CORRECT MEDICAL SURGICAL
NURSING QUESTIONS AND ANSWERS
Oxygen saturation level should be betw 9een5 and 100%; nail beds should be pink
with capillary refill of about 3 seconds; and breath sounds should be present at base
of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The
trachea should be in midline with the sternal notch. The thorax should expand
equally on both sides.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess
most carefully for developing left-sided heart failure?
A) Middle-aged woman with aortic stenosis
B) Older woman who smokes cigarettes daily
C) Older man who has had a myocardial infarction
D) Middle-aged man with pulmonary hypertension - Answer-A
Although most people with heart failure will have failure that progresses from left to
right, it is possible to have left-sided failure alone for a short period. It is also possible
to have heart failure that progresses from right to left. Causes of left ventricular
failure include mitral or aortic valve disease, coronary artery disease (CAD), and
hypertension.
A client asks the nurse why it is important to be weighed every day if he has right-
sided heart failure. What is the nurse's best response?
A) "The hospital requires that all inpatients be weighed daily."
B) "Weight is the best indication that you are gaining or losing fluid."
C) "You need to lose weight to decrease the incidence of heart failure."
D) "Daily weights will help us make sure that you're eating properly." - Answer-B
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid
equals 2.2 pounds.
A patient states that his/her legs have pain with walking that decreases with rest.
The nurse observes absence of hair on the patient's lower leg and the patient has a
thready posterior tibial pulse. How would the nurse position the patient's legs?
A) Slightly bent with a pillow under the knees
B) Dependent position
C) Elevated
D) Crossed at the knee - Answer-B
A patient with arterial insufficiency is taught to position their legs in a dependent
position to use gravity to help perfuse the tissues. Crossing legs at the knee may
interfere with blood flow. Slightly bent legs do not enhance blood flow.
,The nurse is caring for a client with peripheral arterial disease. What priority nursing
intervention does the nurse perform to promote vasodilation?
A) Increase the client's exercise regimen daily.
B) Educate the client to abstain from smoking.
C) Apply a heating pad to the affected limb.
D) Administer an aspirin on a daily basis. - Answer-B
Smoking causes vasoconstriction, and its effects can last up to 1 hour after the
cigarette is finished. Increasing activity may lead to collateral circulation but does not
cause vasodilation. Use of a heating pad is contraindicated in the client with
peripheral artery disease because of the risk of a burn caused by diminished
sensation. The use of aspirin my impede platelet clumping and is contraindicated
only when the client is on anticoagulants.
Which statement by a patient indicates additional teaching is required about the
medication warfarin?
A) "I will increase the intake of green, leafy vegetables for a more healthful diet."
B) "I will restrict the intake of foods high in vitamin C."
C) "I will increase the amount of protein in my diet to protect my kidneys."
D) "I will continue my diabetic diet and restrict sugar." - Answer-A
Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an
anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the
amount of vitamin K is increased in the diet, the medication dose may need to be
adjusted. A diabetic diet would be continued as indicated for a patient receiving
warfarin. Vitamin C is not related to warfarin.
A client has been admitted to the intensive care unit with worsening pulmonary
manifestations of heart failure. What is the nurse's best action?
A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote rest and minimize activities.
D) Place the client in a high Fowler's position. - Answer-A
The client with worsening heart failure is most at risk for pulmonary edema as a
consequence of fluid retention. Administering diuretics will decrease the fluid
overload, thereby decreasing the incidence of pulmonary edema. High Fowler's
position might help the client breathe easier but will not solve the problem. CPR is
not warranted in this situation. Rest is important for clients with heart failure, but this
is not the priority.
What information about nutrition does the nurse teach a client with chronic
obstructive pulmonary disease (COPD)? (Select all that apply.)
A) "Eat dry foods rather than wet foods, which are heavier."
B) "Increase carbohydrate intake for energy."
,C) "Have about six small meals a day."
D) "Practice diaphragmatic breathing against resistance four times daily."
E) "Avoid drinking fluids just before and during meals."
F) "Eat high-fiber foods to promote gastric emptying."
