N162 MEDICAL - SURGICAL SAMPLE 2 REVISION
MATERIAL WITH QUESTIONS AND ANSWERS, A+
GRADE EXPLANATIONS 2024/2025
1 . A few hours after returning to the surgical nursing unit, a
patient who has undergone a subtotal thyroidectomy develops
laryngeal stridor and a cramp in the right hand. Which action
will the nurse anticipate taking next?
a. Infuse IV calcium gluconate.
b. Suction the patients airway.
c. Prepare for endotracheal intubation.
d. Assist with emergency tracheostomy.: ANS: A
The patients clinical manifestations of stridor and cramping are
consistent with tetany caused by hypocalcemia resulting from damage
to the parathyroid glands during surgery. Endotracheal intubation or
tracheostomy may be needed if the calcium does not resolve the
stridor. Suctioning will not correct the stridor.
2. Which action should the nurse take first when caring for a
patient who has just arrived on the unit after a thyroidectomy?
a. Check the dressing for bleeding.
b. Assess respiratory rate and effort.
c.Take the blood pressure and pulse.
d. Support the patients head with pillows.: ANS: B
Airway obstruction is a possible complication after thyroidectomy
because of swelling or bleeding at the site or tetany, and the priority
nursing action is to assess the airway. The other actions also are part of
/ 41
,the standard nursing care post thyroidectomy but are not as high in
priority.
3. While assessing a patient who has just arrived in the post
anesthesia recovery unit (PACU) after a thyroidectomy, the nurse
obtains these data. Which information is most important to
communicate to the surgeon?
a. The patient is sleepy and hard to arouse.
b.The patient has increasing swelling of the neck.
1
c. The patient is complaining of 7110 incisional pain.
d.The patients cardiac monitor shows a heart rate of 112.: ANS:
B
The neck swelling may lead to respiratory difficulty, and rapid
intervention is needed to prevent airway obstruction. The incisional pain
should be treated but is not unusual after surgery. A heart rate of 1 12 is
not unusual in a patient who has been hyperthyroid and has just arrived
in the PACU from surgery. Sleepiness in the immediate postoperative
period is expected.
4. A patient is receiving 3% NaCI solution for correction of
hyponatremia. During administration of the solution, the most
important assessment for the nurse to monitor is
a. lung sounds.
b. urinary output.
c. peripheral pulses.
d. peripheral edema.: ANS: A
/ 41
, N162 MEDICAL - SURGICAL SAMPLE 2 REVISION
MATERIAL WITH QUESTIONS AND ANSWERS, A+
GRADE EXPLANATIONS 2024/2025
Hypertonic solutions cause water retention, so the patient should be
monitored for symptoms of fluid excess. Crackles in the lungs may
indicate the onset of pulmonary edema and are the most serious of the
symptoms of fluid excess listed. Bounding peripheral pulses, peripheral
edema, or changes in urine output also are important to monitor when
administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
5. The nurse has administered 3% saline to a patient with
hyponatremia.Which one of these assessment data will require
the most rapid response by the nurse?
a. The patients radial pulse is 105 beats/minute.
b.There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
d.There are crackles audible throughout both lung fields.: ANS: D
Crackles throughout both lungs suggest that the patient may be
experiencing pulmonary edema, a life-threatening adverse effect of
hypertonic solutions. The increased pulse rate and blood pressure and
the appearance of the urine also should be reported, but they are not as
dangerous as the presence of fluid in the alveoli. 6. The nurse in the
outpatient clinic who notes that a patient has a decreased magnesium
level should ask the patient about
a. daily alcohol intake.
b. intake of dietary protein.
/ 41
, c. multivitamin/mineral use.
d. use of over-the-counter (OTC) laxatives.: ANS: A
Hypomagnesemia is associated with alcoholism. Protein intake
would not have a significant effect on magnesium level. OTC
laxatives (such as milk of magnesia) and use of
multivitamin/mineral supplements would tend to increase
magnesium level. 7. A patient with renal failure who has been
taking aluminum hydroxide/magnesium hydroxide suspension
(Maalox) at home for indigestion is somnolent and has
decreased deep tendon reflexes. Which action should the nurse
take first?
a. Notify the patients health care provider.
b. Withhold the next scheduled dose of Maalox.
c. Review the magnesium level on the patients chart.
d. Check the chart for the most recent potassium level.: ANS: C
The patient has a history and symptoms consistent with
hypermagnesemia; the nurse should check the chart for a recent
serum magnesium level. Notification of the health care provider will
be done after the nurse knows the magnesium level. The Maalox
should be held, but more immediate action is needed to correct the
patients decreased deep tendon reflexes (DTRs) and somnolence.
Monitoring of potassium levels also is important for patients with
renal failure, but the patients current symptoms are not consistent
with hyperkalemia.
