Medical-Surgical B
1. 1.ID: 310947654
Which method elicits the most accurate information during a physical assessment of an
older client?
o Ask the client to recount one's health history.
o Obtain the client's information from a caregiver.
o Review the past medical record for medications.
o Use reliable assessment tools for older adults. Correct
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services
Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric
Depression Scale), or skin breakdown risk (Braden Scale), consider age-related
physiologic and psychosocial changes related to aging and provide the most accurate and
complete information. (A and B) are 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.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 310972705
A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling. Which information
should the nurse offer to facilitate the client's adjustment to HIV infection?
o Inform the client how to protect sexual and needle-sharing partners.
o Teach the client about the medications that are available for treatment.
o Identify the need to test others who have had risky contact with the client.
o Discuss retesting to verify the results, which will ensure continuing contact.
Correct
Encouraging retesting (D) supports hope and gives the client time to cope with the
diagnosis. Although post-test counseling should include education about (A, B, and C),
retesting encourages the client to maintain medical follow-up and management.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 310955083
The nurse hears short, high-pitched sounds just before the end of inspiration in the right
and left lower lobes when auscultating a client's lungs. How should this finding be
recorded?
o Inspiratory wheezes in both lungs. Incorrect
o Crackles in the right and left lower lobes. Correct
o Abnormal lung sounds in the bases of both lungs.
o Pleural friction rub in the right and left lower lobes.
, Fine crackles (B) are short, high-pitched sounds heard just before the end of inspiration
that are the result of rapid equalization of pressure when collapsed alveoli or terminal
bronchioles suddenly snap open. Wheezing (A) is a continuous high-pitched squeaking or
musical sound caused by rapid vibration of bronchial walls that are first evident on
expiration and may be audible. Although (C) describes an adventitious lung sound, this
documentation is vague. (D) is a creaking or grating sound from roughened, inflamed
surfaces of the pleura rubbing together heard during inspiration, expiration, and with no
change during coughing.
Awarded 0.0 points out of 1.0 possible points.
3. 4.ID: 310946670
What assessment finding should the nurse identify that indicates a client with an acute
asthma exacerbation is beginning to improve after treatment?
o Wheezing becomes louder. Correct
o Cough remains unproductive.
o Vesicular breath sounds decrease.
o Bronchodilators stimulate coughing. Incorrect
In an acute asthma attack, air flow may be so significantly restricted that wheezing is
diminished. If the client is successfully responding to bronchodilators and respiratory
treatments, wheezing becomes louder (A) as air flow increases in the airways. As the
airways open and mucous is mobilized in response to treatment, the cough becomes more
productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard
over lung fields (C) and is not an indicator of improvement during asthma treatment.
Bronchodilators do not stimulate coughing (D).
Awarded 0.0 points out of 1.0 possible points.
4. 5.ID: 310944528
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action
should the nurse implement?
o Encourage fluids to 3000 ml/day.
o Check stools for occult blood. Correct
o Provide oral hygiene every 2 hours.
o Check for fever every 4 hours.
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common
side effect of chemotherapy. A client with thrombocytopenia should be assessed
frequently for occult bleeding in the emesis, sputum, feces (B), urine, nasogastric
secretions, or wounds. (A) does not minimize the risk for bleeding associated with
thrombocytopenia. (C) may cause increased bleeding in a client with thromobcytopenia.
(D) assesses for infection, not risk for bleeding.
Awarded 1.0 points out of 1.0 possible points.
5. 6.ID: 310982319
, Three weeks after discharge for an acute myocardial infarction (MI), a client returns to
the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells
the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when
he returned home. He states, I guess we will never have sex again after this. Which
response is best for the nurse to provide?
o Sexual intercourse can be strenuous on your heart, but closeness and intimacy,
such as holding and cuddling, can be maintained with your wife.
o Sexual activity can be resumed whenever you and your wife feel like it because
the sexual response is more emotional rather than physical.
o You should discuss your questions about your sexual activity with your healthcare
provider because sexual activity may be limited by your heart damage.
o Sexual activity is similar in cardiac workload and energy expenditure as climbing
two flights of stairs and may be resumed like other activities. Correct
Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no
more energy expenditure or cardiac stress than walking briskly up two flights of stairs
(D), as long as other guidelines, such as limiting food and alcohol intake before
intercourse, are followed. (A, B, and C) do not provide the best factual information to
reduce the client's anxiety and misconceptions.
Awarded 1.0 points out of 1.0 possible points.
6. 7.ID: 311013663
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled
for surgical placement of a permanent pacemaker. The client asks the nurse how this
devise will help him. How should the nurse explain the action of a synchronous
pacemaker?
o Ventricular irritability is prevented by the constant rate setting of pacemaker.
o Ectopic stimulus in the atria is suppressed by the device usurping depolarization.
o An impulse is fired every second to maintain a heart rate of 60 beats per minute.
o An electrical stimulus is discharged when no ventricular response is sensed.
