MED-SURG EXAM 1 QUESTIONS &
VERIFIED CORRECT ANSWERS ALL
PASSED
The nurse requests the client to sign a surgical informed consent form for an emergency
appendectomy. Which statement by the client indicates further teaching is needed?
1. "I will be glad when this is over so I can go home today."
2. "I will not be able to eat or drink anything prior to my surgery."
3. "I can practice relaxing by listening to my favorite music."
4. "I will need to get up and walk as soon as possible." - Correct Answer ✔✔ 1.
1. The client will be in the hospital for a few days. This is not a day-surgery procedure.
The client needs more teaching.
2. Clients are NPO (nothing by mouth) prior to surgery to prevent aspiration during and
after anesthesia. The client understands the teaching.
3. Listening to music and other relaxing tech- niques can be used to alleviate anxiety
and pain. This statement indicates the client understands the teaching.
4. Clients are encouraged to get out of bed as soon as possible and progress until a
return to daily activity is achieved. The client understands the teaching.
The nurse in the holding area of the surgery department is interviewing a client who
requests to keep his religious medal on during surgery. Which intervention should the
nurse implement?
1. Notify the surgeon about the client's request to wear the medal.
2. Tape the medal to the client and allow the client to wear the medal.
3. Request the family member take the medal prior to surgery.
4. Explain taking the medal to surgery is against the policy. - Correct Answer ✔✔ 2.
1. The surgeon does not need to be notified of the client's request; this can be
addressed by the nursing staff.
2. The medal should be taped and the client should be allowed to wear the medal
because meeting spiritual needs
is essential to this client's care.
3. The client should be allowed to bring the medal to surgery if the medal is taped to the
client.
4. Hospital policies should be established for the well-being of clients, and spiritual
needs should be addressed.
The nurse must obtain surgical consent forms for the scheduled surgery. Which client
would not be able to consent legally to surgery?
1. The 65-year-old client who cannot read or write.
2. The 30-year-old client who does not understand English.
,3. The 16-year-old client who has a fractured ankle.
4. The 80-year-old client who is not oriented to the day. - Correct Answer ✔✔ 3.
1. The 65-year-old client who cannot read can mark an "X" on the form and is legally
able to sign a surgical permit as long as the client understands the benefits,
alternatives, and all potential complications of the surgery.
2. The client who does not speak English can and should have information given and
questions answered in the client's native language.
3. A 16-year-old client is not legally able to give permission for surgery unless the
adolescent has been given an emancipated status by a judge. This information was not
given in the stem.
4. A client is able to give permission unless determined incompetent. Not knowing the
day of the week is not significant.
The nurse is preparing a client for surgery. Which intervention should the nurse
implement first?
1. Check the permit for the spouse's signature.
2. Take and document intake and output.
3. Administer the "on call" sedative.
4. Complete the preoperative checklist. - Correct Answer ✔✔ 4.
1. The client's signature, not the spouse's, should be on the surgical permit.
2. This would be important information if ab- normal, but it is not the first intervention.
3. "On call" sedatives should be administered after the surgical checklist is completed.
4. Completing the preoperative checklist has the highest priority to ensure all details are
completed without omissions.
The nurse is interviewing a surgical client in the holding area. Which information should
the nurse report to the anesthesiologist? (Select all that apply.)
1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes two (2) packs of cigarettes a day.
4. The client has had a chest x-ray which does not show infiltrates.
5. The client reports using herbs. - Correct Answer ✔✔ 1.
3.
5.
1. Loose teeth or caries need to be re- ported to the anesthesiologist so he or she can
make provisions to prevent breaking the teeth and causing the client to possibly
aspirate pieces.
2. The nurse should report any client who is extremely anxious, but the nurse can
address the needs of a client experiencing expected surgical anxiety.
3. Smokers are at a higher risk for complications from anesthesia.
4. No infiltrates on a chest x-ray is a normal finding and does not be reported.
5. Herbs—for example, St. John's wort, licorice, and ginkgo—have serious inter- actions
with anesthesia and with bodily functions such as coagulation.
