Medical-Surgical Nursing 1 Final Exam Review –
Top Ǫuestions & Answers for Success
1.A caregiver assesses a client with a pelvic fracture. Which assessment finding should
the caregiver identify as a complication of this injury?
a. Hypertension
b. Constipation
c. Infection
d. Hematuria - - correct ans- -ANS: D
The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral
damage that may manifest as blood in the urine (hematuria) or stool. The caregiver should also
assess for signs of hemorrhage and hypovolemic shock, which include hypotension and
tachycardia. Constipation and infection are not complications of a pelvic fracture.
DIF: Applying/Application REF: 1069 KEY: Fracture| shock
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2.A caregiver cares for a client placed in skeletal traction. The client asks, "What is the
primary purpose of this type of traction?" How should the caregiver respond?
a. "Skeletal traction will assist in realigning your fractured bone."
b. "This treatment will prevent future complications and back pain."
c. "Traction decreases muscle spasms that occur with a fracture."
d. "This type of traction minimizes damage as a result of fracture treatment." - - correct ans-
-ANS: A
Skeletal traction pins or screws are surgically inserted into the bone to aid in bone
alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm,
,and prevent or correct deformity and tissue damage. These are not primary purposes of
skeletal traction.
DIF: Understanding/Comprehension REF: 1060
KEY: Fracture| traction| patient education
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3.A caregiver cares for a client in skeletal traction. The caregiver notes that the skin around the
client's pin sites is swollen, red, and crusty with dried drainage. Which action should the
caregiver take next?
a. Request a prescription to decrease the traction weight.
b. Apply an antibiotic ointment and a clean dressing.
c. Cleanse the area, scrubbing off the crusty areas.
d. Obtain a prescription to culture the drainage. - - correct ans- -ANS: D
These clinical manifestations indicate inflammation and possible infection. Infected pin
sites can lead to osteomyelitis and should be treated immediately. The caregiver should
obtain a culture and assess vital signs. The provider should be notified. By decreasing the
traction weight, applying a new dressing, or cleansing the area, the infection cannot be
significantly treated.
DIF: Applying/Application REF: 1060
KEY: Fracture| traction| infection
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4.A caregiver plans care for a client with epilepsy who is admitted to the hospital. Which
interventions should the caregiver include in this client's plan of care? (Select all that
apply.)
,a. Have suction equipment at the bedside.
b. Place a padded tongue blade at the bedside.
c. Permit only clear oral fluids.
d. Keep bed rails up at all times.
e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access. - - correct ans- -ANS: A, D, F
Oxygen and suctioning equipment with an airway must be readily available. The bed rails
should be up at all times while the client is in the bed to prevent injury from a fall if the
client has a seizure. If the client does not have an IV access, insert a saline lock, especially
for those clients who are at significant risk for generalized tonic-clonic seizures. The saline
lock provides ready access if IV drug therapy must be given to stop the seizure. Padded
tongue blades may pose a danger to the client during a seizure and should not be used.
Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The
client should be encouraged to eat a well-balanced diet and ambulate while in the
hospital.
5.A caregiver is teaching a client who has chronic headaches. Which statements about
headache triggers should the caregiver include in this client's plan of care? (Select all that
apply.)
a. "Increase your intake of caffeinated beverages."
b. "Incorporate physical exercise into your daily routine."
c. "Avoid all alcoholic beverages."
d. "Participate in a smoking cessation program."
e. "Increase your intake of fruits and vegetables." - - correct ans- -ANS: B, D, E
Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these
factors should be avoided. Clients are taught to eat a balanced diet and to get adequate
exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches
during the headache period.
, 6.A caregiver evaluates the results of diagnostic tests on a client's cerebrospinal fluid
(CSF). Which fluid results alerts the caregiver to possible viral meningitis? (Select all that
apply.)
a. Clear
b. Cloudy
c. Increased protein level
d. Normal glucose level
e. Bacterial organisms present
f. Increased white blood cells - - correct ans- -ANS: A, C, D
In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose
levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF.
In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to
be cloudy.
7.A caregiver assesses a client who is experiencing a cluster headache. Which clinical
manifestations should the caregiver expect to find? (Select all that apply.)
a. Ipsilateral tearing of the eye
b. Miosis
c. Abrupt loss of consciousness
d. Neck and shoulder tenderness
e. Nasal congestion
f. Exophthalmos - - correct ans- -ANS: A, B, E
Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal
congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck
and shoulder tenderness, and exophthalmos are not associated with cluster headaches.