G) "Rest before meals if you have dyspnea." - Answer-C, E, G
When describing patient education approaches, the nurse educator would explain
that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - Answer-C. Informal teaching is individualized one on
one teaching which represents the majority of patient education done by nurses that
occurs when an intervention is explained or a question is answered. Group needs
are often the focus of formal patient education courses or classes. Informal teaching
does not necessarily follow a specific formalized plan. It may be planned with
specific content, but it is individualized responses to patient needs. Formal teaching
involves the use of a curriculum/course plan with standardized content.
A patient expresses a strong interest in returning to their work, family, and hobbies
after having a stroke. Which theory type would the nurse use to develop a plan of
care for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic - Answer-C. Cognitive theorists believe that attention, relevance,
confidence, and satisfaction (ARCS) are the conditions that, when integrated,
motivate someone to learn. Field theorists place significance on how achievement,
power, the need for affiliation, and avoidance motives influence individual behavior.
Sociologic theories are not involved in motivation.
The nurse is assessing a group of clients. Which clients are at greater risk for
hypothermia or frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic - Answer-C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk
for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral
circulation have a higher incidence of frostbite.
Which statement made by a nurse represents the need for further education
regarding pain management in older adult clients?
a. older adults tend to report pain less often than younger adults
, b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much - Answer-
D
There is no evidence to support the idea that older adult clients perceive pain any
differently than younger clients. The other statements are accurate regarding older
clients and pain.
The nurse is working at a first aid booth for a spring training game on a hot day. A
spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F,
pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips
over his feet as the nurse leads him to a cot. What is the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink - Answer-C
The spectator shows signs of heat stroke, which is a medical emergency. The
spectator should be transported to the ED ASAP. The nurs should take actions to
lower his body temp in teh meantime by removing his shirt and sponging his body
with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen
is not as effective in an emergency situation. The client needs to be cooled quickly
and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of
dextrose 5% in 0.45% saline. The client states that the area around the IV site burns.
What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion - Answer-D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution
that contains the potassium and discontinue the IV altogether, in which case the
client would need another site started. Assessing for a blood return may or may not
be successful. The solution could be diluted (less potassium) and the rate could be
slowed once it is determined that the needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic situation
presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - Answer-D
NURSING QUESTIONS AND ANSWERS
Oxygen saturation level should be betw 9een5 and 100%; nail beds should be pink
with capillary refill of about 3 seconds; and breath sounds should be present at base
of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The
trachea should be in midline with the sternal notch. The thorax should expand
equally on both sides.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess
most carefully for developing left-sided heart failure?
A) Middle-aged woman with aortic stenosis
B) Older woman who smokes cigarettes daily
C) Older man who has had a myocardial infarction
D) Middle-aged man with pulmonary hypertension - Answer-A
Although most people with heart failure will have failure that progresses from left to
right, it is possible to have left-sided failure alone for a short period. It is also possible
to have heart failure that progresses from right to left. Causes of left ventricular
failure include mitral or aortic valve disease, coronary artery disease (CAD), and
hypertension.
A client asks the nurse why it is important to be weighed every day if he has right-
sided heart failure. What is the nurse's best response?
A) "The hospital requires that all inpatients be weighed daily."
B) "Weight is the best indication that you are gaining or losing fluid."
C) "You need to lose weight to decrease the incidence of heart failure."
D) "Daily weights will help us make sure that you're eating properly." - Answer-B
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid
equals 2.2 pounds.
A patient states that his/her legs have pain with walking that decreases with rest.
The nurse observes absence of hair on the patient's lower leg and the patient has a
thready posterior tibial pulse. How would the nurse position the patient's legs?
A) Slightly bent with a pillow under the knees
B) Dependent position
C) Elevated
D) Crossed at the knee - Answer-B
A patient with arterial insufficiency is taught to position their legs in a dependent
position to use gravity to help perfuse the tissues. Crossing legs at the knee may
interfere with blood flow. Slightly bent legs do not enhance blood flow.
,The nurse is caring for a client with peripheral arterial disease. What priority nursing
intervention does the nurse perform to promote vasodilation?
A) Increase the client's exercise regimen daily.
B) Educate the client to abstain from smoking.
C) Apply a heating pad to the affected limb.
