MED SURG 168 QUESTIONS AND
ANSWERS 2023 2024 UPDATED AND
VERIFIED
1. A nurse is caring for a client who has a new diagnosis of type 2 diabetes
mellitus and has a referral for a dietary consult. The client tells the nurse, "I
will have to eat whatever the dietitian tells me." Which of the following
statements by the nurse encourages the client's involvement in their plan of
care?
A. "I can assist you with making a list of foods you like for the dietitian."
B. "I understand that the dietary choices can seem overwhelming."
C. "Managing your diabetes will require you to make accommodations."D.
"The dietitian will provide you with the best food choices to manage your
diabetes.": A. "I can assist you with making a list of foods you like for the
dietitian."
2. A hospice nurse is planning care for a client who has lung cancer. Which
of the following statements should the nurse make to incorporate the
client's and family's cultural beliefs?
A. "You should limit discussing past events with the client."
B. "We will respect what is important to you."
C. "We will arrange all burial services."
D. "Grieving should not be done in front of the client.": B. "We will respect
what is important to you."
3. A patient is exhibiting an altered level of consciousness and is
unresponsive to verbal stimuli. To elicit a response from a painful stimulus,
the nurse would:
,A. Press down on the orbital area of the eye.
B. Pinch the trapezius muscle.
C. Use a 25-gauge needle.
D. Elicit a reflex with a reflex hammer.: B. Pinch the trapezius muscle.
4. A nurse is preparing to assist with an ocular irrigation for a client who had
a chemical splash to the left eye. Which of the following actions should the
nurse plan to take?
A. Irrigate the affected eye from the inner corner toward the outer corner.
B. Sit the client up with their head turned toward the right side.
C. Place a strip of pH paper under the upper lid of the affected eye.
D. Irrigate the affected eye using sterile water.: A. Irrigate the affected eye from
the inner corner toward the outer corner.
5. A nurse is caring for a client who has AIDS. Which of the following
isolation precautions should the nurse implement?
A. Droplet precautions
B. Standard precautions
C. Airborne precautions
D. Contact precautions: B. Standard precautions
6. A nurse is performing an abdominal assessment for a client. Which of the
following findings should the nurse identify as the priority?
A. Gurgling bowel sounds every 10 seconds
B. Centrally located umbilical protrusion
C. Abdominal distention during breathing
D. Rebound tenderness with palpation: D. Rebound tenderness with palpation
7. A charge nurse receives a call from the house supervisor requesting
room assignments for four new clients. Based on the admission
diagnoses, which of the following clients requires a private room?
,A. A client who has diabetes mellitus and is presenting with acute
ketoacido-sis
B. An older adult client who was admitted with aspiration pneumonia
C. A client who has a compound fracture of the right femur
D. A client who reports having fever, night sweats, and cough for 2 days: D.
A client who reports having fever, night sweats, and cough for 2 days
8. A nurse is caring for a group of clients. From which of the following
clients should the nurse obtain a blood pressure reading using only the left
extremity?
A. A client who has a peripherally inserted central catheter (PICC) in the left
arm
B. A client who has left-sided Bell's palsy
C. A client who has right-sided weakness due to Parkinson's disease
D. A client who has a right upper extremity arteriovenous fistula: D. A client
who has a right upper extremity arteriovenous fistula
9. A nurse is assessing a client who has increased intracranial pressure.
The nurse should recognize that which of the following is the first sign of
deteriorating neurological status?
A. Cheyne-Stokes respirations
B. Pupillary dilation
C. Altered level of consciousness
D. Decorticate posturing: C. Altered level of consciousness
10. A nurse is assessing a client who has myasthenia gravis. Which of the
following client statements should indicate to the nurse that the client needs
a referral for occupational therapy?
A. "I've been having problems with bladder control."
B. "I have difficulty swallowing food."
C. "I have a hard time with brushing my hair."
D. "I would rather be in a wheelchair than use a walker to get around.": C. "I
have a hard time with brushing my hair."
, 11. A nurse is providing discharge teaching for a client who is receiving
treatment for genital herpes. Which of the following statements by the client
indicates the effectiveness of the teaching?
A. "I should apply antibiotic ointment to the lesions."
B. "I should use natural skin condoms during sexual intercourse."
C. "I should expect my lesions to resolve in 6 weeks."
D. "I should expect to take my medication for 3 weeks.": D. "I should expect to
take my medication for 3 weeks."
12. A nurse is caring for a client who has acute angina. Which of the
following actions should the nurse take first?
A. Administer aspirin.
B. Measure blood pressure.
C. Administer nitroglycerin.
D. Initiate IV access.: C. Administer nitroglycerin.
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'm going to include more cantaloupe in my diet."
B. "I will check my pulse before I take the medication."
C. "I will try to limit foods that contain salt."
D. "I'll check my blood pressure so it doesn't get too high.": A. "I'm going to
include more cantaloupe in my diet."
14. A nurse is caring for a client who has a chest tube. The client asks why
the fluid in the water-seal chamber rises and falls. Which of the following
statements should the nurse make?
A. "This means your lung is fully re-expanded."
B. "Your breathing pattern causes this."
C. "Suction pressure that is too high causes this."
D. "This indicates a possible air leak.": B. "Your breathing pattern causes this."
15. A nurse is administering furosemide 80 mg PO twice daily to a client
who has pulmonary edema. Which of the following assessment findings
indicates to the nurse that the medication is effective?