,Which task would be most appropriate for the nurse to delegate to the unlicensed
assistive personnel (UAP)?
1. Complete the preoperative checklist.
2. Assess the client's preoperative vital signs.
3. Teach the client about coughing and deep breathing.
4. Assist the client to remove clothing and jewelry. - Correct Answer ✔✔ 4.
1. The nurse should complete this form because it requires analysis, which cannot be
delegated to the UAP.
2. Nurses cannot delegate assessment.
3. The nurse cannot delegate teaching to a UAP.
4. The UAP can remove clothing and jewelry.
The nurse is assessing a client in the day surgery unit who states, "I am really afraid of
having this surgery. I'm afraid of what they will find." Which statement would be the best
therapeutic response by the nurse?
1. "Don't worry about your surgery. It is safe."
2. "Tell me why you're worried about your surgery." 3. "Tell me about your fears of
having this surgery."
4. "I understand how you feel. Surgery is frightening." - Correct Answer ✔✔ 3.
1. This statement is giving false reassurance.
2. "Why" is never therapeutic. The client does not owe the nurse an explanation.
3. This statement focuses on the emotion which the client identified and is therapeutic.
4. This statement belittles the client's fear, and no person understands how another
person feels.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal
contents after three (3) tap water enemas. Which intervention should the nurse
implement first?
1. Notify the surgeon of the client's status.
2. Continue giving enemas until clear.
3. Increase the client's IV fluid rate.
4. Obtain STAT serum electrolytes. - Correct Answer ✔✔ 1.
1. The nurse should contact the surgeon because the client is at risk for fluid and
electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and
pediatric clients are more likely to have these imbalances.
2. Administering more enemas will put the client at further risk for fluid volume deficit
and electrolyte imbalance.
3. The IV may need to be increased, but the nurse would need an order for this
intervention.
4. The electrolyte status may need to be assessed, but the nurse would need an order
for this intervention.
, The nurse is caring for a male client scheduled for abdominal surgery. Which
interventions should the nurse include in the plan of care? (Select all that apply.)
1. Perform passive range-of-motion exercises.
2. Discuss how to cough and deep breathe effectively.
3. Tell the client he can have a meal in the PACU.
4. Teach ways to manage postoperative pain.
5. Discuss events which occur in the post-anesthesia care unit. - Correct Answer ✔✔ 2.
4.
5.
1. Passive means the nurse performs the range-of-motion exercises. The client in the
PACU should do active range-of-motion exercises.
2. Coughing effectively aids in the removal of pooled secretions which can cause
pneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis.
3. The client having abdominal surgery will be NPO until bowel sounds return, which will
not occur in the PACU; therefore, the client is not given a meal.
4. The client's postoperative pain should be kept within a tolerable range.
5. These interventions help decrease the client's anxiety.
The nurse is caring for a client scheduled for total hip replacement. Which behavior
indicates the need for further preoperative teaching?
1. The client uses the diaphragm and abdominal muscles to inhale through the nose
and exhale through the mouth.
2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the
feet in a circular motion.
3. The client uses the incentive spirometer and inhales slowly and deeply so the
piston rises to the preset volume.
4. The client gets out of bed by lifting straight upright from the waist and then
swings both legs along the side of the bed. - Correct Answer ✔✔ 4.
1. This is the correct way to perform deep-breathing exercises; therefore, no further
teaching is needed.
2. This is the correct way to perform range- of-motion exercises; therefore, no further
teaching is needed.
3. This is the way to use a volume incentive spirometer; therefore, no further teaching is
needed.
4. The correct way to get out of bed postoperatively is to roll onto the side, grasp the
side rail to maneuver to the side, and then push up with one hand while swinging the
legs over the side. The client needs further teaching.
The nurse is completing a preoperative assessment on a male client who states, "I am
allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist.
