Medical Surgical Assessment A
A nurse is caring for a client who has a compound fracture of the femur and was placed
in balanced suspension skeletal traction 4 days ago. Which of the following actions
should the nurse take?
A) Perform pin site care daily
B) Remove the overbed trapeze
C) Remove the boot every 2 hr
D) Keep the weights on a stable, flat surface - ✔️✔️A) Perform pin site care daily
The nurse should perform pin site care daily with chlorhexidine solution or use a
solution according to facility protocol. The nurse should also monitor the pin sites for
manifestations of infection.
A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which
of the following actions should the nurse take?
A) Lower the side rails of the client's bed
B) Apply wrist restraints to the client
C) Position the client in the semi-Fowler's position
D) Loosen clothing around the client's neck - ✔️✔️D) Loosen clothing around the
client's neck
The nurse should loosen clothing around the client's neck to maintain an open airway
and prevent aspiration.
A nurse is assisting with the care of a client who had a cardiac catheterization via the
right femoral artery. Which of the following actions should the nurse take to prevent
postprocedure complications? (Select all)
A) Monitor the insertion site for bleeding
B) Position the affected extremity at a 45 degree angle
C) Restrict the client's fluid intake
D) Maintain the pressure dressing
E) Check the client's peripheral pulses - ✔️✔️A) Monitor the insertion site for bleeding
The nurse should monitor the client's insertion site for manifestations of hemorrhaging.
D) Maintain the pressure dressing.
,The nurse should maintain the client's pressure dressing to prevent hemorrhaging and
allow for the cannulation site to heal.
E) Check the client's peripheral pulses.
The nurse should assess the client's peripheral pulses to help identify signs of arterial
occlusion.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan
with an IV contrast agent. Which of the following laboratory findings should the nurse
report to the provider prior to the procedure?
A) Sodium 136 mEq/L
B) Potassium 4.8 mEq/L
C) Creatinine 1.9 mg/dL
D) Calcium 10 mg/dL - ✔️✔️C) Creatinine 1.9 mg/dL
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
should report the finding to the provider before the client has a CT scan with an IV
contrast agent. This finding places the client at risk for developing contrast-induced
nephropathy.
A nurse is monitoring a client who is taking acarbose. Which of the following findings
should the nurse identify as an adverse effect of the medication?
A) Polyuria
B) Abdominal cramps
C) Renal insufficiency
D) Insomnia - ✔️✔️B) Abdominal cramps
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the
client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects
of this medication.
A nurse is contributing to the plan of care for a client who has chronic obstructive
pulmonary disease (COPD) and is dyspneic. Which of the following interventions should
the nurse include in the plan?
A) Encourage abdominal breathing
B) Direct the client to inhale with pursed lips
C) Set the oxygen therapy at 5L/min
D) Instruct the client to lean back while coughing - ✔️✔️A) Encourage abdominal
breathing
, The nurse should encourage abdominal breathing, which reduces the workload on the
accessory muscles of respiration during dyspneic episodes.
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who
has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse
administer? (Round the answer to the nearest tenth. Use a leading zero is it applies. Do
not use a trailing zero. - ✔️✔️7mg/10 mg *1mL= 0.7 mL
A nurse is examining a client's IV site and notes a red line up his arm. The client reports
a throbbing, burning pain at the IV site. The nurse should identify that the client's
manifestations indicate which of the following complications of IV therapy?
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms - ✔️✔️A) Thrombophlebitis
The nurse should identify pain, warmth, and a red streak up the arm as indications of
thrombophlebitis.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following should the nurse include in the teaching?
A) Increase intake of fiber-rich foods
B) Take a laxative every morning
C) Maintain a fluid intake of 1200 mL per day
D) Limit activity to preserve energy - ✔️✔️A) Increase intake of fiber-rich foods
The nurse should instruct the client to increase the amount of fiber-rich foods in his diet.
Dried beans and brown rice are examples of fiber-rich foods.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is
taking dantrolene to manage muscle spasms. Which of the following interventions
should the nurse include?
A) Apply hot packs to the client's muscles
B) Schedule physical therapy in the afternoon
C) Encourage the client to complete ADLs
D) Administer valerian to promote sleep - ✔️✔️C) Encourage the client to complete
ADLs
The nurse should encourage the client to complete ADLs and provide assistance as
needed. Performing self-care increases the client's independence, strength, and level of
functioning.
