NUR 155 Med/Surg Final Review Questions With Complete
Solutions
Which statements about peritonitis are true? Select all that
apply.
1. Peritonitis is caused by contamination of the peritoneal
cavity by bacteria or chemicals.
2. Continuous ambulatory peritoneal dialysis (CAPD) can
cause peritonitis.
3. White blood cell counts are often decreased with
peritonitis.
4. Abdominal wall rigidity is a classic finding in patients
with peritonitis.
5. Chemical peritonitis is caused by leaking of pancreatic
enzymes or gastric acids.
A) 1,4
B) 1,3
C) 1,2,4
D) 1,4,5
E) All of these
F) None
C) 1,2,4
,A nurse is assessing a client who has been admitted with a
diagnosis of an obstruction in the small intestine. The nurse
should assess the client for? Select all that apply.
1. Projectile vomiting.
2. Significant abdominal distention.
3. Copious diarrhea.
4. Rapid onset of dehydration.
5. High-pitched bowel sounds.
A) 1,4
B) 1,4,5
C) 2,4
D) 1,2,3
E) All of these
F) None
B) 1,4,5
Rational:
Signs and symptoms of intestinal obstructions in the small
intestine may include projectile vomiting and rapidly developing
dehydration and electrolyte imbalances. The client will also
have bowel sounds, usually high-pitched and tinkling. The client
would not normally have diarrhea and would have minimal
distention.
,A 47-year-old female patient is transferred from the recovery
room to a surgical unit after a transverse colostomy. The nurse
observes the stoma to be deep pink with edema and a small
amount of sanguineous drainage. The nurse should:
A. Place ice packs around the stoma.
B. Notify the surgeon about the stoma.
C. Monitor the stoma every 30 minutes.
D. Document stoma assessment findings.
D. Document stoma assessment findings.
Rationale:
The stoma appearance indicates good circulation to the stoma.
There is no indication that surgical intervention is needed or that
frequent stoma monitoring is required. Swelling of the stoma is
normal for 2 to 3 weeks after surgery, and an ice pack is not
needed.
A client has returned to the medical surgical unit after having
surgery to create an ileostomy. Which goal has the highest
priority at this time?
A. Providing relief from constipation.
B. Assisting the client with self-care activities.
C. Maintaining fluid and electrolyte balance.
D. Minimizing odor formation.
C. Maintaining fluid and electrolyte balance.
Rational:
A high-priority outcome after ileostomy surgery is the
, maintenance of fluid and electrolyte balance. The client will
experience continuous liquid to semi liquid stools. The client
should be engaged in self-care activities, and minimizing odor
formation is important; however, these goals do not take priority
over maintaining fluid and electrolyte balance.
A 72-year-old male patient with dehydration caused by an
exacerbation of ulcerative colitis is receiving 5% dextrose in
normal saline at 125 mL/hour. Which assessment finding by the
nurse is most important to report to the health care provider?
A. Patient has not voided for the last 4 hours.
B. Skin is dry with poor turgor on all extremities.
C. Crackles are heard halfway up the posterior chest.
D. Patient has had 5 loose stools over the last 6 hours.
C. Crackles are heard halfway up the posterior chest.
Rational:
The presence of crackles in an older patient receiving IV fluids
at a high rate suggests volume overload and a need to reduce the
rate of the IV infusion. The other data will also be reported, but
are consistent with the patient's age and diagnosis and do not
require a change in the prescribed treatment.
A 42-year-old male patient has had a herniorrhaphy to repair an
incarcerated inguinal hernia. Which patient teaching will the
nurse provide before discharge?
A. Soak in sitz baths several times each day.
B. Cough 5 times each hour for the next 48 hours.
Solutions
Which statements about peritonitis are true? Select all that
apply.
1. Peritonitis is caused by contamination of the peritoneal
cavity by bacteria or chemicals.
2. Continuous ambulatory peritoneal dialysis (CAPD) can
cause peritonitis.
3. White blood cell counts are often decreased with
peritonitis.
4. Abdominal wall rigidity is a classic finding in patients
with peritonitis.
5. Chemical peritonitis is caused by leaking of pancreatic
enzymes or gastric acids.
A) 1,4
B) 1,3
C) 1,2,4
D) 1,4,5
E) All of these
F) None
C) 1,2,4
,A nurse is assessing a client who has been admitted with a
diagnosis of an obstruction in the small intestine. The nurse
should assess the client for? Select all that apply.
1. Projectile vomiting.
2. Significant abdominal distention.
3. Copious diarrhea.
4. Rapid onset of dehydration.
5. High-pitched bowel sounds.
A) 1,4
B) 1,4,5
C) 2,4
D) 1,2,3
E) All of these
F) None
B) 1,4,5
Rational:
Signs and symptoms of intestinal obstructions in the small
intestine may include projectile vomiting and rapidly developing
dehydration and electrolyte imbalances. The client will also
have bowel sounds, usually high-pitched and tinkling. The client
would not normally have diarrhea and would have minimal
distention.
,A 47-year-old female patient is transferred from the recovery
room to a surgical unit after a transverse colostomy. The nurse
observes the stoma to be deep pink with edema and a small
amount of sanguineous drainage. The nurse should:
A. Place ice packs around the stoma.
B. Notify the surgeon about the stoma.
C. Monitor the stoma every 30 minutes.
D. Document stoma assessment findings.
D. Document stoma assessment findings.
Rationale:
The stoma appearance indicates good circulation to the stoma.
There is no indication that surgical intervention is needed or that
frequent stoma monitoring is required. Swelling of the stoma is
normal for 2 to 3 weeks after surgery, and an ice pack is not
needed.
A client has returned to the medical surgical unit after having
surgery to create an ileostomy. Which goal has the highest
priority at this time?
A. Providing relief from constipation.
B. Assisting the client with self-care activities.
C. Maintaining fluid and electrolyte balance.
D. Minimizing odor formation.
C. Maintaining fluid and electrolyte balance.
Rational:
A high-priority outcome after ileostomy surgery is the
, maintenance of fluid and electrolyte balance. The client will
experience continuous liquid to semi liquid stools. The client
should be engaged in self-care activities, and minimizing odor
formation is important; however, these goals do not take priority
over maintaining fluid and electrolyte balance.
A 72-year-old male patient with dehydration caused by an
exacerbation of ulcerative colitis is receiving 5% dextrose in
normal saline at 125 mL/hour. Which assessment finding by the
nurse is most important to report to the health care provider?
A. Patient has not voided for the last 4 hours.
B. Skin is dry with poor turgor on all extremities.
C. Crackles are heard halfway up the posterior chest.
D. Patient has had 5 loose stools over the last 6 hours.
C. Crackles are heard halfway up the posterior chest.
Rational:
The presence of crackles in an older patient receiving IV fluids
at a high rate suggests volume overload and a need to reduce the
rate of the IV infusion. The other data will also be reported, but
are consistent with the patient's age and diagnosis and do not
require a change in the prescribed treatment.
A 42-year-old male patient has had a herniorrhaphy to repair an
incarcerated inguinal hernia. Which patient teaching will the
nurse provide before discharge?
A. Soak in sitz baths several times each day.
B. Cough 5 times each hour for the next 48 hours.
