NURS 2137 MedSurg Exam #1 Questions
With Complete Answers
A nurse is caring for a client who as Alzheimer's Disease (AD) and falls
frequently. Which of the following actions should the nurse take first to keep the
client safe?
A. Keep the call light near the client
B. Place the client in a room that is close to the nurses' station
C. Encourage the client to ask for assistance
D. Remind the client to walk with someone for support. - ANSWER B.
Rationale: Rationale: Keeping the call light in reach is an appropriate action but
not the first action because the client may not remember to use it. Placing the
client near the nurse's station is the first action the nurse should take.
Encouraging the client to ask for assistance is an appropriate action but not the
first action because the client might forget to ask for help. Reminding client to
walk with someone is also appropriate but not the first action because of the
client forgetting to ask for someone to walk with them.
A nurse is developing a plan of care for the nutritional needs of a client who has
stage IV Parkinson's disease. Which of the following actions should the nurse
include?
A. Provide three large balanced meals a day?
b. Record diet and fluid intake daily
C. Document weight every other week
D. Offer cold fluids such as milkshake
E. Offer nutritional supplements between meals. - ANSWER B, D, E
Rationale: Plan to provide small frequent meals throughout the day. Record the
client's diet and fluid intake daily to assess for dietary needs and to maintain
adequate nutrition and hydration. Document the client's weight weekly to
identify weight loss. Provide cold fluids such as a milkshake because thicker
cold fluids are better tolerated by the client. Offer nutritional supplements
between the meals to maintain the clients weight
A nurse is caring for a client who just experienced a generalized seizure. Which
of the following actions should the nurse perform first?
A. Keep the client in a side-lying position
B. Document the duration of the seizure
C. Reorient the client to the environment
D. Provide client hygiene - ANSWER A.
,Rationale: The greatest risk to the client is aspiration during the postictal phase.
Therefore, the priority intervention is to keep the client in the side-lying position
so secretions can drain from the mouth keeping the airway patent
5. A nurse is assessing a client who has a seizure disorder. The client tells the
nurse. " I am about to have a seizure." Which of the following actions should the
nurse implement?
A. provide privacy
B. Ease the client to the floor if standing
C. move furniture away from the client
D. Loosen the client's clothing
E. Protect the client's head with padding
F. Restrain the client - ANSWER A, B, C, D, E
Rationale: The nurse should implement privacy to minimize the client's possible
embarrassment. The nurse should ease the client to the floor to prevent them
falling or having an injury. The nurse should move the furniture from the client to
prevent injury. The nurse should loosen the client's clothing to minimize
restriction of movement. The nurse should place the client's head in her lap or
protect the client's head with a pillow or blanket during the seizure. The nurse
should not restrain the client. Restraining the client can increase the risk for
injury to the client during the seizure.
A nurse is monitoring a client who is receiving opioid analgesia. Which of the
following findings should the nurse identify as adverse effect of opioid
analgesics?
a. urinary incontinence
b. diarrhea
c. Bradypnea
D. orthostatic hypotension
E. Nausea - ANSWER C, D, E
Rationale: Urinary retention not urinary incontinence is a common adverse
effect of opioids. Constipation not diarrhea is a common adverse effect of the
opioid. Respiratory depression is a common effect of opioid medications, it can
drop respiratory rates to dangerously low levels. Dizziness or lightheadedness
when changing positions is a common adverse effect of opioid medications.
Nausea and vomiting are common adverse effects of opioid analgesia.
A nurse is caring for a client who is receiving morphine via patient-controlled
analgesia (PCA) infusion device after abdominal surgery. Which of the following
client statements indicates the client understands how to use the device?
A. "I'll wait to use the device until it's absolutely necessary"
B. Ill be careful about pushing the button so I don't get an overdose
C. I should tell the nurse if the pain doesn't stop after I use the device
D. I will ask my son to push the dose button when I am sleeping. - ANSWER C
,Rationale: The client may use the device when the first begin to fell the pain. It
will help prevent unnecessary worsening of the pain and more doses of
analgesia to prevent the pain. A feature of the PCA is the lockout mechanism
which enforces a preset minimum interval between medication doses, this
safety feature is one means of preventing an overdose because the client cannot
self-administer another dose of medication until that interval has passed even if
they push the button. If the patient is not achieving adequate pain control, he
should le the nurse know so that she can initiate a reevaluation of the client's
pain management plan. The client is the only one who should operate the PCA
pump. In situations where the client is not able to do so the provider may
authorize a nurse or a family member to operate the pump.
