MEDICAL SURGICAL NURSING Q AND A
PHYSIOLOGICAL INTEGRITY
(ELIMINATION)
1. What would be the priority of care for a client who presents with nausea,
diarrhea, muscle weakness, and an abnormal ECG and is taking
aldactone, zestril, and glucotrol?
a. Evaluate the potassium level.
b. Evaluate the sodium level.
c. Review the importance of eating bananas.
d. Assess for signs and symptoms of dehydration.
Correct (a) Aldactone is a potassium sparing diuretic, and when given
with zestril, there is a potential problem with hyperkalemia. Option b, is
inaccurate. Option c, is high in potassium and could contribute to the
complication of hyperkalemia. While option d is appropriate, it is not a
priority to option a. Since the client has already developed an abnormal
ECG, it is apparent there is alteration in the fluid and electrolytes.
2. An order has been received to obtain a consent for an intravenous
pyelogram (IVP). The most important information for the nurse to obtain is:
a. color of urine
b. renal history
c. last bowel movement
d. iodine sensitivity
Correct (d) The fluoroscopic exam of the urinary tract is visualized after
an injection of a radiopaque dye. People who have iodine sensitivity
may have an allergic reaction. Although options a, b, and c, are
important in the overall assessment, they do not specifically address
iodine sensitivity.
3. Which assessment would be most appropriate for monitoring a client state
of hydration?
a. Daily weight
b. I&O
c. Skin turgor
d. Characteristic of lips and mucous membranes.
Correct (a) Daily weight is the most appropriate evaluation out of these
options. It is the most measurable. While options b, c, and d are
correct, they are not a priority to option a.
4. Upon auscultation of a clients bowel sounds, the nurse notes soft gurgling
sounds occurring every 5 -20 seconds. This indicates:
, a. excessive intestinal motility
b. reduced intestinal peristalsis
c. normal sounds
d. rapid gastric emptying.
Correct (c) option c, is the correct description of bowel sounds, options
a, b, and d all reflect abnormal bowel sounds related to hypo or
hypermotility of the GI tract.
5. A client expresses concern as to what to expect during a gastroscopy. The
nurse would explain that the client.
a. may feel fullness in the throat and a sense of gagging during the
test
b. should be able to speak during the procedure.
c. Will need no sedation to provide anesthesia.
d. Will be able to eat or drink immediately following the procedure.
Correct (a) the gastroscopy is a semi-flexible tube which when inserted
into the esophagus will cause gagging. Option b and c are incorrect
because the client will not be able to communicate verbally during the
procedure and is usually provided with a sedative to relieve anxiety
an d facilitate insertion of the tube. Option d, is incorrect because the
clients throat is anesthetized. Fluids and food should be withheld for at
least 2 to 4 hours until the gag reflex returns.
6. Which nursing observation would relate to a postoperative complication
in the client with postoperative ileostomy?
a. The ileostomy does not require daily irrigations to maintain function.
b. The stoma appears tight and there is a decreased amount of stool
c. An impaction appears to be forming in the distal anal area.
d. A weight gain of 5 pounds related to increased fluid retention.
Correct (b) if there is a decrease in flow of stool in an ileostomy, along
with changes in the appearance of the stoma stricture. Option a , is
incorrect because ileostomies are not irrigated. Option c, is incorrect
because the anal area is not functional. Option d, is related to cardiac
or renal problems.
7. A client with a permanent colostomy on the transverse colon questions the
nurse as to whether or not he will ever be able to establish bowel control.
The nursing response would be based on which concept?
a. There is little chance that the client will gain adequate control with
this colostomy.
b. Control may be achieved with colostomy irrigations twice a day.
c. Daily colostomy irrigations and diet are frequently used to maintain
colostomy control.
, d. A high residue diet that provides bulk to the stool may be used to
maintain bowel control.
Correct (c) diet and irrigations are the common methods used for
colostomy control. Option a, is incorrect because clients gradually are
able to control and adapt to their individual bowel because irrigation of
the colostomy is usually needed only once a day. Option d, is incorrect
because diet may assist in control but cannot be used alone and
irrigation are more successful.
8. A client on chemotherapy has a WBC count of 1,200/mm. Based on this
data, which nursing action should be taken first?
a. Check temperature q 4h.
b. Monitor urine output
c. Assess for bleeding gums.
d. Obtain an order for blood cultures.
Correct (a) it is important to monitor for infection which would be
evidenced by an elevated temperature in a client who has such a low
WBC count. Option b is important to monitor because of problems of
increased uric acid excretion from chemo therapeutic drugs but in not
applicable to this situation. Option c, would be associated with a low
platelet count. Option d, would be secondary to option a.
9. Which of the following statements, if made by a client with oliguric renal
failure, would indicate a need for further teaching?
a. I will only eat processed foods in moderation
b. I must limit the amount of salt I eat.
c. I won’t eat pickles and green olives anymore
d. I will use a salt substitute instead of table salt.
Correct (d) option d, is correct. Many salt substitutes contain potassium
and could lead to hyperkalemia in clients with renal failure. This must
be clarified with the client. Options a, b, and c, indicate an
understanding by the client of the need to limit sodium intake.
10. A client is to receive cimetidine ( Tagamet) 300 mg PO QID and Mylanta.
The reason for administering these drugs at least 1 hour apart is:
a. both drugs act to coat the stomach lining.
b. Antacids have no effect on absorption of cimetidine.
c. Antacids enhance absorption of cimetidine.
d. Antacids interfere with absorption of cimetidine.