2. Label the client's allergies on the front of the chart.
3. Ask the client what happens when he takes the codeine.
VERIFIED CORRECT ANSWERS ALL
PASSED
The nurse requests the client to sign a surgical informed consent form for an emergency
appendectomy. Which statement by the client indicates further teaching is needed?
1. "I will be glad when this is over so I can go home today."
2. "I will not be able to eat or drink anything prior to my surgery."
3. "I can practice relaxing by listening to my favorite music."
4. "I will need to get up and walk as soon as possible." - Correct Answer ✔✔ 1.
1. The client will be in the hospital for a few days. This is not a day-surgery procedure.
The client needs more teaching.
2. Clients are NPO (nothing by mouth) prior to surgery to prevent aspiration during and
after anesthesia. The client understands the teaching.
3. Listening to music and other relaxing tech- niques can be used to alleviate anxiety
and pain. This statement indicates the client understands the teaching.
4. Clients are encouraged to get out of bed as soon as possible and progress until a
return to daily activity is achieved. The client understands the teaching.
The nurse in the holding area of the surgery department is interviewing a client who
requests to keep his religious medal on during surgery. Which intervention should the
nurse implement?
1. Notify the surgeon about the client's request to wear the medal.
2. Tape the medal to the client and allow the client to wear the medal.
3. Request the family member take the medal prior to surgery.
4. Explain taking the medal to surgery is against the policy. - Correct Answer ✔✔ 2.
1. The surgeon does not need to be notified of the client's request; this can be
addressed by the nursing staff.
2. The medal should be taped and the client should be allowed to wear the medal
because meeting spiritual needs
is essential to this client's care.
3. The client should be allowed to bring the medal to surgery if the medal is taped to the
client.
4. Hospital policies should be established for the well-being of clients, and spiritual
needs should be addressed.
The nurse must obtain surgical consent forms for the scheduled surgery. Which client
would not be able to consent legally to surgery?
1. The 65-year-old client who cannot read or write.
2. The 30-year-old client who does not understand English.
,3. The 16-year-old client who has a fractured ankle.
4. The 80-year-old client who is not oriented to the day. - Correct Answer ✔✔ 3.
1. The 65-year-old client who cannot read can mark an "X" on the form and is legally
able to sign a surgical permit as long as the client understands the benefits,
alternatives, and all potential complications of the surgery.
2. The client who does not speak English can and should have information given and
questions answered in the client's native language.
3. A 16-year-old client is not legally able to give permission for surgery unless the
adolescent has been given an emancipated status by a judge. This information was not
given in the stem.
4. A client is able to give permission unless determined incompetent. Not knowing the
day of the week is not significant.
The nurse is preparing a client for surgery. Which intervention should the nurse
implement first?
1. Check the permit for the spouse's signature.
2. Take and document intake and output.
3. Administer the "on call" sedative.
4. Complete the preoperative checklist. - Correct Answer ✔✔ 4.
1. The client's signature, not the spouse's, should be on the surgical permit.
2. This would be important information if ab- normal, but it is not the first intervention.
3. "On call" sedatives should be administered after the surgical checklist is completed.
4. Completing the preoperative checklist has the highest priority to ensure all details are
completed without omissions.
The nurse is interviewing a surgical client in the holding area. Which information should
the nurse report to the anesthesiologist? (Select all that apply.)
1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes two (2) packs of cigarettes a day.
4. The client has had a chest x-ray which does not show infiltrates.
5. The client reports using herbs. - Correct Answer ✔✔ 1.
3.
5.
1. Loose teeth or caries need to be re- ported to the anesthesiologist so he or she can
make provisions to prevent breaking the teeth and causing the client to possibly
aspirate pieces.
2. The nurse should report any client who is extremely anxious, but the nurse can
address the needs of a client experiencing expected surgical anxiety.
3. Smokers are at a higher risk for complications from anesthesia.
4. No infiltrates on a chest x-ray is a normal finding and does not be reported.
5. Herbs—for example, St. John's wort, licorice, and ginkgo—have serious inter- actions
with anesthesia and with bodily functions such as coagulation.