A nurse is assessing a client for changes in the level of consciousness using the
Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speak
incoherently, moves his extremities when pain is applied. Which of the following
GCS scores should the nurse document?
a. E2+V3+M5=10
B. E3+V4+M4=11
C. E4+V5+M6=15
D. E2+V2+M4=8 - ANSWER B
Rationale: The nurse should calculate the score E3 represents opening eyes
secondary to voice commands E2 is eyes opening secondary to pain E4 is eyes
opening spontaneously. E2 and E4 are not correct for this patient. The nurse
should score the patient as V4 which represents verbal conversion incoherrant
or disoriented. V2 is verbal response with no words just sounds, V3 represents
words spoken inappropriately, and V5 represents verbal conversation as
coherent and oriented which is not correct for this patient. The nurse should
score the patient M5 which represents motor response as a general withdrawal
from pain. M5 represents motor response to pain with a local reaction and M6 is
a client is able to follow commands, neither of which is correct for this patient.
A nurse is caring for a patient who is post procedure following a lumbar
puncture and reports a throbbing headache when sitting up right. Which of the
following actions should the nurse take? (Select all that apply)
a. uses the Glasgow coma scale when assessing the patient
b. assists the client to a supine position
c. administers and opioid medication
d. encourages the client to increase fluid intake
e. instructs the client to perform deep breathing and coughing exercises -
ANSWER B,C,D
Rationale: GCS is used to assess level of consciousness and is not needed after
this procedure. Assist the client to a supine position will help alleviate the
headache post lumbar puncture. Administration of analgesic for the pain is
indicated post lumbar puncture. The nurse should encourage increased fluid
, intake to maintain a positive fluid balance which can relieve a headache post
lumbar puncture. Coughing can increase ICP which can result in an increased
amount of pain
Which normal physiologic process contributes most to the need for acid-base
balance?
A. Continuous organ production of bicarbonate from carbonic acid
B. Continuous alveolar exchange of oxygen and carbon dioxide
C. Continuous metabolic production of free hydrogen ions
D. Continuous kidney formation of urine from blood - ANSWER Answer: C
Rationale:
All normal metabolism results in the removal of hydrogen ions from more
complex compounds to use in the generation of cellular energy. Normal alveolar
exchange of oxygen and carbon dioxide actually are part of acid-base balance
mechanisms and do not contribute to imbalance. No normal or pathologic
condition causes the excess formation of bicarbonate. Normal kidney formation
of urine from blood is part of the balance mechanisms and does not contribute to
the need for balance.
Which set of client arterial blood gas (ABG) values indicates to the nurse that
some mechanisms are working to partially compensate for an acid-base
imbalance?
A. pH 7.42; PaO2 92 mm Hg; CO2 41 mm Hg; HCO3− 28 mEq/L (mmol/L)
B. pH 7.46; PaO2 98 mm Hg; CO2 38 mm Hg; HCO3− 30 mEq/L (mmol/L)
C. pH 7.22; PaO2 60 mm Hg; CO2 80 mm Hg; HCO3− 22 mEq/L (mmol/L)
D. pH 7.29; PaO2 78 mm Hg; CO2 82 mm Hg; HCO3− 36 mEq/L (mmol/L) -
ANSWER Answer: D
Rationale:
The ABG values listed for D indicate chronic respiratory acidosis with partial
compensation. The PaO2 is low and the PaCO2 is quite high, which would lower
the pH. However, the pH is not as low as would be expected by these values
because the HCO3− level is elevated to compensate. This compensation is only
partial because the pH is still below normal, indicating acidosis is still present.
The values listed in C indicate an acute respiratory acidosis (low pH, low PaO2
and high PaCO2 coupled with a normal bicarbonate level) in which no
compensation has occurred. The values listed in A are all totally normal showing
no imbalance and no compensation. The values listed in B show a slight
metabolic alkalosis (elevated pH) with normal oxygen and carbon dioxide values
accompanied by a slightly elevated bicarbonate level.
With which clients does the nurse remain alert for the possibility of metabolic
alkalosis? Select all that apply.
