Nursing: Medical-Surgical Reveiw Final
EXAM 100+ QUESTIONS & ANSWERS /
ADVANCED PHARMACOLOGY FOR CARE OF
FAMILY|AGRADE
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 - 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
c. encourage fluids to 3000 mL per day
D. change the client's position every two hours - 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 - 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
The nurse is assessing a client with a cuffed tracheostomy tube in place who is
breathing spontaneously. to evaluate if the client can tolerate cuff deflation to
promote speaking and swallowing, what action should the nurse implement?
A. observe the client for coughing colored sputum after drinking a small amount
of colored water
B. ask the client to try to speak
C. auscultate for pulmonary crackles after the client drinks a small amount of
clear water
D. assess for respiratory distress - ANSWER//A. observe the client four coughing
colored sputum after drinking a small amount of colored water
to evaluate the risk for aspiration after the cuff is deflated, the client should be
instructed to swallow a small amount of colored water, then be observed for
coughing up colored sputum, or the tracheostomy should be suctioned for the
presence of colored water.
What assessment finding should the nurse identify that indicates a client with an
acute asthma exacerbation is beginning to improve after treatment?
A. vesicular breath sounds decrease
B. wheezing becomes louder
C. bronchodilators stimulate coughing
D. cough remains unproductive - ANSWER//B. wheezing becomes louder
In an acute asthma attack, air flow may be so significantly restricted that
wheezing is diminished. If the client is successfully responding to
bronchodilators and respiratory treatments, wheezing becomes louder as air flow
increases in the airways. As the airways open and mucous is mobilized in
response to treatment, the cough becomes more productive. vesicular sounds
are soft, low-pitched, gentle, rustling sounds heard over lung fields.
A client with sickle cell anemia is admitted with severe abdominal pain and the
diagnosis is sickle cell crisis. What is the most important nursing action to
implement?
A. limit the client's intake of oral fluids
, B. teach the client about prevention of crises
C. evaluate the effectiveness of narcotic analgesics
D. encourage the client to ambulate as tolerated - ANSWER//C. evaluate the
effectiveness of narcotic analgesics
Pain management is the priority for a client during sickle cell crisis. Continuous
narcotic analgesics are the mainstay of pain control, which should be evaluated
frequently to determine if the client's pain is adequately controlled.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. What
action should the nurse implement?
A. provide oral hygiene every 2 hours
B. check for fever every 4 hours
C. encourage fluids to 3000 mL/day
D. check stools for occult blood - ANSWER//D. check stools for occult blod
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a
common side effect of chemotherapy. A client with thrombocytopenia should be
assessed frequently for occult bleeding in the emesis, sputum, feces, urine,
nasogastric secretions, or wounds.
A client is admitted for complaints of chest pain and aching for the past 4 days.
the results for serum creatine kinase-MB (CK-MB) and troponin are obtained.
What rationale should the nurse use to evaluate the laboratory findings?
A. serum myoglobin levels are needed to confirm myocardial damage
B. myocardial damage that occurred several days earlier is best validated by
serum troponin levels
C. the most reliable indicator of myocardial necrosis is serum CK-MB
D. serum cardiac markers are inconclusive in determining myocardial injury after
waiting several days - ANSWER//B. myocardial damage that occurred several
days earlier is best validated by serum troponin levels
Serum CK-MB and troponin are the two most important serum cardiac markers
for confirming myocardial infarction. CK-MB begins to rise in the first 3 to 12
hours after the myocardial infarction, peaks in 24 hours, and returns to normal in
2 to 3 days. the troponin level rises as quickly but remains elevated for 2 weeks.
Three weeks after discharge fro an acute myocardial infarction (MI), a client
returns to the cardiac center for follow-up. When the nurse asks about sleep
patterns, the client tells the nurse that he sleeps fine but that his wife moved into
the spare bedroom to sleep when he returned home. He states "I guess we will
never have sex again after this." Which response is best for the nurse to provide?
