Nursing: Medical-Surgical Review Questions with Answers Rated A
A. use reliable assessment tools for older adults
Specific assessment tools (D) for an older adult, such
Which method elicits the most accurate information dur- as Older Adult Resource Services Center Instrument,
ing a physical assessment of an older adult? mini-mental assessment, fall risk, depression, or skin
A. use reliable assessment tools for older adults breakdown risk, consider age-related physiologic and
B. Review the past medical record for medications psychosocial changes related to aging and provide the
C. Ask the client to recount one's health history most accurate and complete information. A and B are
D. Obtain the client's information from a caregiver 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 otter to B. discuss retesting to verify results, which will ensure
facilitate the client's adjustment to HIV infection? continuing contact
A. teach the client about the medications that are available
for treatment encouraging retesting supports hope and gives the client
B. discuss retesting to verify the results, which will ensure time to cope with the diagnosis. Although post-test coun-
continuing contact seling should include education about A, B, and C, retest-
C. identify the need to test others who have had risky ing encourages the client to maintain medical follow-up
contact with the client and management.
D. inform the client how to protect sexual and nee-
dle-sharing partners
D. return to pre-illness weight
The nurse is caring for a client with HIV infection who
MAC is an opportunistic infection that presents as a TB like
develops Mycobacterium avium complex (MAC). what is
pulmonary process. MAC is a major contributing factor to
the most significant desired outcome for this client?
the development of wasting syndrome, so the most signif-
A. free from injury of drug side ettects
icant desired outcome is the client's return to a pre-ill-
ness weight. drug schedules and side ettects remain a
, life-long management problem. Client outcomes for ade-
quate oxygenation are often dependent on management
B. maintenance of intact perineal skin
of anemia, maintenance of activities without fatigue, and
c. adequate oxygenation
supplemental oxygen to prevent hypoxia. Skin integrity is
D. return to pre-illness weight
dependent upon resolution of diarrhea, which is not as
significant as optimal nutrition.
a. assist the client to ambulate in the hall
A client who had abdominal surgery two days ago has Post-operative abdominal distention is caused by de-
prescriptions for intravenous morphine sulfate 4 mg every creased peristalsis as a result of handling the intestine
2 hours and a clear liquid diet. the client complains of during surgery, limited dietary intake before and after
feeling distended and has sharp, cramping gas pains. surgery, and anesthetic and analgesic agents. Peristalsis
What nursing intervention should be implemented? is stimulated and distention minimized by implementing
A. assist the client to ambulate in the hall early and frequent ambulation. Based on the client's sta-
B. obtain a prescription for a laxative tus, laxatives or withholding dietary progression are not
C. administer the prescribed morphine sulfate indicated at this time. although pain management should
D. withhold all oral fluid and food be implemented, another analgesic prescription may be
needed because morphine reduces intestinal motility and
contributes to the client's gas pains.
B. turn ott the television and darken the room
A client with Meniere's disease is incapacitated by vertigo
and is lying in bed grasping the side rails and staring
to decrease the client's vertigo during an acute attack
at the television. Which nursing intervention should the of Meniere's disease, any visual stimuli or rotational
nurse implement?
movement, such as sudden head movements or position
A. keep the head of the bed elevated 30 degrees changes, should be minimized. Turning ott the television
B. turn ott the television and darken the room and darkening the room minimize fluorescent lights, flick-
c. encourage fluids to 3000 mL per day ering television lights, and distracting sound. The other
D. change the client's position every two hours are inettective in managing the client's symptoms.
a client who has a chronic cough with blood-tinged spu- B. allow the client nothing by mouth until the gag reflex
tum returns to the unit after a bronchoscopy. What nurs- returns
ing interventions should be implemented in the immedi-
, ate post-procedural period? the nasal pharynx and oral pharynx are anesthetized with
A. check vital signs every 15 minutes for 2 hours local anesthetic spray prior to bronchoscopy, and the
B. allow the client nothing by mouth until the gag reflex bronchoscope is coated with lidocaine gel to inhibit the
returns gag reflex and prevent laryngeal spasm during insertion.
C. encourage fluid intake to promote elimination of the The client should be NPO until the client's gag reflex re-
contrast media turns to prevent aspiration from any oral intake or secre-
D. keep the client on bed rest for 8 hours tions. The others are not indicated after bronchoscopy
The nurse is assessing a client with a cutted tracheostomy
tube in place who is breathing spontaneously. to eval-
A. observe the client four coughing colored sputum after
uate if the client can tolerate cutt deflation to promote
drinking a small amount of colored water
speaking and swallowing, what action should the nurse
implement?
to evaluate the risk for aspiration after the cutt is deflated,
A. observe the client for coughing colored sputum after
the client should be instructed to swallow a small amount
drinking a small amount of colored water
of colored water, then be observed for coughing up col-
B. ask the client to try to speak
ored sputum, or the tracheostomy should be suctioned for
C. auscultate for pulmonary crackles after the client drinks
the presence of colored water.
a small amount of clear water
D. assess for respiratory distress
B. wheezing becomes louder
What assessment finding should the nurse identify that
In an acute asthma attack, air flow may be so significantly
indicates a client with an acute asthma exacerbation is
restricted that wheezing is diminished. If the client is suc-
beginning to improve after treatment?
cessfully responding to bronchodilators and respiratory
A. vesicular breath sounds decrease
treatments, wheezing becomes louder as air flow increas-
B. wheezing becomes louder
es in the airways. As the airways open and mucous is
C. bronchodilators stimulate coughing
mobilized in response to treatment, the cough becomes
D. cough remains unproductive
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
C. evaluate the ettectiveness of narcotic analgesics
abdominal pain and the diagnosis is sickle cell crisis. What
is the most important nursing action to implement?
