med surg questions with answers completely solved
1. When administering IV morphine every 3-4 hrs PRN post op. What are the nurses'
interventions?
● Administer drug over 5 mins
● Tell the patient to ask for assistance getting out of bed
Rationale–Morphine is an opioid agonist used to provide analgesia in clients with moderate to
severe pain. When given intravenously, it has a rapid onset of action and should be given over 5
minutes. Pain assessment should be performed before the administration of morphine and at
20 minutes after IV administration. During administration, the level of consciousness and vital
signs should be assessed periodically; when the respiratory rate <10/minute, the nurse should
assess sedation. Morphine can cause sedation, so clients should be instructed about potential
drowsiness or dizziness and should call for assistance when getting out of bed or ambulating.
Clients should be advised to change position cautiously to minimize the risk of orthostatic
hypotension. Clients who are on prolonged bed rest or who are immobilized should breathe
deeply, cough, and turn to prevent atelectasis. Atelectasis is a concern in postoperative clients
who may avoid deep breathing due to pain.
2. A client with ulcercolitisis is scheduled for a lower GI endoscopy that shows ulcerations
and stricirtions. What is true about this disorder?
● Anemia is a common finding
Rationale– Ulcerative colitis (UC) is a disorder of inflammation of the colonic mucosa.
Ulcerations and structures are characteristic. Onset is usually gradual. Diagnostic tests include
CBC (complete blood count), erythrocyte sedimentation rate, endoscopy, and stool culture.
Anemia occurs in UC due to loss of blood from friable mucosa in the stool. Abdominal rigidity
does not occur as a symptom in UC, although abdominal tenderness is usually seen. Disease is
limited to the colon and rectum in UC. Other symptoms include tenesmus, fever, loose or watery
stools with pus or mucus, crampy abdominal pain, anorexia, fluid and electrolyte imbalances,
and malnutrition.
3. A charge nurse on the med- surg unit was just told that a disaster proctol is being
implemented. What action should the nurse take?
● Make a list of patients who can be discharged
Rationale- Following the initiation of disaster protocol, the charge nurse should identify that
clients who are stable can be discharged to allow clients who are harmed by the disaster to be
admitted. The charge nurse should make a list of potential client dismissals and work
collaboratively with providers to obtain discharge prescriptions. Clients Who Can Be Potentially
Discharged Following a Disaster • Ambulatory clients who were admitted previously for
observation • Ambulatory clients who admitted for undergoing diagnostic evaluation • Clients
who are stable and can be cared for at home by family or support services • Clients who are
stable and can be transferred to another facility • Clients who have remained stable for a
minimum of 3 days.
4. The nurse is performing an assessment of a client with cholesteatoma where the incus is
affected. At what mark on the drawing of the ear is the client's condition located?
** Where the H is located**
,5. A nurse is caring for a client on the telemetry unit and sees the following rhythm on the
monitor. Which of the following is the priority action by the nurse?
Correct Answer: B. Begin chest compressions The rhythm is ventricular fibrillation, a
terminal rhythm that indicates cardiac arrest. Immediate initiation of CPR, beginning with
chest compressions, is associated with improved outcomes. Defibrillation should be
performed as soon as the defibrillator or AED is available. Ventricular fibrillation
represents chaotic electrical activity in the heart with ineffective pumping and no cardiac
output. Defibrillation stuns the heart and stops the electrical activity, allowing the natural
pacemaker to take over.
6. A nurse is caring for a client who has undergone surgical procedure earlier in the day.
The client has been treated with oxycodone for acute pain and has not voided in 5
hours. Which of the following actions will the nurse prioritize when urinary retention is
suspected in a post-op client?
Correct Answer: B. Palpation of the suprapubic area Medications that may cause urinary
retention include opioid analgesics, tricyclic antidepressants, and anticholinergic drugs.
These medications may increase the tone of the bladder sphincter or relax the muscles
of the bladder wall. By palpating the suprapubic region, the nurse can determine if
urinary retention is a likely cause of the client’s failure to void. Clients who have urinary
, retention will have distention and dullness to percussion, and discomfort with palpation
of the suprapubic region.
7. A nurse is caring for a client in the telemetry unit who complains of chest pain and
becomes unresponsive and pulseless. The first response of the nurse should be to:
Correct Answer: B. Call for help and begin chest compressions Once the nurse
determines that the client is unresponsive and pulseless, the first response should be to
alert someone to notify the RRT or call a code. Once that is done, the nurse should
immediately start CPR. When the RRT arrives, they will connect the client to a crash cart
monitor to determine the cardiac rhythm
8. A nurse working in the emergency department is caring for an adult client with
appendicitis who only speaks Vietnamese. The physician wants to obtain consent for an
appendectomy. The client's 15-year-old son is present and speaks English. The nurse
should:
Correct Answer: A. Call for a Vietnamese translator Informed consent implies that the
client has received the appropriate information and has had an opportunity to talk about
risks with the surgeon. In a situation in which this exchange cannot occur directly
because of language differences, the nurse must call a professional translator who can
accurately translate between the client and the surgeon. Asking a family member to
translate can violate client confidentiality rights.
