Medical Surgical Assessment A Questions With Complete
Solutions
A home health nurse is reinforcing teaching with a client about
preventing complications of peripheral vascular disease. Which
of the following statements indicates that the client is adhering
to the nurse's instructions?
A) "I apply rubbing alcohol to my feet every day to prevent
infection"
B) "I will wear clean, knee-high wool socks everyday to help
improve my circulation"
C) "I use hot water bottles to keep my feet warm at night"
D) "I don't cross my legs anymore" Correct Answers D) "I
don't cross my legs anymore"
Clients who have peripheral vascular disease should not cross
their legs because it can impede circulation.
A nurse enters the room of a client whose transfusion of packed
RBCs was initiated 15 min ago by the RN. The client reports
dyspnea and urticaria. Which of the following actions should the
nurse perform first?
A) Count the client's respiratory rate
B) Ask the client if chest pain is present
C) Stop the infusion
D) Administer an antihistamine Correct Answers C) Stop the
infusion
,Evidence-based practice indicates the nurse should stop the
infusion of the blood product as soon as manifestations occur
because they can indicate a transfusion reaction.
A nurse in a long-term care facility is collecting data from a
client who reports fullness in the rectum and abdominal
cramping. Which of the following findings should indicate to the
nurse that the client might have a fecal impaction?
A) Halitosis
B) Hemorrhoids
C) Rebound tenderness
D) Small liquid stools Correct Answers D) Small liquid stools
Small liquid stools can be the result of fecal material being
expelled around an impaction.
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 Answers 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 assisting a client who reports difficulty falling asleep.
Which of the following activities should the nurse recommend
to promote sleep?
A) Get out of bed if unable to fall asleep within 60 min.
B) Take a brisk walk before sleeping.
C) Listen to soft music before sleeping.
D) Drink adequate amounts of fluids before sleeping. Correct
Answers C) Listen to soft music before sleeping.
Listening to soft music can help the client to relax and reduces
environmental stressors.
A nurse is assisting in the care of a client who has
manifestations of sepsis. Which of the following provider
prescriptions should the nurse implement first?
A) Collect a sputum culture
B) Administer ceftriaxone by intermittent IV bolus
C) Initiate oxygen at 4 L/min via nasal cannula
D) Obtain blood cultures Correct Answers C) Initiate oxygen at
4 L/min via nasal cannula
When using the airway, breathing, circulation approach to client
care, the first action the nurse should take is to initiate oxygen.
Clients who have manifestations of sepsis are often hypoxic,
tachypneic, or have a PaCO2 level less than 32 mm Hg. The
nurse should provide supplemental oxygen to keep the client's
oxygen saturation levels at 95% or greater, which will maximize
, the ability of the hemoglobin to support the oxygen needs of the
body.
A nurse is assisting in the plan of care regarding bowel
retraining for a client who has a cervical spinal cord injury.
Which of the following interventions should the nurse plan to
implement first?
A) Determine the client's daily elimination habits.
B) Administer a suppository to the client 30 min prior to
defecation time.
C) Offer the client 4 oz of warm prune juice to promote
elimination.
D) Provide dietary bulk to the client to ease the passage of stool.
Correct Answers A) Determine the client's daily elimination
habits.
The first action the nurse should take using the nursing process
is to collect data on the client's daily bowel elimination habits to
establish a routine defecation time.
A nurse is assisting the charge nurse with developing an in-
service about caring for clients who have internal sealed
radiation implants. Which of the following information should
the nurse include?
A) Restrict the time pregnant women are allowed in the client's
room to 15 min
B) Pick up a radiation implant with a double-gloved hand if it
becomes dislodged
C) Limit time spent in the client's room to 2 hr during an 8 hr
shift
Solutions
A home health nurse is reinforcing teaching with a client about
preventing complications of peripheral vascular disease. Which
of the following statements indicates that the client is adhering
to the nurse's instructions?
A) "I apply rubbing alcohol to my feet every day to prevent
infection"
B) "I will wear clean, knee-high wool socks everyday to help
improve my circulation"
C) "I use hot water bottles to keep my feet warm at night"
D) "I don't cross my legs anymore" Correct Answers D) "I
don't cross my legs anymore"
Clients who have peripheral vascular disease should not cross
their legs because it can impede circulation.
A nurse enters the room of a client whose transfusion of packed
RBCs was initiated 15 min ago by the RN. The client reports
dyspnea and urticaria. Which of the following actions should the
nurse perform first?
A) Count the client's respiratory rate
B) Ask the client if chest pain is present
C) Stop the infusion
D) Administer an antihistamine Correct Answers C) Stop the
infusion
,Evidence-based practice indicates the nurse should stop the
infusion of the blood product as soon as manifestations occur
because they can indicate a transfusion reaction.
A nurse in a long-term care facility is collecting data from a
client who reports fullness in the rectum and abdominal
cramping. Which of the following findings should indicate to the
nurse that the client might have a fecal impaction?
A) Halitosis
B) Hemorrhoids
C) Rebound tenderness
D) Small liquid stools Correct Answers D) Small liquid stools
Small liquid stools can be the result of fecal material being
expelled around an impaction.
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 Answers 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 assisting a client who reports difficulty falling asleep.
Which of the following activities should the nurse recommend
to promote sleep?
A) Get out of bed if unable to fall asleep within 60 min.
B) Take a brisk walk before sleeping.
C) Listen to soft music before sleeping.
D) Drink adequate amounts of fluids before sleeping. Correct
Answers C) Listen to soft music before sleeping.
Listening to soft music can help the client to relax and reduces
environmental stressors.
A nurse is assisting in the care of a client who has
manifestations of sepsis. Which of the following provider
prescriptions should the nurse implement first?
A) Collect a sputum culture
B) Administer ceftriaxone by intermittent IV bolus
C) Initiate oxygen at 4 L/min via nasal cannula
D) Obtain blood cultures Correct Answers C) Initiate oxygen at
4 L/min via nasal cannula
When using the airway, breathing, circulation approach to client
care, the first action the nurse should take is to initiate oxygen.
Clients who have manifestations of sepsis are often hypoxic,
tachypneic, or have a PaCO2 level less than 32 mm Hg. The
nurse should provide supplemental oxygen to keep the client's
oxygen saturation levels at 95% or greater, which will maximize
, the ability of the hemoglobin to support the oxygen needs of the
body.
A nurse is assisting in the plan of care regarding bowel
retraining for a client who has a cervical spinal cord injury.
Which of the following interventions should the nurse plan to
implement first?
A) Determine the client's daily elimination habits.
B) Administer a suppository to the client 30 min prior to
defecation time.
C) Offer the client 4 oz of warm prune juice to promote
elimination.
D) Provide dietary bulk to the client to ease the passage of stool.
Correct Answers A) Determine the client's daily elimination
habits.
The first action the nurse should take using the nursing process
is to collect data on the client's daily bowel elimination habits to
establish a routine defecation time.
A nurse is assisting the charge nurse with developing an in-
service about caring for clients who have internal sealed
radiation implants. Which of the following information should
the nurse include?
A) Restrict the time pregnant women are allowed in the client's
room to 15 min
B) Pick up a radiation implant with a double-gloved hand if it
becomes dislodged
C) Limit time spent in the client's room to 2 hr during an 8 hr
shift
