ANSWER AND RATIONALE
MEDICAL SURGICAL NURSING PART I
1. Nurse Rene is caring for a client admitted to the hospital with suspected atelectasis. When assessing
this client, Nurse Rene would expect which of the following?
a. a respiration which is deep and slow
b. diminished breath sounds
c. an unproductive dry cough
d. normal body temperature
2. The physician ordered Nurse Manny to monitor a client for the complication of subcutaneous
emphysema after the insertion of chest tubes, the nurse should do which of the following?
a. assess for the presence of barrel shaped chest
b. auscultate for the presence of crackles
c. palpate for crepitus around chest tubes insertion site
d. assess inspirations and expiration for depth and length
3. Mr. B. age 45 with a long history of asthma is scheduled for surgery. Preoperative teaching by the nurse
should include the fact that Mr. B.:
a. will be prone to respiratory tract infection
b. can control and limit asthmatic attacks
c. should limit coughing to prevent chest distention
d. can control anxiety and ↓ severity of asthma attack
4. A nurse is preparing a discharge plan in the care of a client with COPD. The nurse should anticipate
which of the following? The client will:
a. develop infections easily
b. maintain current status
c. require less supplemental O2
d. will show permanent improvement
1. Ans. B
Rationale: Atelectasis involves collapsing of the alveoli distal to the bronchioles. Breath sounds will be
diminished in the lower lobes.
,2. Ans. C
Rationale: Subcutaneous emphysema occurs when air leaks from the intrapleural space through
thoracotomy or around the chest tube into the soft tissue
a. related to prolonged trapping of air in the alveoli asstd. With emphysema
b. unnecessary. Crackles occur in the lungs. Crepitus occur in soft tissues
d. inappropriate assessment for subcutaneous emphysema.
3. Ans. A
Rationale: Hypersecretion of mucous glands provides an excellent, warm, moist medium for
microorganisms
b. Asthma is not a disease that can be voluntarily controlled
c. Coughing must be encouraged, prevents retention of mucus, which is an excellent medium for
microorganism. Excessive secretions also limit gaseous exchange.
d. anxiety is not willfully controlled.
4. Ans. A.
Rationale: At high risk for development of respiratory infection
B & C. Unrealistic expectation because is slowly progressive.
D. Treatment may slow progression of the disease but permanent improvement is unlikely.
5. Manny, age 25 is admitted to the hospital for pneumonia. He has persistent cough and complains of
severe pain on coughing. Which of the following instructions should the nurse tell Manny to reduce the
discomfort he is having?
a. “Hold your cough as much as possible.”
b. “Keep the head of your bed flat to help with coughing.”
c. “Limit your intake of fluid to decrease the amount of sputum.”
d. “Splint your chest wall with a pillow for comfort.”
6. A client is admitted with severe dyspnea and hemoptysis. To facilitate maximum air exchange, the
client should be placed in which of the following positions?
a. supine c. high Fowler’s
b. orthopneic d. semi-Fowler’s
7. A client is admitted with suspected cancer of the lungs. A bronchoscopy is performed. After the
procedure, the client developed pleural effusion. The is most likely the result of which of the following?
a. excessive fluid intake
b. inadequate chest expansion
c. extension of cancerous lesions
d. irritation from the procedure
8. A nurse is caring for a client ordered for postural drainage To assist the client in obtaining maximum
benefits after the procedure, the nurse should do which of the following actions?
a. administer O2 ordered prn
b. place client in a sitting position
c. encourage client to cough deeply
, 9. Sputum analysis is ordered when a client with pneumonia expectorates green sputum. Which of the
following guideline should the nurse include in the teaching plan?
a. fluids will be restricted the night before the test
b. the client will be asked to take several deep abdominal breaths and then to take one more breath,
bend forward, and cough into the provided sterile container.
c. If bronchoscopy is required for specimen collection, the client will have no oral intake for 12 hours
before the procedure.
d. after the bronchoscopy, the client will receive a drink of water.
5. Ans. D
Rationale: This will help reduce the discomfort when coughing.
A. & B. May increase the discomfort and frequency of coughing
D. Promoting fluid intake is appropriate in this situation.
6. . Ans B Rationale: This is a sitting position that permits maximum lung expansion for gaseous exchange
because the abdominal organs do not provide pressure against the diaphragm and gravity facilitates the
descent of the diaphragm.
A. Does not permit the diaphragm to descent by gravity and pressure of abdominal organs against the
diaphragm limits its movement.
C. & D this position does not maximize lung expansion to the same degree as the orthopneic
position
7. Ans. C
Rationale: Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid
to that space.
A. excessive intake is normally balanced by urine output
b. inadequate chest expansion results from pleural effusion and not the cause of it
D. bronchoscopy does not involve the pleural space.
8. Ans. C
Rationale: Coughing is needed to raise the secretions for expectoration
A. O2 will not help mobilize secretions
B. Sitting allow secretions to remain in the lungs unless coughing is encouraged
C. Rest should be encouraged only after coughing to bring up secretions mobilized by postural drainage.
9. Ans. B.
Rationale: This is the most appropriate instruction for the procedure.
A. Client should be instructed to drink plenty of fluids before the test.
C. If specimen is taken during bronchoscopy, client should fast 6 hours before the procedure.
D. He can have fluids when gag reflex returns.
10. A client with pulmonary embolism is discharged but will remain on warfarin therapy for up to 6 months
for which of the following reasons?
a. prevent further embolism formation
b. minimize the growth of new or existing thrombi
c. continue to reduce the size of the pulmonary embolism
d. break up the existing embolism until it is totally gone.