8.A caregiver assesses a client who is experiencing an absence seizure. For which clinical
manifestations should the caregiver assess? (Select all that apply.)
a. Intermittent rigidity
Top Ǫuestions & Answers for Success
1.A caregiver assesses a client with a pelvic fracture. Which assessment finding should
the caregiver identify as a complication of this injury?
a. Hypertension
b. Constipation
c. Infection
d. Hematuria - - correct ans- -ANS: D
The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral
damage that may manifest as blood in the urine (hematuria) or stool. The caregiver should also
assess for signs of hemorrhage and hypovolemic shock, which include hypotension and
tachycardia. Constipation and infection are not complications of a pelvic fracture.
DIF: Applying/Application REF: 1069 KEY: Fracture| shock
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2.A caregiver cares for a client placed in skeletal traction. The client asks, "What is the
primary purpose of this type of traction?" How should the caregiver respond?
a. "Skeletal traction will assist in realigning your fractured bone."
b. "This treatment will prevent future complications and back pain."
c. "Traction decreases muscle spasms that occur with a fracture."
d. "This type of traction minimizes damage as a result of fracture treatment." - - correct ans-
-ANS: A
Skeletal traction pins or screws are surgically inserted into the bone to aid in bone
alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm,
,and prevent or correct deformity and tissue damage. These are not primary purposes of
skeletal traction.
DIF: Understanding/Comprehension REF: 1060
KEY: Fracture| traction| patient education
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3.A caregiver cares for a client in skeletal traction. The caregiver notes that the skin around the
client's pin sites is swollen, red, and crusty with dried drainage. Which action should the
caregiver take next?
a. Request a prescription to decrease the traction weight.
b. Apply an antibiotic ointment and a clean dressing.
c. Cleanse the area, scrubbing off the crusty areas.
d. Obtain a prescription to culture the drainage. - - correct ans- -ANS: D
These clinical manifestations indicate inflammation and possible infection. Infected pin
sites can lead to osteomyelitis and should be treated immediately. The caregiver should
obtain a culture and assess vital signs. The provider should be notified. By decreasing the
traction weight, applying a new dressing, or cleansing the area, the infection cannot be
significantly treated.
DIF: Applying/Application REF: 1060
KEY: Fracture| traction| infection
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4.A caregiver plans care for a client with epilepsy who is admitted to the hospital. Which
interventions should the caregiver include in this client's plan of care? (Select all that
apply.)
,a. Have suction equipment at the bedside.
b. Place a padded tongue blade at the bedside.
c. Permit only clear oral fluids.
d. Keep bed rails up at all times.
e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access. - - correct ans- -ANS: A, D, F
Oxygen and suctioning equipment with an airway must be readily available. The bed rails
should be up at all times while the client is in the bed to prevent injury from a fall if the
client has a seizure. If the client does not have an IV access, insert a saline lock, especially
for those clients who are at significant risk for generalized tonic-clonic seizures. The saline
lock provides ready access if IV drug therapy must be given to stop the seizure. Padded
tongue blades may pose a danger to the client during a seizure and should not be used.
Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The
client should be encouraged to eat a well-balanced diet and ambulate while in the
hospital.
5.A caregiver is teaching a client who has chronic headaches. Which statements about
headache triggers should the caregiver include in this client's plan of care? (Select all that
apply.)
a. "Increase your intake of caffeinated beverages."
b. "Incorporate physical exercise into your daily routine."
c. "Avoid all alcoholic beverages."
d. "Participate in a smoking cessation program."
e. "Increase your intake of fruits and vegetables." - - correct ans- -ANS: B, D, E
Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these
factors should be avoided. Clients are taught to eat a balanced diet and to get adequate
exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches
during the headache period.
, 6.A caregiver evaluates the results of diagnostic tests on a client's cerebrospinal fluid
(CSF). Which fluid results alerts the caregiver to possible viral meningitis? (Select all that
apply.)
a. Clear
b. Cloudy
c. Increased protein level
d. Normal glucose level
e. Bacterial organisms present
f. Increased white blood cells - - correct ans- -ANS: A, C, D
In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose
levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF.
In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to
be cloudy.
7.A caregiver assesses a client who is experiencing a cluster headache. Which clinical
manifestations should the caregiver expect to find? (Select all that apply.)
a. Ipsilateral tearing of the eye
b. Miosis
c. Abrupt loss of consciousness
d. Neck and shoulder tenderness
e. Nasal congestion
f. Exophthalmos - - correct ans- -ANS: A, B, E
Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal
congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck
and shoulder tenderness, and exophthalmos are not associated with cluster headaches.
8.A caregiver assesses a client who is experiencing an absence seizure. For which clinical
manifestations should the caregiver assess? (Select all that apply.)
a. Intermittent rigidity