Correct
The artificial cardiac pacemaker is an electronic device used to pace the heart when the
normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias
like atrial fibrillation with a slow ventricular response. Pacing modes that are
synchronous (impulse generated on demand or as needed according to the patient's
intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the
myocardium stimulating it to contract when no ventricular depolarization is sensed (D).
(A, B, and C) do not provide accurate information.
Awarded 1.0 points out of 1.0 possible points.
7. 8.ID: 310946602
The nurse completes visual inspection of a client's abdomen. What technique should the
nurse perform next in the abdominal examination?
o Percussion.
, o Auscultation. Correct
o Deep palpation.
o Light palpation.
Auscultation (B) of the client's abdomen is performed next because manual manipulation
(A, C, and D) can stimulate the bowel and create false sounds heard during auscultation.
Awarded 1.0 points out of 1.0 possible points.
8. 9.ID: 310962725
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary
colostomy, the nurse determines that the client's stoma is dry and dark red in color. What
action should the nurse implement?
o Notify the surgeon. Correct
o Document the assessment.
o Secure a colostomy pouch over the stoma.
o Place petrolatum gauze dressing over the stoma.
The stoma should appear reddish pink and moist, which indicates circulatory perfusion to
the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark
red or purple, the stoma is ischemic, and the surgeon should be notified immediately (A).
Although (B, C, and D) may be implemented, the findings require immediate medical
attention.
Awarded 1.0 points out of 1.0 possible points.
9. 10.ID: 310969487
The nurse is caring for a client with end stage liver disease who is being assessed for the
presence of asterixis. To assess the client for asterixis, what position should the nurse ask
the client to demonstrate?
o Extend the left arm laterally with the left palm upward.
o Extend the arm, dorsiflex the wrist, and extend the fingers. Correct
o Extend the arms and hold this position for 30 seconds.
o Extend arms with both legs adducted to shoulder width.
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen
frequently in hepatic encephalopathy. The tremor is induced by extending the arm and
dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist
while attempting to hold position (B). (A, C, and D) do not illicit axterixis.
Awarded 1.0 points out of 1.0 possible points.
10. 11.ID: 310993993
A client is admitted to the emergency department after being lost for four days while
hiking in a national forest. Upon review of the laboratory results, the nurse determines the
client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional
assessment should the nurse make?
o Body mass index.
1. 1.ID: 310947654
Which method elicits the most accurate information during a physical assessment of an
older client?
o Ask the client to recount one's health history.
o Obtain the client's information from a caregiver.
o Review the past medical record for medications.
o Use reliable assessment tools for older adults. Correct
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services
Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric
Depression Scale), or skin breakdown risk (Braden Scale), consider age-related
physiologic and psychosocial changes related to aging and provide the most accurate and
complete information. (A and B) are 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.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 310972705
A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling. Which information
should the nurse offer to facilitate the client's adjustment to HIV infection?
o Inform the client how to protect sexual and needle-sharing partners.
o Teach the client about the medications that are available for treatment.
o Identify the need to test others who have had risky contact with the client.
o Discuss retesting to verify the results, which will ensure continuing contact.
Correct
Encouraging retesting (D) supports hope and gives the client time to cope with the
diagnosis. Although post-test counseling should include education about (A, B, and C),
retesting encourages the client to maintain medical follow-up and management.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 310955083
The nurse hears short, high-pitched sounds just before the end of inspiration in the right
and left lower lobes when auscultating a client's lungs. How should this finding be
recorded?
o Inspiratory wheezes in both lungs. Incorrect
o Crackles in the right and left lower lobes. Correct
o Abnormal lung sounds in the bases of both lungs.
o Pleural friction rub in the right and left lower lobes.
, Fine crackles (B) are short, high-pitched sounds heard just before the end of inspiration
that are the result of rapid equalization of pressure when collapsed alveoli or terminal
bronchioles suddenly snap open. Wheezing (A) is a continuous high-pitched squeaking or
musical sound caused by rapid vibration of bronchial walls that are first evident on
expiration and may be audible. Although (C) describes an adventitious lung sound, this
documentation is vague. (D) is a creaking or grating sound from roughened, inflamed
surfaces of the pleura rubbing together heard during inspiration, expiration, and with no
change during coughing.
Awarded 0.0 points out of 1.0 possible points.
3. 4.ID: 310946670
What assessment finding should the nurse identify that indicates a client with an acute
asthma exacerbation is beginning to improve after treatment?
o Wheezing becomes louder. Correct
o Cough remains unproductive.
o Vesicular breath sounds decrease.
o Bronchodilators stimulate coughing. Incorrect
In an acute asthma attack, air flow may be so significantly restricted that wheezing is
diminished. If the client is successfully responding to bronchodilators and respiratory
treatments, wheezing becomes louder (A) as air flow increases in the airways. As the
airways open and mucous is mobilized in response to treatment, the cough becomes more
productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard
over lung fields (C) and is not an indicator of improvement during asthma treatment.