/ 41
MATERIAL WITH QUESTIONS AND ANSWERS, A+
GRADE EXPLANATIONS 2024/2025
1 . A few hours after returning to the surgical nursing unit, a
patient who has undergone a subtotal thyroidectomy develops
laryngeal stridor and a cramp in the right hand. Which action
will the nurse anticipate taking next?
a. Infuse IV calcium gluconate.
b. Suction the patients airway.
c. Prepare for endotracheal intubation.
d. Assist with emergency tracheostomy.: ANS: A
The patients clinical manifestations of stridor and cramping are
consistent with tetany caused by hypocalcemia resulting from damage
to the parathyroid glands during surgery. Endotracheal intubation or
tracheostomy may be needed if the calcium does not resolve the
stridor. Suctioning will not correct the stridor.
2. Which action should the nurse take first when caring for a
patient who has just arrived on the unit after a thyroidectomy?
a. Check the dressing for bleeding.
b. Assess respiratory rate and effort.
c.Take the blood pressure and pulse.
d. Support the patients head with pillows.: ANS: B
Airway obstruction is a possible complication after thyroidectomy
because of swelling or bleeding at the site or tetany, and the priority
nursing action is to assess the airway. The other actions also are part of
/ 41
,the standard nursing care post thyroidectomy but are not as high in
priority.
3. While assessing a patient who has just arrived in the post
anesthesia recovery unit (PACU) after a thyroidectomy, the nurse
obtains these data. Which information is most important to
communicate to the surgeon?
a. The patient is sleepy and hard to arouse.
b.The patient has increasing swelling of the neck.
1
c. The patient is complaining of 7110 incisional pain.
d.The patients cardiac monitor shows a heart rate of 112.: ANS:
B
The neck swelling may lead to respiratory difficulty, and rapid
intervention is needed to prevent airway obstruction. The incisional pain
should be treated but is not unusual after surgery. A heart rate of 1 12 is
not unusual in a patient who has been hyperthyroid and has just arrived
in the PACU from surgery. Sleepiness in the immediate postoperative
period is expected.
4. A patient is receiving 3% NaCI solution for correction of
hyponatremia. During administration of the solution, the most
important assessment for the nurse to monitor is
a. lung sounds.
b. urinary output.
c. peripheral pulses.
d. peripheral edema.: ANS: A
/ 41
, N162 MEDICAL - SURGICAL SAMPLE 2 REVISION
MATERIAL WITH QUESTIONS AND ANSWERS, A+
GRADE EXPLANATIONS 2024/2025
Hypertonic solutions cause water retention, so the patient should be
monitored for symptoms of fluid excess. Crackles in the lungs may
indicate the onset of pulmonary edema and are the most serious of the
symptoms of fluid excess listed. Bounding peripheral pulses, peripheral
edema, or changes in urine output also are important to monitor when
administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
5. The nurse has administered 3% saline to a patient with
hyponatremia.Which one of these assessment data will require
the most rapid response by the nurse?
a. The patients radial pulse is 105 beats/minute.
b.There is sediment and blood in the patients urine.
c. The blood pressure increases from 120/80 to 142/94.
d.There are crackles audible throughout both lung fields.: ANS: D
Crackles throughout both lungs suggest that the patient may be
experiencing pulmonary edema, a life-threatening adverse effect of
hypertonic solutions. The increased pulse rate and blood pressure and
the appearance of the urine also should be reported, but they are not as
dangerous as the presence of fluid in the alveoli. 6. The nurse in the
outpatient clinic who notes that a patient has a decreased magnesium
level should ask the patient about
a. daily alcohol intake.
b. intake of dietary protein.
/ 41
, c. multivitamin/mineral use.
d. use of over-the-counter (OTC) laxatives.: ANS: A
Hypomagnesemia is associated with alcoholism. Protein intake
would not have a significant effect on magnesium level. OTC
laxatives (such as milk of magnesia) and use of
multivitamin/mineral supplements would tend to increase
magnesium level. 7. A patient with renal failure who has been
taking aluminum hydroxide/magnesium hydroxide suspension
(Maalox) at home for indigestion is somnolent and has
decreased deep tendon reflexes. Which action should the nurse
take first?
a. Notify the patients health care provider.
b. Withhold the next scheduled dose of Maalox.
c. Review the magnesium level on the patients chart.
d. Check the chart for the most recent potassium level.: ANS: C
The patient has a history and symptoms consistent with
hypermagnesemia; the nurse should check the chart for a recent
serum magnesium level. Notification of the health care provider will
be done after the nurse knows the magnesium level. The Maalox
should be held, but more immediate action is needed to correct the
patients decreased deep tendon reflexes (DTRs) and somnolence.
Monitoring of potassium levels also is important for patients with
renal failure, but the patients current symptoms are not consistent
with hyperkalemia.
/ 41