Correct (d) antacids interfere with absorption of several drugs. Care
should be taken when scheduling them with drugs such as cimetidine
PHYSIOLOGICAL INTEGRITY
(ELIMINATION)
1. What would be the priority of care for a client who presents with nausea,
diarrhea, muscle weakness, and an abnormal ECG and is taking
aldactone, zestril, and glucotrol?
a. Evaluate the potassium level.
b. Evaluate the sodium level.
c. Review the importance of eating bananas.
d. Assess for signs and symptoms of dehydration.
Correct (a) Aldactone is a potassium sparing diuretic, and when given
with zestril, there is a potential problem with hyperkalemia. Option b, is
inaccurate. Option c, is high in potassium and could contribute to the
complication of hyperkalemia. While option d is appropriate, it is not a
priority to option a. Since the client has already developed an abnormal
ECG, it is apparent there is alteration in the fluid and electrolytes.
2. An order has been received to obtain a consent for an intravenous
pyelogram (IVP). The most important information for the nurse to obtain is:
a. color of urine
b. renal history
c. last bowel movement
d. iodine sensitivity
Correct (d) The fluoroscopic exam of the urinary tract is visualized after
an injection of a radiopaque dye. People who have iodine sensitivity
may have an allergic reaction. Although options a, b, and c, are
important in the overall assessment, they do not specifically address
iodine sensitivity.
3. Which assessment would be most appropriate for monitoring a client state
of hydration?
a. Daily weight
b. I&O
c. Skin turgor
d. Characteristic of lips and mucous membranes.
Correct (a) Daily weight is the most appropriate evaluation out of these
options. It is the most measurable. While options b, c, and d are
correct, they are not a priority to option a.
4. Upon auscultation of a clients bowel sounds, the nurse notes soft gurgling
sounds occurring every 5 -20 seconds. This indicates:
, a. excessive intestinal motility
b. reduced intestinal peristalsis
c. normal sounds
d. rapid gastric emptying.
Correct (c) option c, is the correct description of bowel sounds, options
a, b, and d all reflect abnormal bowel sounds related to hypo or
hypermotility of the GI tract.
5. A client expresses concern as to what to expect during a gastroscopy. The
nurse would explain that the client.
a. may feel fullness in the throat and a sense of gagging during the
test
b. should be able to speak during the procedure.
c. Will need no sedation to provide anesthesia.
d. Will be able to eat or drink immediately following the procedure.
Correct (a) the gastroscopy is a semi-flexible tube which when inserted
into the esophagus will cause gagging. Option b and c are incorrect
because the client will not be able to communicate verbally during the
procedure and is usually provided with a sedative to relieve anxiety
an d facilitate insertion of the tube. Option d, is incorrect because the
clients throat is anesthetized. Fluids and food should be withheld for at
least 2 to 4 hours until the gag reflex returns.
6. Which nursing observation would relate to a postoperative complication
in the client with postoperative ileostomy?
a. The ileostomy does not require daily irrigations to maintain function.
b. The stoma appears tight and there is a decreased amount of stool
c. An impaction appears to be forming in the distal anal area.
d. A weight gain of 5 pounds related to increased fluid retention.
Correct (b) if there is a decrease in flow of stool in an ileostomy, along
with changes in the appearance of the stoma stricture. Option a , is
incorrect because ileostomies are not irrigated. Option c, is incorrect
because the anal area is not functional. Option d, is related to cardiac
or renal problems.
7. A client with a permanent colostomy on the transverse colon questions the
nurse as to whether or not he will ever be able to establish bowel control.
The nursing response would be based on which concept?
a. There is little chance that the client will gain adequate control with
this colostomy.
b. Control may be achieved with colostomy irrigations twice a day.
c. Daily colostomy irrigations and diet are frequently used to maintain
colostomy control.
, d. A high residue diet that provides bulk to the stool may be used to
maintain bowel control.
Correct (c) diet and irrigations are the common methods used for
colostomy control. Option a, is incorrect because clients gradually are
able to control and adapt to their individual bowel because irrigation of
the colostomy is usually needed only once a day. Option d, is incorrect
because diet may assist in control but cannot be used alone and
irrigation are more successful.
8. A client on chemotherapy has a WBC count of 1,200/mm. Based on this
data, which nursing action should be taken first?
a. Check temperature q 4h.
b. Monitor urine output
c. Assess for bleeding gums.
d. Obtain an order for blood cultures.
Correct (a) it is important to monitor for infection which would be
evidenced by an elevated temperature in a client who has such a low
WBC count. Option b is important to monitor because of problems of
increased uric acid excretion from chemo therapeutic drugs but in not
applicable to this situation. Option c, would be associated with a low
platelet count. Option d, would be secondary to option a.
9. Which of the following statements, if made by a client with oliguric renal
failure, would indicate a need for further teaching?
a. I will only eat processed foods in moderation
b. I must limit the amount of salt I eat.
c. I won’t eat pickles and green olives anymore
d. I will use a salt substitute instead of table salt.
Correct (d) option d, is correct. Many salt substitutes contain potassium
and could lead to hyperkalemia in clients with renal failure. This must
be clarified with the client. Options a, b, and c, indicate an
understanding by the client of the need to limit sodium intake.
10. A client is to receive cimetidine ( Tagamet) 300 mg PO QID and Mylanta.
The reason for administering these drugs at least 1 hour apart is:
a. both drugs act to coat the stomach lining.
b. Antacids have no effect on absorption of cimetidine.
c. Antacids enhance absorption of cimetidine.
d. Antacids interfere with absorption of cimetidine.
Correct (d) antacids interfere with absorption of several drugs. Care
should be taken when scheduling them with drugs such as cimetidine