A. Client who has been NPO for 36 hours without fluid replacement
B. Client receiving a rapid infusion of normal saline
C. Client who has been self-managing indigestion with chronic ingestion of
bicarbonate
With Complete Answers
A nurse is caring for a client who as Alzheimer's Disease (AD) and falls
frequently. Which of the following actions should the nurse take first to keep the
client safe?
A. Keep the call light near the client
B. Place the client in a room that is close to the nurses' station
C. Encourage the client to ask for assistance
D. Remind the client to walk with someone for support. - ANSWER B.
Rationale: Rationale: Keeping the call light in reach is an appropriate action but
not the first action because the client may not remember to use it. Placing the
client near the nurse's station is the first action the nurse should take.
Encouraging the client to ask for assistance is an appropriate action but not the
first action because the client might forget to ask for help. Reminding client to
walk with someone is also appropriate but not the first action because of the
client forgetting to ask for someone to walk with them.
A nurse is developing a plan of care for the nutritional needs of a client who has
stage IV Parkinson's disease. Which of the following actions should the nurse
include?
A. Provide three large balanced meals a day?
b. Record diet and fluid intake daily
C. Document weight every other week
D. Offer cold fluids such as milkshake
E. Offer nutritional supplements between meals. - ANSWER B, D, E
Rationale: Plan to provide small frequent meals throughout the day. Record the
client's diet and fluid intake daily to assess for dietary needs and to maintain
adequate nutrition and hydration. Document the client's weight weekly to
identify weight loss. Provide cold fluids such as a milkshake because thicker
cold fluids are better tolerated by the client. Offer nutritional supplements
between the meals to maintain the clients weight
A nurse is caring for a client who just experienced a generalized seizure. Which
of the following actions should the nurse perform first?
A. Keep the client in a side-lying position
B. Document the duration of the seizure
C. Reorient the client to the environment
D. Provide client hygiene - ANSWER A.
,Rationale: The greatest risk to the client is aspiration during the postictal phase.
Therefore, the priority intervention is to keep the client in the side-lying position
so secretions can drain from the mouth keeping the airway patent
5. A nurse is assessing a client who has a seizure disorder. The client tells the
nurse. " I am about to have a seizure." Which of the following actions should the
nurse implement?
A. provide privacy
B. Ease the client to the floor if standing
C. move furniture away from the client
D. Loosen the client's clothing
E. Protect the client's head with padding
F. Restrain the client - ANSWER A, B, C, D, E
Rationale: The nurse should implement privacy to minimize the client's possible
embarrassment. The nurse should ease the client to the floor to prevent them
falling or having an injury. The nurse should move the furniture from the client to
prevent injury. The nurse should loosen the client's clothing to minimize
restriction of movement. The nurse should place the client's head in her lap or
protect the client's head with a pillow or blanket during the seizure. The nurse
should not restrain the client. Restraining the client can increase the risk for
injury to the client during the seizure.
A nurse is monitoring a client who is receiving opioid analgesia. Which of the
following findings should the nurse identify as adverse effect of opioid
analgesics?
a. urinary incontinence
b. diarrhea
c. Bradypnea
D. orthostatic hypotension
E. Nausea - ANSWER C, D, E
Rationale: Urinary retention not urinary incontinence is a common adverse
effect of opioids. Constipation not diarrhea is a common adverse effect of the
opioid. Respiratory depression is a common effect of opioid medications, it can
drop respiratory rates to dangerously low levels. Dizziness or lightheadedness
when changing positions is a common adverse effect of opioid medications.
Nausea and vomiting are common adverse effects of opioid analgesia.
A nurse is caring for a client who is receiving morphine via patient-controlled
analgesia (PCA) infusion device after abdominal surgery. Which of the following
client statements indicates the client understands how to use the device?
A. "I'll wait to use the device until it's absolutely necessary"
B. Ill be careful about pushing the button so I don't get an overdose
C. I should tell the nurse if the pain doesn't stop after I use the device
D. I will ask my son to push the dose button when I am sleeping. - ANSWER C
,Rationale: The client may use the device when the first begin to fell the pain. It
will help prevent unnecessary worsening of the pain and more doses of
analgesia to prevent the pain. A feature of the PCA is the lockout mechanism
which enforces a preset minimum interval between medication doses, this
safety feature is one means of preventing an overdose because the client cannot
self-administer another dose of medication until that interval has passed even if
they push the button. If the patient is not achieving adequate pain control, he
should le the nurse know so that she can initiate a reevaluation of the client's
pain management plan. The client is the only one who should operate the PCA
pump. In situations where the client is not able to do so the provider may
authorize a nurse or a family member to operate the pump.