9. The nurse is caring for a child with renal failure and consequent hyperkalemia. Which of
the following cardiac rhythms would the nurse expect to see in this child?
10. A charge nurse is providing education to staff about skin care in the elderly client. The
nurse will review all of the following changes associated with the normal aging process,
EXCEPT:
Correct Answer: B. The outer layer of skin sloughs off and is replaced with new cells
every few days As a person ages, the skin begins to lose fat, water, and collagen,
resulting in loss of turgor and elasticity. Blood supply to the skin decreases, making it
harder for an aging adult's body to regulate the temperature. This is one of the reasons
older adults feel cold at higher temperatures. Although the outer layer of skin is replaced
, every few days in younger people, this cell replacement does not occur as quickly in
older adults.
11. A nurse is updating the plan of care for a client who has a new diagnosis of hypertension
and a prescription for atenolol. Which of the following referrals should the nurse request
from the provider as the priority referral?
Correct Answer: C. Pharmacist The nurse should request a referral for a pharmacist to
inform the client about the new medication the client has been prescribed.
12. What is the most appropriate nursing action when administering a unit of packed red
blood cells to a client with a bleeding peptic ulcer and anemia who currently has D5W
infusing through a 20-gauge catheter?
Correct Answer: A. Discontinue D5W and flush the catheter with normal saline before
starting transfusion The only fluid that can be administered with a blood transfusion is
normal saline. Cell lysis may result from a dextrose solution, and other IV solutions are
incompatible with blood and may result in precipitation. A dedicated IV line must be used
to infuse blood products. If using tubing that is currently in place, the infusion and tubing
should be discontinued, and the catheter should be flushed with normal saline before
connecting the tubing for administration of blood. After the transfusion is complete, the
nurse should clear the catheter with a flush of NS before administering any fluids or
medications.
13. A nurse is caring for a client who is receiving an IV infusion via an infusion site in the left
hand. Which of the following findings should the nurse identify as an indication of an
infiltration?
Correct Answer: C. Edema in the palm of the hand The nurse should identify that
edema, pallor, and coolness around the insertion site can indicate an infiltration, which is
1. When administering IV morphine every 3-4 hrs PRN post op. What are the nurses'
interventions?
● Administer drug over 5 mins
● Tell the patient to ask for assistance getting out of bed
Rationale–Morphine is an opioid agonist used to provide analgesia in clients with moderate to
severe pain. When given intravenously, it has a rapid onset of action and should be given over 5
minutes. Pain assessment should be performed before the administration of morphine and at
20 minutes after IV administration. During administration, the level of consciousness and vital
signs should be assessed periodically; when the respiratory rate <10/minute, the nurse should
assess sedation. Morphine can cause sedation, so clients should be instructed about potential
drowsiness or dizziness and should call for assistance when getting out of bed or ambulating.
Clients should be advised to change position cautiously to minimize the risk of orthostatic
hypotension. Clients who are on prolonged bed rest or who are immobilized should breathe
deeply, cough, and turn to prevent atelectasis. Atelectasis is a concern in postoperative clients
who may avoid deep breathing due to pain.
2. A client with ulcercolitisis is scheduled for a lower GI endoscopy that shows ulcerations
and stricirtions. What is true about this disorder?
● Anemia is a common finding
Rationale– Ulcerative colitis (UC) is a disorder of inflammation of the colonic mucosa.
Ulcerations and structures are characteristic. Onset is usually gradual. Diagnostic tests include
CBC (complete blood count), erythrocyte sedimentation rate, endoscopy, and stool culture.
Anemia occurs in UC due to loss of blood from friable mucosa in the stool. Abdominal rigidity
does not occur as a symptom in UC, although abdominal tenderness is usually seen. Disease is
limited to the colon and rectum in UC. Other symptoms include tenesmus, fever, loose or watery
stools with pus or mucus, crampy abdominal pain, anorexia, fluid and electrolyte imbalances,
and malnutrition.
3. A charge nurse on the med- surg unit was just told that a disaster proctol is being
implemented. What action should the nurse take?
● Make a list of patients who can be discharged
Rationale- Following the initiation of disaster protocol, the charge nurse should identify that
clients who are stable can be discharged to allow clients who are harmed by the disaster to be
admitted. The charge nurse should make a list of potential client dismissals and work
collaboratively with providers to obtain discharge prescriptions. Clients Who Can Be Potentially
Discharged Following a Disaster • Ambulatory clients who were admitted previously for
observation • Ambulatory clients who admitted for undergoing diagnostic evaluation • Clients
who are stable and can be cared for at home by family or support services • Clients who are
stable and can be transferred to another facility • Clients who have remained stable for a
minimum of 3 days.