A. use reliable assessment tools for older adults
Specific assessment tools (D) for an older adult, such
Which method elicits the most accurate information dur- as Older Adult Resource Services Center Instrument,
ing a physical assessment of an older adult? mini-mental assessment, fall risk, depression, or skin
A. use reliable assessment tools for older adults breakdown risk, consider age-related physiologic and
B. Review the past medical record for medications psychosocial changes related to aging and provide the
C. Ask the client to recount one's health history most accurate and complete information. A and B are
D. Obtain the client's information from a caregiver 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 otter to B. discuss retesting to verify results, which will ensure
facilitate the client's adjustment to HIV infection? continuing contact
A. teach the client about the medications that are available
for treatment encouraging retesting supports hope and gives the client
B. discuss retesting to verify the results, which will ensure time to cope with the diagnosis. Although post-test coun-
continuing contact seling should include education about A, B, and C, retest-
C. identify the need to test others who have had risky ing encourages the client to maintain medical follow-up
contact with the client and management.
D. inform the client how to protect sexual and nee-
dle-sharing partners
D. return to pre-illness weight
The nurse is caring for a client with HIV infection who
MAC is an opportunistic infection that presents as a TB like
develops Mycobacterium avium complex (MAC). what is
pulmonary process. MAC is a major contributing factor to
the most significant desired outcome for this client?
the development of wasting syndrome, so the most signif-
A. free from injury of drug side ettects
icant desired outcome is the client's return to a pre-ill-
ness weight. drug schedules and side ettects remain a
, life-long management problem. Client outcomes for ade-
quate oxygenation are often dependent on management
B. maintenance of intact perineal skin
of anemia, maintenance of activities without fatigue, and
c. adequate oxygenation
supplemental oxygen to prevent hypoxia. Skin integrity is
D. return to pre-illness weight
dependent upon resolution of diarrhea, which is not as
significant as optimal nutrition.
a. assist the client to ambulate in the hall
A client who had abdominal surgery two days ago has Post-operative abdominal distention is caused by de-
prescriptions for intravenous morphine sulfate 4 mg every creased peristalsis as a result of handling the intestine
2 hours and a clear liquid diet. the client complains of during surgery, limited dietary intake before and after
feeling distended and has sharp, cramping gas pains. surgery, and anesthetic and analgesic agents. Peristalsis
What nursing intervention should be implemented? is stimulated and distention minimized by implementing
A. assist the client to ambulate in the hall early and frequent ambulation. Based on the client's sta-
B. obtain a prescription for a laxative tus, laxatives or withholding dietary progression are not
C. administer the prescribed morphine sulfate indicated at this time. although pain management should
D. withhold all oral fluid and food be implemented, another analgesic prescription may be
needed because morphine reduces intestinal motility and
contributes to the client's gas pains.
B. turn ott the television and darken the room
A client with Meniere's disease is incapacitated by vertigo
and is lying in bed grasping the side rails and staring
to decrease the client's vertigo during an acute attack
at the television. Which nursing intervention should the of Meniere's disease, any visual stimuli or rotational
nurse implement?
movement, such as sudden head movements or position
A. keep the head of the bed elevated 30 degrees changes, should be minimized. Turning ott the television
B. turn ott the television and darken the room and darkening the room minimize fluorescent lights, flick-
c. encourage fluids to 3000 mL per day ering television lights, and distracting sound. The other
D. change the client's position every two hours are inettective in managing the client's symptoms.
a client who has a chronic cough with blood-tinged spu- B. allow the client nothing by mouth until the gag reflex
tum returns to the unit after a bronchoscopy. What nurs- returns
ing interventions should be implemented in the immedi-
, ate post-procedural period? the nasal pharynx and oral pharynx are anesthetized with
A. check vital signs every 15 minutes for 2 hours local anesthetic spray prior to bronchoscopy, and the
B. allow the client nothing by mouth until the gag reflex bronchoscope is coated with lidocaine gel to inhibit the
returns gag reflex and prevent laryngeal spasm during insertion.
C. encourage fluid intake to promote elimination of the The client should be NPO until the client's gag reflex re-
contrast media turns to prevent aspiration from any oral intake or secre-
D. keep the client on bed rest for 8 hours tions. The others are not indicated after bronchoscopy
The nurse is assessing a client with a cutted tracheostomy
tube in place who is breathing spontaneously. to eval-
A. observe the client four coughing colored sputum after
uate if the client can tolerate cutt deflation to promote
drinking a small amount of colored water
speaking and swallowing, what action should the nurse
implement?
to evaluate the risk for aspiration after the cutt is deflated,
A. observe the client for coughing colored sputum after
the client should be instructed to swallow a small amount
drinking a small amount of colored water
of colored water, then be observed for coughing up col-
B. ask the client to try to speak
ored sputum, or the tracheostomy should be suctioned for
C. auscultate for pulmonary crackles after the client drinks
the presence of colored water.
a small amount of clear water
D. assess for respiratory distress
B. wheezing becomes louder
What assessment finding should the nurse identify that
In an acute asthma attack, air flow may be so significantly
indicates a client with an acute asthma exacerbation is
restricted that wheezing is diminished. If the client is suc-
beginning to improve after treatment?
cessfully responding to bronchodilators and respiratory
A. vesicular breath sounds decrease
treatments, wheezing becomes louder as air flow increas-
B. wheezing becomes louder
es in the airways. As the airways open and mucous is
C. bronchodilators stimulate coughing
mobilized in response to treatment, the cough becomes
D. cough remains unproductive
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
C. evaluate the ettectiveness of narcotic analgesics
abdominal pain and the diagnosis is sickle cell crisis. What
is the most important nursing action to implement?