A nurse is caring for a client who has a compound fracture of the femur and was placed
in balanced suspension skeletal traction 4 days ago. Which of the following actions
should the nurse take?
A) Perform pin site care daily
B) Remove the overbed trapeze
C) Remove the boot every 2 hr
D) Keep the weights on a stable, flat surface - ✔️✔️A) Perform pin site care daily
The nurse should perform pin site care daily with chlorhexidine solution or use a
solution according to facility protocol. The nurse should also monitor the pin sites for
manifestations of infection.
A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which
of the following actions should the nurse take?
A) Lower the side rails of the client's bed
B) Apply wrist restraints to the client
C) Position the client in the semi-Fowler's position
D) Loosen clothing around the client's neck - ✔️✔️D) Loosen clothing around the
client's neck
The nurse should loosen clothing around the client's neck to maintain an open airway
and prevent aspiration.
A nurse is assisting with the care of a client who had a cardiac catheterization via the
right femoral artery. Which of the following actions should the nurse take to prevent
postprocedure complications? (Select all)
A) Monitor the insertion site for bleeding
B) Position the affected extremity at a 45 degree angle
C) Restrict the client's fluid intake
D) Maintain the pressure dressing
E) Check the client's peripheral pulses - ✔️✔️A) Monitor the insertion site for bleeding
The nurse should monitor the client's insertion site for manifestations of hemorrhaging.
D) Maintain the pressure dressing.
,The nurse should maintain the client's pressure dressing to prevent hemorrhaging and
allow for the cannulation site to heal.
E) Check the client's peripheral pulses.
The nurse should assess the client's peripheral pulses to help identify signs of arterial
occlusion.
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan
with an IV contrast agent. Which of the following laboratory findings should the nurse
report to the provider prior to the procedure?
A) Sodium 136 mEq/L
B) Potassium 4.8 mEq/L
C) Creatinine 1.9 mg/dL
D) Calcium 10 mg/dL - ✔️✔️C) Creatinine 1.9 mg/dL
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse
should report the finding to the provider before the client has a CT scan with an IV
contrast agent. This finding places the client at risk for developing contrast-induced
nephropathy.
A nurse is monitoring a client who is taking acarbose. Which of the following findings
should the nurse identify as an adverse effect of the medication?
A) Polyuria
B) Abdominal cramps
C) Renal insufficiency
D) Insomnia - ✔️✔️B) Abdominal cramps
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the
client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects
of this medication.
A nurse is contributing to the plan of care for a client who has chronic obstructive
pulmonary disease (COPD) and is dyspneic. Which of the following interventions should
the nurse include in the plan?
A) Encourage abdominal breathing
B) Direct the client to inhale with pursed lips
C) Set the oxygen therapy at 5L/min
D) Instruct the client to lean back while coughing - ✔️✔️A) Encourage abdominal
breathing
, The nurse should encourage abdominal breathing, which reduces the workload on the
accessory muscles of respiration during dyspneic episodes.
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who
has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse
administer? (Round the answer to the nearest tenth. Use a leading zero is it applies. Do
not use a trailing zero. - ✔️✔️7mg/10 mg *1mL= 0.7 mL
A nurse is examining a client's IV site and notes a red line up his arm. The client reports
a throbbing, burning pain at the IV site. The nurse should identify that the client's
manifestations indicate which of the following complications of IV therapy?
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms - ✔️✔️A) Thrombophlebitis
The nurse should identify pain, warmth, and a red streak up the arm as indications of
thrombophlebitis.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following should the nurse include in the teaching?
A) Increase intake of fiber-rich foods
B) Take a laxative every morning
C) Maintain a fluid intake of 1200 mL per day
D) Limit activity to preserve energy - ✔️✔️A) Increase intake of fiber-rich foods
The nurse should instruct the client to increase the amount of fiber-rich foods in his diet.
Dried beans and brown rice are examples of fiber-rich foods.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is
taking dantrolene to manage muscle spasms. Which of the following interventions
should the nurse include?
A) Apply hot packs to the client's muscles
B) Schedule physical therapy in the afternoon
C) Encourage the client to complete ADLs
D) Administer valerian to promote sleep - ✔️✔️C) Encourage the client to complete
ADLs
The nurse should encourage the client to complete ADLs and provide assistance as
needed. Performing self-care increases the client's independence, strength, and level of
functioning.