,Which task would be most appropriate for the nurse to delegate to the unlicensed
assistive personnel (UAP)?
1. Complete the preoperative checklist.
2. Assess the client's preoperative vital signs.
3. Teach the client about coughing and deep breathing.
4. Assist the client to remove clothing and jewelry. - Correct Answer ✔✔ 4.
1. The nurse should complete this form because it requires analysis, which cannot be
delegated to the UAP.
2. Nurses cannot delegate assessment.
3. The nurse cannot delegate teaching to a UAP.
4. The UAP can remove clothing and jewelry.
The nurse is assessing a client in the day surgery unit who states, "I am really afraid of
having this surgery. I'm afraid of what they will find." Which statement would be the best
therapeutic response by the nurse?
1. "Don't worry about your surgery. It is safe."
2. "Tell me why you're worried about your surgery." 3. "Tell me about your fears of
having this surgery."
4. "I understand how you feel. Surgery is frightening." - Correct Answer ✔✔ 3.
1. This statement is giving false reassurance.
2. "Why" is never therapeutic. The client does not owe the nurse an explanation.
3. This statement focuses on the emotion which the client identified and is therapeutic.
4. This statement belittles the client's fear, and no person understands how another
person feels.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal
contents after three (3) tap water enemas. Which intervention should the nurse
implement first?
1. Notify the surgeon of the client's status.
2. Continue giving enemas until clear.
3. Increase the client's IV fluid rate.
4. Obtain STAT serum electrolytes. - Correct Answer ✔✔ 1.
1. The nurse should contact the surgeon because the client is at risk for fluid and
electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and
pediatric clients are more likely to have these imbalances.
2. Administering more enemas will put the client at further risk for fluid volume deficit
and electrolyte imbalance.
3. The IV may need to be increased, but the nurse would need an order for this
intervention.
4. The electrolyte status may need to be assessed, but the nurse would need an order
for this intervention.
, The nurse is caring for a male client scheduled for abdominal surgery. Which
interventions should the nurse include in the plan of care? (Select all that apply.)
1. Perform passive range-of-motion exercises.
2. Discuss how to cough and deep breathe effectively.
3. Tell the client he can have a meal in the PACU.
4. Teach ways to manage postoperative pain.
5. Discuss events which occur in the post-anesthesia care unit. - Correct Answer ✔✔ 2.
4.
5.
1. Passive means the nurse performs the range-of-motion exercises. The client in the
PACU should do active range-of-motion exercises.
2. Coughing effectively aids in the removal of pooled secretions which can cause
pneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis.
3. The client having abdominal surgery will be NPO until bowel sounds return, which will
not occur in the PACU; therefore, the client is not given a meal.
4. The client's postoperative pain should be kept within a tolerable range.
5. These interventions help decrease the client's anxiety.
The nurse is caring for a client scheduled for total hip replacement. Which behavior
indicates the need for further preoperative teaching?
1. The client uses the diaphragm and abdominal muscles to inhale through the nose
and exhale through the mouth.
2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the
feet in a circular motion.
3. The client uses the incentive spirometer and inhales slowly and deeply so the
piston rises to the preset volume.
4. The client gets out of bed by lifting straight upright from the waist and then
swings both legs along the side of the bed. - Correct Answer ✔✔ 4.
1. This is the correct way to perform deep-breathing exercises; therefore, no further
teaching is needed.
2. This is the correct way to perform range- of-motion exercises; therefore, no further
teaching is needed.
3. This is the way to use a volume incentive spirometer; therefore, no further teaching is
needed.
4. The correct way to get out of bed postoperatively is to roll onto the side, grasp the
side rail to maneuver to the side, and then push up with one hand while swinging the
legs over the side. The client needs further teaching.
The nurse is completing a preoperative assessment on a male client who states, "I am
allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist.
2. Label the client's allergies on the front of the chart.
3. Ask the client what happens when he takes the codeine.