A. sexual activity can be resumed whenever you and you wife feel like it because
the sexual response is more emotional rather than physical
EXAM 100+ QUESTIONS & ANSWERS /
ADVANCED PHARMACOLOGY FOR CARE OF
FAMILY|AGRADE
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 - 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
c. encourage fluids to 3000 mL per day
D. change the client's position every two hours - 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 - 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
The nurse is assessing a client with a cuffed tracheostomy tube in place who is
breathing spontaneously. to evaluate if the client can tolerate cuff deflation to
promote speaking and swallowing, what action should the nurse implement?
A. observe the client for coughing colored sputum after drinking a small amount
of colored water
B. ask the client to try to speak
C. auscultate for pulmonary crackles after the client drinks a small amount of
clear water
D. assess for respiratory distress - ANSWER//A. observe the client four coughing
colored sputum after drinking a small amount of colored water
to evaluate the risk for aspiration after the cuff is deflated, the client should be
instructed to swallow a small amount of colored water, then be observed for
coughing up colored sputum, or the tracheostomy should be suctioned for the
presence of colored water.
What assessment finding should the nurse identify that indicates a client with an
acute asthma exacerbation is beginning to improve after treatment?
A. vesicular breath sounds decrease
B. wheezing becomes louder
C. bronchodilators stimulate coughing
D. cough remains unproductive - ANSWER//B. wheezing becomes louder
In an acute asthma attack, air flow may be so significantly restricted that
wheezing is diminished. If the client is successfully responding to
bronchodilators and respiratory treatments, wheezing becomes louder as air flow
increases in the airways. As the airways open and mucous is mobilized in
response to treatment, the cough becomes more productive. vesicular sounds
are soft, low-pitched, gentle, rustling sounds heard over lung fields.
A client with sickle cell anemia is admitted with severe abdominal pain and the
diagnosis is sickle cell crisis. What is the most important nursing action to
implement?
A. limit the client's intake of oral fluids
, B. teach the client about prevention of crises
C. evaluate the effectiveness of narcotic analgesics
D. encourage the client to ambulate as tolerated - ANSWER//C. evaluate the
effectiveness of narcotic analgesics
Pain management is the priority for a client during sickle cell crisis. Continuous
narcotic analgesics are the mainstay of pain control, which should be evaluated
frequently to determine if the client's pain is adequately controlled.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. What
action should the nurse implement?
A. provide oral hygiene every 2 hours
B. check for fever every 4 hours
C. encourage fluids to 3000 mL/day
D. check stools for occult blood - ANSWER//D. check stools for occult blod
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a
common side effect of chemotherapy. A client with thrombocytopenia should be
assessed frequently for occult bleeding in the emesis, sputum, feces, urine,
nasogastric secretions, or wounds.
A client is admitted for complaints of chest pain and aching for the past 4 days.
the results for serum creatine kinase-MB (CK-MB) and troponin are obtained.
What rationale should the nurse use to evaluate the laboratory findings?
A. serum myoglobin levels are needed to confirm myocardial damage
B. myocardial damage that occurred several days earlier is best validated by
serum troponin levels
C. the most reliable indicator of myocardial necrosis is serum CK-MB
D. serum cardiac markers are inconclusive in determining myocardial injury after
waiting several days - ANSWER//B. myocardial damage that occurred several
days earlier is best validated by serum troponin levels
Serum CK-MB and troponin are the two most important serum cardiac markers
for confirming myocardial infarction. CK-MB begins to rise in the first 3 to 12
hours after the myocardial infarction, peaks in 24 hours, and returns to normal in
2 to 3 days. the troponin level rises as quickly but remains elevated for 2 weeks.
Three weeks after discharge fro an acute myocardial infarction (MI), a client
returns to the cardiac center for follow-up. When the nurse asks about sleep
patterns, the client tells the nurse that he sleeps fine but that his wife moved into
the spare bedroom to sleep when he returned home. He states "I guess we will
never have sex again after this." Which response is best for the nurse to provide?
A. sexual activity can be resumed whenever you and you wife feel like it because
the sexual response is more emotional rather than physical
