ADULT MEDICAL SURGICAL PRE-ASSESSMENT TEST
QUESTIONS WITH COMPLETE SOLUTIONS
1) A nurse is caring for a client who has HIV. Which of the following laboratory values
is the nurse's priority?
A) Positive Western blot test
B) CD4-T-cell count 180 cells/mm3
C) Platelets 150,000/mm3
D) WBC 5,000/mm3 -- Correct Answer ✔✔ CD4-T-cell count 180
cells/mm3
A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the
priority for the nurse to report to the provider.
2) A nurse is caring for a client who is 2 hr postoperative following a transurethral
resection of the prostate (TURP) gland. Which of the following assessments should
the nurse view to be an indication of a postoperative complication?
A) Output of burgundy colored urine
B) Pulse rate of 88/min
C) Oral temperature of 38.2° C (100.76° F)
, D) An urge to void despite having an indwelling urinary catheter -- Correct
Answer ✔✔ Output of burgundy colored urine
Output of burgundy colored urine may indicate venous bleeding, a potential
complication following a TURP. Should this occur, the nurse should inform the
provider and anticipate an order for increased CBI rate or manual irrigation of the
catheter.
3) When caring for a client with a chest tube, the nurse notes continuous bubbling in
the chest tube water seal chamber. What does this indicate?
A) An air leak.
B) A normal finding.
C) Lung re-expansion.
D) High suction setting. -- Correct Answer ✔✔ An air leak.
Continuous bubbling in the water seal chamber indicates an air leak. If this is
observed, the nurse should attempt to locate the source of the air leak and
intervene accordingly (tighten the connections, replace drainage system).
4) A nurse in a burn treatment center is caring for a client who is admitted with
severe burns to both lower extremities and is scheduled for an escharotomy. The
client's spouse asks the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
A) "Large incisions will be made in the eschar to improve circulation."
B) "This procedure involves placing the client into a shower and removing the
dead tissue."
C) "A piece of healthy skin will be removed from an unburned area and
grafted over the burned area."
QUESTIONS WITH COMPLETE SOLUTIONS
1) A nurse is caring for a client who has HIV. Which of the following laboratory values
is the nurse's priority?
A) Positive Western blot test
B) CD4-T-cell count 180 cells/mm3
C) Platelets 150,000/mm3
D) WBC 5,000/mm3 -- Correct Answer ✔✔ CD4-T-cell count 180
cells/mm3
A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely
immunocompromised and is at high risk for infection. Therefore, this value is the
priority for the nurse to report to the provider.
2) A nurse is caring for a client who is 2 hr postoperative following a transurethral
resection of the prostate (TURP) gland. Which of the following assessments should
the nurse view to be an indication of a postoperative complication?
A) Output of burgundy colored urine
B) Pulse rate of 88/min
C) Oral temperature of 38.2° C (100.76° F)
, D) An urge to void despite having an indwelling urinary catheter -- Correct
Answer ✔✔ Output of burgundy colored urine
Output of burgundy colored urine may indicate venous bleeding, a potential
complication following a TURP. Should this occur, the nurse should inform the
provider and anticipate an order for increased CBI rate or manual irrigation of the
catheter.
3) When caring for a client with a chest tube, the nurse notes continuous bubbling in
the chest tube water seal chamber. What does this indicate?
A) An air leak.
B) A normal finding.
C) Lung re-expansion.
D) High suction setting. -- Correct Answer ✔✔ An air leak.
Continuous bubbling in the water seal chamber indicates an air leak. If this is
observed, the nurse should attempt to locate the source of the air leak and
intervene accordingly (tighten the connections, replace drainage system).
4) A nurse in a burn treatment center is caring for a client who is admitted with
severe burns to both lower extremities and is scheduled for an escharotomy. The
client's spouse asks the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
A) "Large incisions will be made in the eschar to improve circulation."
B) "This procedure involves placing the client into a shower and removing the
dead tissue."
C) "A piece of healthy skin will be removed from an unburned area and
grafted over the burned area."
