MEDICAL SURGICAL ASSESSMENT A: QUESTIONS WITH
ACCURATE SOLUTIONS
A nurse is caring for a client who is 24 hr postoperative following abdominal surgery
and has an NG tube. Which of the following actions should the nurse plan to take to
decrease the risk of postoperative complications?
A) Offer sips of water to the client following oral care.
B) Massage the client's lower extremities with lotion every 2 hr.
C) Encourage the client to use an incentive spirometer every hour while awake.
D) Place one or two pillows beneath the client's knees while he is in bed. -- Correct
Answer ✔✔ C) Encourage the client to use an incentive spirometer every hour while
awake.
The nurse should assist the client to use the incentive spirometer in addition to
coughing and deep breathing every hour while awake for the first 24 hr postoperatively
and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the
client's alveoli and improve ventilation to prevent postoperative pneumonia.
A nurse is contributing to the plan of care for a client who is having difficulty eating
following a stroke. Which of the following interventions should the nurse plan to
implement first?
A) Collaborate with a dietitian.
B) Provide nutritional supplements.
C) Recommend a referral for a speech language pathologist.
D) Inform assistive personnel about proper positioning. -- Correct Answer ✔✔ C)
Recommend a referral for a speech language pathologist.
,The greatest risk to the client following a stroke is injury from aspiration. Therefore, the
first intervention the nurse should include in the plan of care is to recommend a referral
for a speech language pathologist. A speech language pathologist can conduct a swallow
study to determine the client's risk for aspiration, provide teaching to the client
regarding swallowing techniques, and recommend the consistency of foods and liquids.
A nurse is caring for a client who is in Buck's traction. Which of the following
interventions should the nurse perform to reduce skin breakdown?
A) Keep the skin dry and free of perspiration.
B) Use hot water and antibacterial soap to bathe the client.
C) Massage the skin over bony prominences to promote circulation.
D) Limit the use of moisturizers on the skin over bony prominences. -- Correct Answer
✔✔ A) Keep the skin dry and free of perspiration.
The nurse should not leave moisture on the skin for prolonged periods of time because
it can cause skin breakdown.
A nurse is reviewing the laboratory results of a client who has chronic kidney failure and
is receiving epoetin alfa. The nurse should identify that which of the following laboratory
values indicates the treatment is effective?
A) BUN 40 mg/dL
B) Hgb 11 g/dL
C) Urine specific gravity 1.035
D) Blood glucose 105 mg/dL -- Correct Answer ✔✔ B) Hgb 11 g/dL
Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in
increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the
epoetin alfa treatment is effective.
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new
prescription for baclofen. Which of the following instructions should the nurse include
in the teaching?
,A) Consume a low-purine diet.
B) Avoid stopping this medication suddenly.
C) Use chamomile tea to alleviate insomnia.
D) Take this medication on an empty stomach. -- Correct Answer ✔✔ B) Avoid
stopping this medication suddenly.
The nurse should instruct the client to avoid stopping baclofen suddenly because it can
result in adverse reactions, including seizures, paranoia, and hallucinations.
A nurse is performing an ECG on a client who is scheduled for surgery the following
morning. In which of the following locations should the nurse place the V1 electrode?
(Hotspots A,B,C,D) -- Correct Answer ✔✔ C is correct.
The nurse should identify that the V1 electrode should be placed in the 4th intercostal
space just to the right of the sternum. Correct placement of the electrodes is vital in
obtaining accurate information about the electrical activity of the heart.
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client
who has skin cancer. Which of the following information should the nurse include in the
teaching?
A) Mohs surgery is a horizontal shaving of thin layers of the tumor.
B) Mohs surgery uses liquid nitrogen to destroy the cancerous tissue.
C) Mohs surgery is the preferred treatment for melanoma skin cancer.
D) Mohs surgery is a palliative treatment for metastatic skin cancer. -- Correct Answer
✔✔ A) Mohs surgery is a horizontal shaving of thin layers of the tumor.
Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure,
which involves a horizontal shaving of thin layers of a tumor, has a high treatment rate.
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus
(MRSA) infection in a surgical wound. Which of the following information should the
nurse plan to share with visitors?
A) Visitors should call prior to visiting the client.
B) Visitors must don a gown and gloves prior to entering the client's room.
C) Visitors need to wear a mask when in close proximity to the client.
, D) Visitors may not bring fresh flowers into the client's room. -- Correct Answer ✔✔
B) Visitors must don a gown and gloves prior to entering the client's room.
The nurse should provide teaching to the visitors regarding the infection control
measures for a client who is on contact isolation precautions. Contact precautions
require visitors to put on a gown and gloves prior to entering the room of a client who
has MRSA to prevent the spread of infection.
A nurse is reinforcing teaching about dietary changes with a client who has
cardiovascular disease. Which of the following images indicates the type of cooking fat
the nurse should recommend the client use when preparing meals?
A) Butter
B) Coconut Oil
C) Olive Oil
D) Shortening -- Correct Answer ✔✔ C) Olive Oil
The nurse should instruct the client who has cardiovascular disease to consume foods
which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or
other vegetable oils, rather than foods that are high in saturated fat. The nurse should
reinforce that oils high in monounsaturated fats help decrease the client's cardiovascular
risk by lowering LDL cholesterol and triglyceride levels.
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which
of the following actions should the nurse take?
A) Keep the door of the client's room closed at all times.
B) Remove gloves after leaving the client's room.
C) Wear a mask when working within 1 m (3 feet) of the client.
D) Have a designated stethoscope in the client's room. -- Correct Answer ✔✔ D) Have
a designated stethoscope in the client's room.
The nurse should designate equipment to leave in the client's room to avoid cross-
contamination. The designated equipment should be disposed of or decontaminated
before leaving the client's room.