A nurse is assessing a client for changes in the level of consciousness using the
Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speak
incoherently, moves his extremities when pain is applied. Which of the following
GCS scores should the nurse document?
a. E2+V3+M5=10
B. E3+V4+M4=11
C. E4+V5+M6=15
D. E2+V2+M4=8 - ANSWER B
Rationale: The nurse should calculate the score E3 represents opening eyes
secondary to voice commands E2 is eyes opening secondary to pain E4 is eyes
opening spontaneously. E2 and E4 are not correct for this patient. The nurse
should score the patient as V4 which represents verbal conversion incoherrant
or disoriented. V2 is verbal response with no words just sounds, V3 represents
words spoken inappropriately, and V5 represents verbal conversation as
coherent and oriented which is not correct for this patient. The nurse should
score the patient M5 which represents motor response as a general withdrawal
from pain. M5 represents motor response to pain with a local reaction and M6 is
a client is able to follow commands, neither of which is correct for this patient.
A nurse is caring for a patient who is post procedure following a lumbar
puncture and reports a throbbing headache when sitting up right. Which of the
following actions should the nurse take? (Select all that apply)
a. uses the Glasgow coma scale when assessing the patient
b. assists the client to a supine position
c. administers and opioid medication
d. encourages the client to increase fluid intake
e. instructs the client to perform deep breathing and coughing exercises -
ANSWER B,C,D
Rationale: GCS is used to assess level of consciousness and is not needed after
this procedure. Assist the client to a supine position will help alleviate the
headache post lumbar puncture. Administration of analgesic for the pain is
indicated post lumbar puncture. The nurse should encourage increased fluid
, intake to maintain a positive fluid balance which can relieve a headache post
lumbar puncture. Coughing can increase ICP which can result in an increased
amount of pain
Which normal physiologic process contributes most to the need for acid-base
balance?
A. Continuous organ production of bicarbonate from carbonic acid
B. Continuous alveolar exchange of oxygen and carbon dioxide
C. Continuous metabolic production of free hydrogen ions
D. Continuous kidney formation of urine from blood - ANSWER Answer: C
Rationale:
All normal metabolism results in the removal of hydrogen ions from more
complex compounds to use in the generation of cellular energy. Normal alveolar
exchange of oxygen and carbon dioxide actually are part of acid-base balance
mechanisms and do not contribute to imbalance. No normal or pathologic
condition causes the excess formation of bicarbonate. Normal kidney formation
of urine from blood is part of the balance mechanisms and does not contribute to
the need for balance.
Which set of client arterial blood gas (ABG) values indicates to the nurse that
some mechanisms are working to partially compensate for an acid-base
imbalance?
A. pH 7.42; PaO2 92 mm Hg; CO2 41 mm Hg; HCO3− 28 mEq/L (mmol/L)
B. pH 7.46; PaO2 98 mm Hg; CO2 38 mm Hg; HCO3− 30 mEq/L (mmol/L)
C. pH 7.22; PaO2 60 mm Hg; CO2 80 mm Hg; HCO3− 22 mEq/L (mmol/L)
D. pH 7.29; PaO2 78 mm Hg; CO2 82 mm Hg; HCO3− 36 mEq/L (mmol/L) -
ANSWER Answer: D
Rationale:
The ABG values listed for D indicate chronic respiratory acidosis with partial
compensation. The PaO2 is low and the PaCO2 is quite high, which would lower
the pH. However, the pH is not as low as would be expected by these values
because the HCO3− level is elevated to compensate. This compensation is only
partial because the pH is still below normal, indicating acidosis is still present.
The values listed in C indicate an acute respiratory acidosis (low pH, low PaO2
and high PaCO2 coupled with a normal bicarbonate level) in which no
compensation has occurred. The values listed in A are all totally normal showing
no imbalance and no compensation. The values listed in B show a slight
metabolic alkalosis (elevated pH) with normal oxygen and carbon dioxide values
accompanied by a slightly elevated bicarbonate level.
With which clients does the nurse remain alert for the possibility of metabolic
alkalosis? Select all that apply.
A. Client who has been NPO for 36 hours without fluid replacement
B. Client receiving a rapid infusion of normal saline
C. Client who has been self-managing indigestion with chronic ingestion of
bicarbonate
