CALIFORNIA STATE: MEDSURG Q & A
1. A nurse is caring for a client who has a central venous access device and
notes the tubing has become disconnected. The client develops dyspnea and
tachycardia. Which of the following actions should the nurse take first?
a. Obtain ABG values
b. Perform an ECG
c. Turn the client to his left side
d. Clamp the catheter
2. A nurse is providing discharge teaching to a client who has impaired
immune system due to chemotherapy. Which of the following information should
the nurse include in the teaching?
a. Wash your perineal area 2 times each day with antimicrobial soap
b. Change the water in your drinking glass every 4 hours
c. Wash your toothbrush in the dishwasher once each month
d. Change your pet litter box daily
3. A nurse is caring for a client who has advanced liver disease. Which of the
following laboratory results should the nurse monitor when assessing the client?
a. Serum Ammonia
b. Glucose level
c. Phosphate level
d. Serum troponin
4. A nurse is caring for a client who has admitted with nausea, vomiting, and
a possible bowel obstruction. An NG tube is placed and set to low intermittent
suction. Which of the following findings should the nurse report to the provider?
a. The client reports being extremely thirsty with a sore throat
b. The amount of drainage is gradually decreasing
c. The clients abdomen becomes distended and firm
d. The drainage is bright green in color with brown fecal material
,5. A nurse is caring for a client who takes Lisinopril for HTN. Which of the
following client statements indicates an adverse effect of the medication?
a. I have a heightened sense of taste
, b. I have a nagging, dry cough
c. I have to urinate frequently
d. I seem to be bruising more easily
6. A nurse is caring for a client who has an endotracheal tube. Which of the
following actions should the nurse take to verify tube placement?
a. Deflate the cuff to check the tube placement
b. Place the client’s head and neck in a flexed position
c. Observe for symmetry of chest expansion
d. Document the tube length where it passes the chin
7. A nurse is providing discharge teaching to a client who has chronic urinary
tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice
daily. Which of the following instructions should the nurse include in the
teaching?
a. Take a laxative to prevent constipations
b. Take an antacid 30 min before taking the medication
c. Monitor heart rate once daily
d. Drink 2 to 3 L of fluid daily
8. A nurse is caring for a client who presents to the emergency department
after experiencing a heat stroke. Which of the following actions should the nurse
take?
a. Apply a cooling blanket.
b. Assess axillary temperature every 15 min.
c. Administer an antipyretic
d. Administer lactated Ringers.
9. A nurse is presenting an in-service program about Parkinson’s disease (PD).
Which of the following statements should the nurse include in the teaching?
a. PD cause clients to have an increased sympathetic nervous system
response
b. PD results in the development of neurofibrillary tangles within the
client’s brain
c. PD results from a decreased amount of dopamine in the client’s brain
, d. PD manifestations worse due to the clients
decreased production of acetylcholine.
10. A nurse is reviewing the medical record of a client who is to undergo open
heart surgery. Which of the following findings should the nurse report to the
provider as a contraindication to receiving heparin?
a. Thrombocytopenia
b. Thalassemia
c. Rheumatoid arthritis
d. COPD
11. A nurse is assessing a client who has skeletal traction for a femoral
fracture. The nurse notes that the weights are testing on the floor. Which of
the following actions should the nurse take?
a. Pull the client up in bed
b. Tie knots in the ropes near the pulleys to shorten them
c. Increase the elevation of the affected extremity
d. Remove one of the weights
12. A nurse is reviewing a medical record of a client who has acute gout. The
nurse expects an increase in which of the following laboratory results?
a. Intrinsic factor
b. Chloride level
c. Uric acid
d. Creatinine kinase
13. A nurse is providing teaching to a client who is to start furosemide therapy
for heart failure. Which of the following statements indicates that the client
understands a potential adverse effect of this medication?
a. “I will check my pulse before I take this medication.”
b. “I’ll check my blood pressure so it doesn’t get too high.”
c. “I’m going to include more cantaloupe in my diet.”
d. “I will try to limit foods that contain salt.”