ACCURATE SOLUTIONS
A nurse is caring for a client who is 24 hr postoperative following abdominal surgery
and has an NG tube. Which of the following actions should the nurse plan to take to
decrease the risk of postoperative complications?
A) Offer sips of water to the client following oral care.
B) Massage the client's lower extremities with lotion every 2 hr.
C) Encourage the client to use an incentive spirometer every hour while awake.
D) Place one or two pillows beneath the client's knees while he is in bed. -- Correct
Answer ✔✔ C) Encourage the client to use an incentive spirometer every hour while
awake.
The nurse should assist the client to use the incentive spirometer in addition to
coughing and deep breathing every hour while awake for the first 24 hr postoperatively
and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the
client's alveoli and improve ventilation to prevent postoperative pneumonia.
A nurse is contributing to the plan of care for a client who is having difficulty eating
following a stroke. Which of the following interventions should the nurse plan to
implement first?
A) Collaborate with a dietitian.
B) Provide nutritional supplements.
C) Recommend a referral for a speech language pathologist.
D) Inform assistive personnel about proper positioning. -- Correct Answer ✔✔ C)
Recommend a referral for a speech language pathologist.
,The greatest risk to the client following a stroke is injury from aspiration. Therefore, the
first intervention the nurse should include in the plan of care is to recommend a referral
for a speech language pathologist. A speech language pathologist can conduct a swallow
study to determine the client's risk for aspiration, provide teaching to the client
regarding swallowing techniques, and recommend the consistency of foods and liquids.
A nurse is caring for a client who is in Buck's traction. Which of the following
interventions should the nurse perform to reduce skin breakdown?
A) Keep the skin dry and free of perspiration.
B) Use hot water and antibacterial soap to bathe the client.
C) Massage the skin over bony prominences to promote circulation.
D) Limit the use of moisturizers on the skin over bony prominences. -- Correct Answer
✔✔ A) Keep the skin dry and free of perspiration.
The nurse should not leave moisture on the skin for prolonged periods of time because
it can cause skin breakdown.
A nurse is reviewing the laboratory results of a client who has chronic kidney failure and
is receiving epoetin alfa. The nurse should identify that which of the following laboratory
values indicates the treatment is effective?
A) BUN 40 mg/dL
B) Hgb 11 g/dL
C) Urine specific gravity 1.035
D) Blood glucose 105 mg/dL -- Correct Answer ✔✔ B) Hgb 11 g/dL
Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in
increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the
epoetin alfa treatment is effective.
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new
prescription for baclofen. Which of the following instructions should the nurse include
in the teaching?
,A) Consume a low-purine diet.
B) Avoid stopping this medication suddenly.
C) Use chamomile tea to alleviate insomnia.
D) Take this medication on an empty stomach. -- Correct Answer ✔✔ B) Avoid
stopping this medication suddenly.
The nurse should instruct the client to avoid stopping baclofen suddenly because it can
result in adverse reactions, including seizures, paranoia, and hallucinations.
A nurse is performing an ECG on a client who is scheduled for surgery the following
morning. In which of the following locations should the nurse place the V1 electrode?
(Hotspots A,B,C,D) -- Correct Answer ✔✔ C is correct.
The nurse should identify that the V1 electrode should be placed in the 4th intercostal
space just to the right of the sternum. Correct placement of the electrodes is vital in
obtaining accurate information about the electrical activity of the heart.
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client
who has skin cancer. Which of the following information should the nurse include in the
teaching?
A) Mohs surgery is a horizontal shaving of thin layers of the tumor.
B) Mohs surgery uses liquid nitrogen to destroy the cancerous tissue.
C) Mohs surgery is the preferred treatment for melanoma skin cancer.
D) Mohs surgery is a palliative treatment for metastatic skin cancer. -- Correct Answer
✔✔ A) Mohs surgery is a horizontal shaving of thin layers of the tumor.
Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure,
which involves a horizontal shaving of thin layers of a tumor, has a high treatment rate.
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus
(MRSA) infection in a surgical wound. Which of the following information should the
nurse plan to share with visitors?
A) Visitors should call prior to visiting the client.
B) Visitors must don a gown and gloves prior to entering the client's room.
C) Visitors need to wear a mask when in close proximity to the client.
, D) Visitors may not bring fresh flowers into the client's room. -- Correct Answer ✔✔
B) Visitors must don a gown and gloves prior to entering the client's room.
The nurse should provide teaching to the visitors regarding the infection control
measures for a client who is on contact isolation precautions. Contact precautions
require visitors to put on a gown and gloves prior to entering the room of a client who
has MRSA to prevent the spread of infection.
A nurse is reinforcing teaching about dietary changes with a client who has
cardiovascular disease. Which of the following images indicates the type of cooking fat
the nurse should recommend the client use when preparing meals?
A) Butter
B) Coconut Oil
C) Olive Oil
D) Shortening -- Correct Answer ✔✔ C) Olive Oil
The nurse should instruct the client who has cardiovascular disease to consume foods
which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or
other vegetable oils, rather than foods that are high in saturated fat. The nurse should
reinforce that oils high in monounsaturated fats help decrease the client's cardiovascular
risk by lowering LDL cholesterol and triglyceride levels.
A nurse is contributing to the plan of care for a client who has a methicillin-resistant
Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which
of the following actions should the nurse take?
A) Keep the door of the client's room closed at all times.
B) Remove gloves after leaving the client's room.
C) Wear a mask when working within 1 m (3 feet) of the client.
D) Have a designated stethoscope in the client's room. -- Correct Answer ✔✔ D) Have
a designated stethoscope in the client's room.
The nurse should designate equipment to leave in the client's room to avoid cross-
contamination. The designated equipment should be disposed of or decontaminated
before leaving the client's room.
