider
effect of chemotherapy. A client with because sexual activity may be limited by your
thrombocytopenia should be assessed frequently heart damage