11. A client is taking theophylline for the management of asthma. The nurse would advice the client to
MEDICAL SURGICAL NURSING PART I
1. Nurse Rene is caring for a client admitted to the hospital with suspected atelectasis. When assessing
this client, Nurse Rene would expect which of the following?
a. a respiration which is deep and slow
b. diminished breath sounds
c. an unproductive dry cough
d. normal body temperature
2. The physician ordered Nurse Manny to monitor a client for the complication of subcutaneous
emphysema after the insertion of chest tubes, the nurse should do which of the following?
a. assess for the presence of barrel shaped chest
b. auscultate for the presence of crackles
c. palpate for crepitus around chest tubes insertion site
d. assess inspirations and expiration for depth and length
3. Mr. B. age 45 with a long history of asthma is scheduled for surgery. Preoperative teaching by the nurse
should include the fact that Mr. B.:
a. will be prone to respiratory tract infection
b. can control and limit asthmatic attacks
c. should limit coughing to prevent chest distention
d. can control anxiety and ↓ severity of asthma attack
4. A nurse is preparing a discharge plan in the care of a client with COPD. The nurse should anticipate
which of the following? The client will:
a. develop infections easily
b. maintain current status
c. require less supplemental O2
d. will show permanent improvement
1. Ans. B
Rationale: Atelectasis involves collapsing of the alveoli distal to the bronchioles. Breath sounds will be
diminished in the lower lobes.
,2. Ans. C
Rationale: Subcutaneous emphysema occurs when air leaks from the intrapleural space through
thoracotomy or around the chest tube into the soft tissue
a. related to prolonged trapping of air in the alveoli asstd. With emphysema
b. unnecessary. Crackles occur in the lungs. Crepitus occur in soft tissues
d. inappropriate assessment for subcutaneous emphysema.
3. Ans. A
Rationale: Hypersecretion of mucous glands provides an excellent, warm, moist medium for
microorganisms
b. Asthma is not a disease that can be voluntarily controlled
c. Coughing must be encouraged, prevents retention of mucus, which is an excellent medium for
microorganism. Excessive secretions also limit gaseous exchange.
d. anxiety is not willfully controlled.
4. Ans. A.
Rationale: At high risk for development of respiratory infection
B & C. Unrealistic expectation because is slowly progressive.
D. Treatment may slow progression of the disease but permanent improvement is unlikely.
5. Manny, age 25 is admitted to the hospital for pneumonia. He has persistent cough and complains of
severe pain on coughing. Which of the following instructions should the nurse tell Manny to reduce the
discomfort he is having?
a. “Hold your cough as much as possible.”
b. “Keep the head of your bed flat to help with coughing.”
c. “Limit your intake of fluid to decrease the amount of sputum.”
d. “Splint your chest wall with a pillow for comfort.”
6. A client is admitted with severe dyspnea and hemoptysis. To facilitate maximum air exchange, the
client should be placed in which of the following positions?
a. supine c. high Fowler’s
b. orthopneic d. semi-Fowler’s
7. A client is admitted with suspected cancer of the lungs. A bronchoscopy is performed. After the
procedure, the client developed pleural effusion. The is most likely the result of which of the following?
a. excessive fluid intake
b. inadequate chest expansion
c. extension of cancerous lesions
d. irritation from the procedure
8. A nurse is caring for a client ordered for postural drainage To assist the client in obtaining maximum
benefits after the procedure, the nurse should do which of the following actions?
a. administer O2 ordered prn
b. place client in a sitting position
c. encourage client to cough deeply
, 9. Sputum analysis is ordered when a client with pneumonia expectorates green sputum. Which of the
following guideline should the nurse include in the teaching plan?
a. fluids will be restricted the night before the test
b. the client will be asked to take several deep abdominal breaths and then to take one more breath,
bend forward, and cough into the provided sterile container.
c. If bronchoscopy is required for specimen collection, the client will have no oral intake for 12 hours
before the procedure.
d. after the bronchoscopy, the client will receive a drink of water.
5. Ans. D
Rationale: This will help reduce the discomfort when coughing.
A. & B. May increase the discomfort and frequency of coughing
D. Promoting fluid intake is appropriate in this situation.
6. . Ans B Rationale: This is a sitting position that permits maximum lung expansion for gaseous exchange
because the abdominal organs do not provide pressure against the diaphragm and gravity facilitates the
descent of the diaphragm.
A. Does not permit the diaphragm to descent by gravity and pressure of abdominal organs against the
diaphragm limits its movement.
C. & D this position does not maximize lung expansion to the same degree as the orthopneic
position
7. Ans. C
Rationale: Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid
to that space.
A. excessive intake is normally balanced by urine output
b. inadequate chest expansion results from pleural effusion and not the cause of it
D. bronchoscopy does not involve the pleural space.
8. Ans. C
Rationale: Coughing is needed to raise the secretions for expectoration
A. O2 will not help mobilize secretions
B. Sitting allow secretions to remain in the lungs unless coughing is encouraged
C. Rest should be encouraged only after coughing to bring up secretions mobilized by postural drainage.
9. Ans. B.
Rationale: This is the most appropriate instruction for the procedure.
A. Client should be instructed to drink plenty of fluids before the test.
C. If specimen is taken during bronchoscopy, client should fast 6 hours before the procedure.
D. He can have fluids when gag reflex returns.
10. A client with pulmonary embolism is discharged but will remain on warfarin therapy for up to 6 months
for which of the following reasons?
a. prevent further embolism formation
b. minimize the growth of new or existing thrombi
c. continue to reduce the size of the pulmonary embolism
d. break up the existing embolism until it is totally gone.
11. A client is taking theophylline for the management of asthma. The nurse would advice the client to