Bronchodilators do not stimulate coughing (D).
Awarded 0.0 points out of 1.0 possible points.
4. 5.ID: 310944528
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action
should the nurse implement?
o Encourage fluids to 3000 ml/day.
o Check stools for occult blood. Correct
o Provide oral hygiene every 2 hours.
o Check for fever every 4 hours.
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common
side effect of chemotherapy. A client with thrombocytopenia should be assessed
frequently for occult bleeding in the emesis, sputum, feces (B), urine, nasogastric
secretions, or wounds. (A) does not minimize the risk for bleeding associated with
thrombocytopenia. (C) may cause increased bleeding in a client with thromobcytopenia.
(D) assesses for infection, not risk for bleeding.
Awarded 1.0 points out of 1.0 possible points.
5. 6.ID: 310982319
, Three weeks after discharge for an acute myocardial infarction (MI), a client returns to
the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells
the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when
he returned home. He states, I guess we will never have sex again after this. Which
response is best for the nurse to provide?
o Sexual intercourse can be strenuous on your heart, but closeness and intimacy,
such as holding and cuddling, can be maintained with your wife.
o Sexual activity can be resumed whenever you and your wife feel like it because
the sexual response is more emotional rather than physical.
o You should discuss your questions about your sexual activity with your healthcare
provider because sexual activity may be limited by your heart damage.
o Sexual activity is similar in cardiac workload and energy expenditure as climbing
two flights of stairs and may be resumed like other activities. Correct
Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no
more energy expenditure or cardiac stress than walking briskly up two flights of stairs
(D), as long as other guidelines, such as limiting food and alcohol intake before
intercourse, are followed. (A, B, and C) do not provide the best factual information to
reduce the client's anxiety and misconceptions.
Awarded 1.0 points out of 1.0 possible points.
6. 7.ID: 311013663
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled
for surgical placement of a permanent pacemaker. The client asks the nurse how this
devise will help him. How should the nurse explain the action of a synchronous
pacemaker?
o Ventricular irritability is prevented by the constant rate setting of pacemaker.
o Ectopic stimulus in the atria is suppressed by the device usurping depolarization.
o An impulse is fired every second to maintain a heart rate of 60 beats per minute.
o An electrical stimulus is discharged when no ventricular response is sensed.
Correct
The artificial cardiac pacemaker is an electronic device used to pace the heart when the
normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias
like atrial fibrillation with a slow ventricular response. Pacing modes that are
synchronous (impulse generated on demand or as needed according to the patient's
intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the
myocardium stimulating it to contract when no ventricular depolarization is sensed (D).
(A, B, and C) do not provide accurate information.
Awarded 1.0 points out of 1.0 possible points.
7. 8.ID: 310946602
The nurse completes visual inspection of a client's abdomen. What technique should the
nurse perform next in the abdominal examination?
o Percussion.
, o Auscultation. Correct
o Deep palpation.
o Light palpation.
Auscultation (B) of the client's abdomen is performed next because manual manipulation
(A, C, and D) can stimulate the bowel and create false sounds heard during auscultation.
Awarded 1.0 points out of 1.0 possible points.
8. 9.ID: 310962725
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary
colostomy, the nurse determines that the client's stoma is dry and dark red in color. What
action should the nurse implement?
o Notify the surgeon. Correct
o Document the assessment.
o Secure a colostomy pouch over the stoma.
o Place petrolatum gauze dressing over the stoma.
The stoma should appear reddish pink and moist, which indicates circulatory perfusion to
the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark
red or purple, the stoma is ischemic, and the surgeon should be notified immediately (A).
Although (B, C, and D) may be implemented, the findings require immediate medical
attention.
Awarded 1.0 points out of 1.0 possible points.
9. 10.ID: 310969487
The nurse is caring for a client with end stage liver disease who is being assessed for the
presence of asterixis. To assess the client for asterixis, what position should the nurse ask
the client to demonstrate?
o Extend the left arm laterally with the left palm upward.
o Extend the arm, dorsiflex the wrist, and extend the fingers. Correct
o Extend the arms and hold this position for 30 seconds.
o Extend arms with both legs adducted to shoulder width.
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen
frequently in hepatic encephalopathy. The tremor is induced by extending the arm and
dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist
while attempting to hold position (B). (A, C, and D) do not illicit axterixis.
Awarded 1.0 points out of 1.0 possible points.
10. 11.ID: 310993993
A client is admitted to the emergency department after being lost for four days while
hiking in a national forest. Upon review of the laboratory results, the nurse determines the
client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional
assessment should the nurse make?
o Body mass index.