4. The nurse is performing an assessment of a client with cholesteatoma where the incus is
affected. At what mark on the drawing of the ear is the client's condition located?
** Where the H is located**
,5. A nurse is caring for a client on the telemetry unit and sees the following rhythm on the
monitor. Which of the following is the priority action by the nurse?
Correct Answer: B. Begin chest compressions The rhythm is ventricular fibrillation, a
terminal rhythm that indicates cardiac arrest. Immediate initiation of CPR, beginning with
chest compressions, is associated with improved outcomes. Defibrillation should be
performed as soon as the defibrillator or AED is available. Ventricular fibrillation
represents chaotic electrical activity in the heart with ineffective pumping and no cardiac
output. Defibrillation stuns the heart and stops the electrical activity, allowing the natural
pacemaker to take over.
6. A nurse is caring for a client who has undergone surgical procedure earlier in the day.
The client has been treated with oxycodone for acute pain and has not voided in 5
hours. Which of the following actions will the nurse prioritize when urinary retention is
suspected in a post-op client?
Correct Answer: B. Palpation of the suprapubic area Medications that may cause urinary
retention include opioid analgesics, tricyclic antidepressants, and anticholinergic drugs.
These medications may increase the tone of the bladder sphincter or relax the muscles
of the bladder wall. By palpating the suprapubic region, the nurse can determine if
urinary retention is a likely cause of the client’s failure to void. Clients who have urinary
, retention will have distention and dullness to percussion, and discomfort with palpation
of the suprapubic region.
7. A nurse is caring for a client in the telemetry unit who complains of chest pain and
becomes unresponsive and pulseless. The first response of the nurse should be to:
Correct Answer: B. Call for help and begin chest compressions Once the nurse
determines that the client is unresponsive and pulseless, the first response should be to
alert someone to notify the RRT or call a code. Once that is done, the nurse should
immediately start CPR. When the RRT arrives, they will connect the client to a crash cart
monitor to determine the cardiac rhythm
8. A nurse working in the emergency department is caring for an adult client with
appendicitis who only speaks Vietnamese. The physician wants to obtain consent for an
appendectomy. The client's 15-year-old son is present and speaks English. The nurse
should:
Correct Answer: A. Call for a Vietnamese translator Informed consent implies that the
client has received the appropriate information and has had an opportunity to talk about
risks with the surgeon. In a situation in which this exchange cannot occur directly
because of language differences, the nurse must call a professional translator who can
accurately translate between the client and the surgeon. Asking a family member to
translate can violate client confidentiality rights.
9. The nurse is caring for a child with renal failure and consequent hyperkalemia. Which of
the following cardiac rhythms would the nurse expect to see in this child?
10. A charge nurse is providing education to staff about skin care in the elderly client. The
nurse will review all of the following changes associated with the normal aging process,
EXCEPT:
Correct Answer: B. The outer layer of skin sloughs off and is replaced with new cells
every few days As a person ages, the skin begins to lose fat, water, and collagen,
resulting in loss of turgor and elasticity. Blood supply to the skin decreases, making it
harder for an aging adult's body to regulate the temperature. This is one of the reasons
older adults feel cold at higher temperatures. Although the outer layer of skin is replaced
, every few days in younger people, this cell replacement does not occur as quickly in
older adults.
11. A nurse is updating the plan of care for a client who has a new diagnosis of hypertension
and a prescription for atenolol. Which of the following referrals should the nurse request
from the provider as the priority referral?
Correct Answer: C. Pharmacist The nurse should request a referral for a pharmacist to
inform the client about the new medication the client has been prescribed.
12. What is the most appropriate nursing action when administering a unit of packed red
blood cells to a client with a bleeding peptic ulcer and anemia who currently has D5W
infusing through a 20-gauge catheter?
Correct Answer: A. Discontinue D5W and flush the catheter with normal saline before
starting transfusion The only fluid that can be administered with a blood transfusion is
normal saline. Cell lysis may result from a dextrose solution, and other IV solutions are
incompatible with blood and may result in precipitation. A dedicated IV line must be used
to infuse blood products. If using tubing that is currently in place, the infusion and tubing
should be discontinued, and the catheter should be flushed with normal saline before
connecting the tubing for administration of blood. After the transfusion is complete, the
nurse should clear the catheter with a flush of NS before administering any fluids or
medications.
13. A nurse is caring for a client who is receiving an IV infusion via an infusion site in the left
hand. Which of the following findings should the nurse identify as an indication of an
infiltration?
Correct Answer: C. Edema in the palm of the hand The nurse should identify that
edema, pallor, and coolness around the insertion site can indicate an infiltration, which is