14. A nurse is assessing a client who is 12hr postoperative following a colon
resection. Which of the following findings should the nurse report to the surgeon?
a. Heart rate 90/min
1. A nurse is caring for a client who has a central venous access device and
notes the tubing has become disconnected. The client develops dyspnea and
tachycardia. Which of the following actions should the nurse take first?
a. Obtain ABG values
b. Perform an ECG
c. Turn the client to his left side
d. Clamp the catheter
2. A nurse is providing discharge teaching to a client who has impaired
immune system due to chemotherapy. Which of the following information should
the nurse include in the teaching?
a. Wash your perineal area 2 times each day with antimicrobial soap
b. Change the water in your drinking glass every 4 hours
c. Wash your toothbrush in the dishwasher once each month
d. Change your pet litter box daily
3. A nurse is caring for a client who has advanced liver disease. Which of the
following laboratory results should the nurse monitor when assessing the client?
a. Serum Ammonia
b. Glucose level
c. Phosphate level
d. Serum troponin
4. A nurse is caring for a client who has admitted with nausea, vomiting, and
a possible bowel obstruction. An NG tube is placed and set to low intermittent
suction. Which of the following findings should the nurse report to the provider?
a. The client reports being extremely thirsty with a sore throat
b. The amount of drainage is gradually decreasing
c. The clients abdomen becomes distended and firm
d. The drainage is bright green in color with brown fecal material
,5. A nurse is caring for a client who takes Lisinopril for HTN. Which of the
following client statements indicates an adverse effect of the medication?
a. I have a heightened sense of taste
, b. I have a nagging, dry cough
c. I have to urinate frequently
d. I seem to be bruising more easily
6. A nurse is caring for a client who has an endotracheal tube. Which of the
following actions should the nurse take to verify tube placement?
a. Deflate the cuff to check the tube placement
b. Place the client’s head and neck in a flexed position
c. Observe for symmetry of chest expansion
d. Document the tube length where it passes the chin
7. A nurse is providing discharge teaching to a client who has chronic urinary
tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice
daily. Which of the following instructions should the nurse include in the
teaching?
a. Take a laxative to prevent constipations
b. Take an antacid 30 min before taking the medication
c. Monitor heart rate once daily
d. Drink 2 to 3 L of fluid daily
8. A nurse is caring for a client who presents to the emergency department
after experiencing a heat stroke. Which of the following actions should the nurse
take?
a. Apply a cooling blanket.
b. Assess axillary temperature every 15 min.
c. Administer an antipyretic
d. Administer lactated Ringers.
9. A nurse is presenting an in-service program about Parkinson’s disease (PD).
Which of the following statements should the nurse include in the teaching?
a. PD cause clients to have an increased sympathetic nervous system
response
b. PD results in the development of neurofibrillary tangles within the
client’s brain
c. PD results from a decreased amount of dopamine in the client’s brain
, d. PD manifestations worse due to the clients
decreased production of acetylcholine.
10. A nurse is reviewing the medical record of a client who is to undergo open
heart surgery. Which of the following findings should the nurse report to the
provider as a contraindication to receiving heparin?
a. Thrombocytopenia
b. Thalassemia
c. Rheumatoid arthritis
d. COPD
11. A nurse is assessing a client who has skeletal traction for a femoral
fracture. The nurse notes that the weights are testing on the floor. Which of
the following actions should the nurse take?
a. Pull the client up in bed
b. Tie knots in the ropes near the pulleys to shorten them
c. Increase the elevation of the affected extremity
d. Remove one of the weights
12. A nurse is reviewing a medical record of a client who has acute gout. The
nurse expects an increase in which of the following laboratory results?
a. Intrinsic factor
b. Chloride level
c. Uric acid
d. Creatinine kinase
13. A nurse is providing teaching to a client who is to start furosemide therapy
for heart failure. Which of the following statements indicates that the client
understands a potential adverse effect of this medication?
a. “I will check my pulse before I take this medication.”
b. “I’ll check my blood pressure so it doesn’t get too high.”
c. “I’m going to include more cantaloupe in my diet.”
d. “I will try to limit foods that contain salt.”
14. A nurse is assessing a client who is 12hr postoperative following a colon
resection. Which of the following findings should the nurse report to the surgeon?
a. Heart rate 90/min