ANSWERS 2023 2024 UPDATED AND
VERIFIED
1. A nurse is caring for a client who has a new diagnosis of type 2 diabetes
mellitus and has a referral for a dietary consult. The client tells the nurse, "I
will have to eat whatever the dietitian tells me." Which of the following
statements by the nurse encourages the client's involvement in their plan of
care?
A. "I can assist you with making a list of foods you like for the dietitian."
B. "I understand that the dietary choices can seem overwhelming."
C. "Managing your diabetes will require you to make accommodations."D.
"The dietitian will provide you with the best food choices to manage your
diabetes.": A. "I can assist you with making a list of foods you like for the
dietitian."
2. A hospice nurse is planning care for a client who has lung cancer. Which
of the following statements should the nurse make to incorporate the
client's and family's cultural beliefs?
A. "You should limit discussing past events with the client."
B. "We will respect what is important to you."
C. "We will arrange all burial services."
D. "Grieving should not be done in front of the client.": B. "We will respect
what is important to you."
3. A patient is exhibiting an altered level of consciousness and is
unresponsive to verbal stimuli. To elicit a response from a painful stimulus,
the nurse would:
,A. Press down on the orbital area of the eye.
B. Pinch the trapezius muscle.
C. Use a 25-gauge needle.
D. Elicit a reflex with a reflex hammer.: B. Pinch the trapezius muscle.
4. A nurse is preparing to assist with an ocular irrigation for a client who had
a chemical splash to the left eye. Which of the following actions should the
nurse plan to take?
A. Irrigate the affected eye from the inner corner toward the outer corner.
B. Sit the client up with their head turned toward the right side.
C. Place a strip of pH paper under the upper lid of the affected eye.
D. Irrigate the affected eye using sterile water.: A. Irrigate the affected eye from
the inner corner toward the outer corner.
5. A nurse is caring for a client who has AIDS. Which of the following
isolation precautions should the nurse implement?
A. Droplet precautions
B. Standard precautions
C. Airborne precautions
D. Contact precautions: B. Standard precautions
6. A nurse is performing an abdominal assessment for a client. Which of the
following findings should the nurse identify as the priority?
A. Gurgling bowel sounds every 10 seconds
B. Centrally located umbilical protrusion
C. Abdominal distention during breathing
D. Rebound tenderness with palpation: D. Rebound tenderness with palpation
7. A charge nurse receives a call from the house supervisor requesting
room assignments for four new clients. Based on the admission
diagnoses, which of the following clients requires a private room?
,A. A client who has diabetes mellitus and is presenting with acute
ketoacido-sis
B. An older adult client who was admitted with aspiration pneumonia
C. A client who has a compound fracture of the right femur
D. A client who reports having fever, night sweats, and cough for 2 days: D.
A client who reports having fever, night sweats, and cough for 2 days
8. A nurse is caring for a group of clients. From which of the following
clients should the nurse obtain a blood pressure reading using only the left
extremity?
A. A client who has a peripherally inserted central catheter (PICC) in the left
arm
B. A client who has left-sided Bell's palsy
C. A client who has right-sided weakness due to Parkinson's disease
D. A client who has a right upper extremity arteriovenous fistula: D. A client
who has a right upper extremity arteriovenous fistula
9. A nurse is assessing a client who has increased intracranial pressure.
The nurse should recognize that which of the following is the first sign of
deteriorating neurological status?
A. Cheyne-Stokes respirations
B. Pupillary dilation
C. Altered level of consciousness
D. Decorticate posturing: C. Altered level of consciousness
10. A nurse is assessing a client who has myasthenia gravis. Which of the
following client statements should indicate to the nurse that the client needs
a referral for occupational therapy?
A. "I've been having problems with bladder control."
B. "I have difficulty swallowing food."
C. "I have a hard time with brushing my hair."
D. "I would rather be in a wheelchair than use a walker to get around.": C. "I
have a hard time with brushing my hair."
, 11. A nurse is providing discharge teaching for a client who is receiving
treatment for genital herpes. Which of the following statements by the client
indicates the effectiveness of the teaching?
A. "I should apply antibiotic ointment to the lesions."
B. "I should use natural skin condoms during sexual intercourse."
C. "I should expect my lesions to resolve in 6 weeks."
D. "I should expect to take my medication for 3 weeks.": D. "I should expect to
take my medication for 3 weeks."
12. A nurse is caring for a client who has acute angina. Which of the
following actions should the nurse take first?
A. Administer aspirin.
B. Measure blood pressure.
C. Administer nitroglycerin.
D. Initiate IV access.: C. Administer nitroglycerin.
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'm going to include more cantaloupe in my diet."
B. "I will check my pulse before I take the medication."
C. "I will try to limit foods that contain salt."
D. "I'll check my blood pressure so it doesn't get too high.": A. "I'm going to
include more cantaloupe in my diet."
14. A nurse is caring for a client who has a chest tube. The client asks why
the fluid in the water-seal chamber rises and falls. Which of the following
statements should the nurse make?
A. "This means your lung is fully re-expanded."
B. "Your breathing pattern causes this."
C. "Suction pressure that is too high causes this."
D. "This indicates a possible air leak.": B. "Your breathing pattern causes this."
15. A nurse is administering furosemide 80 mg PO twice daily to a client
who has pulmonary edema. Which of the following assessment findings
indicates to the nurse that the medication is effective?