D) Administer an aspirin on a daily basis. - Answer-B
Smoking causes vasoconstriction, and its effects can last up to 1 hour after the
cigarette is finished. Increasing activity may lead to collateral circulation but does not
cause vasodilation. Use of a heating pad is contraindicated in the client with
peripheral artery disease because of the risk of a burn caused by diminished
sensation. The use of aspirin my impede platelet clumping and is contraindicated
only when the client is on anticoagulants.
Which statement by a patient indicates additional teaching is required about the
medication warfarin?
A) "I will increase the intake of green, leafy vegetables for a more healthful diet."
B) "I will restrict the intake of foods high in vitamin C."
C) "I will increase the amount of protein in my diet to protect my kidneys."
D) "I will continue my diabetic diet and restrict sugar." - Answer-A
Foods such as green, leafy vegetables have high levels of vitamin K. Warfarin is an
anticoagulant that acts by interfering with vitamin K-dependent clotting factors. If the
amount of vitamin K is increased in the diet, the medication dose may need to be
adjusted. A diabetic diet would be continued as indicated for a patient receiving
warfarin. Vitamin C is not related to warfarin.
A client has been admitted to the intensive care unit with worsening pulmonary
manifestations of heart failure. What is the nurse's best action?
A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote rest and minimize activities.
D) Place the client in a high Fowler's position. - Answer-A
The client with worsening heart failure is most at risk for pulmonary edema as a
consequence of fluid retention. Administering diuretics will decrease the fluid
overload, thereby decreasing the incidence of pulmonary edema. High Fowler's
position might help the client breathe easier but will not solve the problem. CPR is
not warranted in this situation. Rest is important for clients with heart failure, but this
is not the priority.
What information about nutrition does the nurse teach a client with chronic
obstructive pulmonary disease (COPD)? (Select all that apply.)
A) "Eat dry foods rather than wet foods, which are heavier."
B) "Increase carbohydrate intake for energy."
,C) "Have about six small meals a day."
D) "Practice diaphragmatic breathing against resistance four times daily."
E) "Avoid drinking fluids just before and during meals."
F) "Eat high-fiber foods to promote gastric emptying."
G) "Rest before meals if you have dyspnea." - Answer-C, E, G
When describing patient education approaches, the nurse educator would explain
that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - Answer-C. Informal teaching is individualized one on
one teaching which represents the majority of patient education done by nurses that
occurs when an intervention is explained or a question is answered. Group needs
are often the focus of formal patient education courses or classes. Informal teaching
does not necessarily follow a specific formalized plan. It may be planned with
specific content, but it is individualized responses to patient needs. Formal teaching
involves the use of a curriculum/course plan with standardized content.
A patient expresses a strong interest in returning to their work, family, and hobbies
after having a stroke. Which theory type would the nurse use to develop a plan of
care for the best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic - Answer-C. Cognitive theorists believe that attention, relevance,
confidence, and satisfaction (ARCS) are the conditions that, when integrated,
motivate someone to learn. Field theorists place significance on how achievement,
power, the need for affiliation, and avoidance motives influence individual behavior.
Sociologic theories are not involved in motivation.
The nurse is assessing a group of clients. Which clients are at greater risk for
hypothermia or frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic - Answer-C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk
for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral
circulation have a higher incidence of frostbite.
Which statement made by a nurse represents the need for further education
regarding pain management in older adult clients?
a. older adults tend to report pain less often than younger adults
, b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much - Answer-
D
There is no evidence to support the idea that older adult clients perceive pain any
differently than younger clients. The other statements are accurate regarding older
clients and pain.
The nurse is working at a first aid booth for a spring training game on a hot day. A
spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F,
pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips
over his feet as the nurse leads him to a cot. What is the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink - Answer-C
The spectator shows signs of heat stroke, which is a medical emergency. The
spectator should be transported to the ED ASAP. The nurs should take actions to
lower his body temp in teh meantime by removing his shirt and sponging his body
with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen
is not as effective in an emergency situation. The client needs to be cooled quickly
and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of
dextrose 5% in 0.45% saline. The client states that the area around the IV site burns.
What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
c. document the finding
d. stop the IV infusion - Answer-D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution
that contains the potassium and discontinue the IV altogether, in which case the
client would need another site started. Assessing for a blood return may or may not
be successful. The solution could be diluted (less potassium) and the rate could be
slowed once it is determined that the needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic situation
presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - Answer-D
