MEDICAL SURGICAL ASSESSMENT EXAM NEWEST /
MEDICAL SURGICAL ASSESSMENT PREPARATION /
MEDIC, Exams of Nursing
A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the
perimeter, and bone is exposed. Which is the nurse's best action?
A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy. C
A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue
necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present.
When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential
intervention consists of débridement of the necrotic tissue and a possible graft to promote
healing.
The nurse is preparing to administer tube feedings through a client's new Salem sump
nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the
feeding. Which is the priority action of the nurse?
A) Start the tube feeding as ordered and check the residual in 30 minutes.
B) Inject air into the nasogastric tube while auscultating the client's epigastric area.
C) Lower the head of the client's bed and attempt to aspirate fluid again.
D) Obtain orders for a chest x-ray to confirm placement before starting the feeding. D
The nurse must verify tube placement before beginning any tube feeding or administering any
medications through a tube. The most accurate way to determine placement is via chest x-ray.
The nurse could cause the client to aspirate if she or he started the feeding then checked later
for placement. Insufflation does not provide accurate results and should not be used to verify
tube placement. The nurse must keep the client's head elevated at least 30 degrees.
A client has a urinary tract infection. Which assessment by the nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries C
1|Page
,Clients who are severely immune compromised or who have diabetes mellitus are more prone
to fungal urinary tract infection. The nurse should assess for these factors. A physical
examination and a post-void residual may be needed, but not until further information is
obtained. Travel to foreign countries probably would not be as important, because even if
exposed, the client needs some degree of immune compromise to develop a fungal urinary
tract infection.
When a diabetic patient asks about maintaining adequate blood glucose levels, which of the
following statements by the nurse relates most directly to the necessity of maintaining blood
glucose levels no lower than about 74 mg/dl?
A) "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce
ATP."
B) "The presence of glucose in the blood counteracts the formation of lactic acid and prevents
acidosis."
C) "The central nervous system cannot store glucose and needs a continuous supply of glucose
for fuel."
D) "Glucose is the only type of fuel used by body cells to produce the energy needed for
physiologic activity." C
The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply
from the body's circulation is needed to meet the fuel demands of the central nervous system.
The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks.
The client states that she is hungry all the time and doesn't understand why. Which assessment
finding could explain the client's weight gain and hunger?
A) The client's glycosylated hemoglobin level is 6%.
B) The client started taking dexamethasone (Decadron) daily.
C) The client started taking naproxen sodium (Naprosyn) daily.
D) The client's thyroxine (T4) level is 8 mcg/dL. B
Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid
metabolism, predisposing the client to obesity when taken on a long-term basis. In addition,
corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric
upset and ulceration and decreased appetite and weight loss. The client's glycosylated
hemoglobin and thyroid levels are within normal limits and would not explain the hunger and
weight gain.
2|Page
,The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which
interventions are appropriate? (Select all that apply.)
A) Use a rubber ring to decrease sacral pressure when up in the chair.
B) Place a small pillow between bony surfaces.
C) Keep the heels off the bed surfaces.
D) Use a lift sheet to assist with repositioning.
E) Reposition the client who is in a chair every 2 hours.
F) Elevate the head of the bed to 45 degrees.
G) Limit fluids and proteins in the diet. B,C,D
A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases
friction and shear, and heels have poor circulation and are at high risk for pressure sores, so
they should be kept off hard surfaces. Head of the bed elevation greater than 30 degrees
increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining
tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring
impairs capillary blood flow, increasing the risk for a pressure sore.
A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago
is brought to the intensive care unit. Which prescribed medication does the nurse prepare to
administer?
A) Tissue plasminogen activator
B) Heparin sodium
C) Warfarin (Coumadin)
D) Gabapentin (Neurontin) A
The client who has had a thrombotic stroke has a 3-hour time frame from the onset of
symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral
artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for
administration of this therapy. The other medications do not assist in the re-establishment of
blood flow for a client with a confirmed thrombotic stroke.
A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension.
Which is the priority nursing intervention?
A) Place the client in Trendelenburg position to facilitate blood flow to the heart.
B) Take the client's apical pulse for 1 full minute before drug administration.
C) Instruct the client to drink 3 L of fluid daily when taking this medication.
D) Educate the client to sit on the side of the bed for a few minutes before rising. D
3|Page
, Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension
with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a
few minutes to prevent hypotension-induced falls. No indication is known for assessment of the
apical pulse for 1 full minute before taking captopril. Placing the client in a Trendelenburg
position is not indicated. In case of a precipitous drop in blood pressure, a modified
Trendelenburg position may be used. Adequate fluid intake is necessary but is not the priority in
this situation.
A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse
monitor for in this client?
A) New-onset confusion
B) Repeated syncope
C) Abdominal distention
D) Spontaneous ecchymosis D
Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver
dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums,
and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention.
A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask,
gloves, and gown while administering drugs to the client. What is the nurse's best response?
A) "I am preventing the spread of infection from you to me or any other client here."
B) "The clothing protects me from accidentally absorbing these drugs."
C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask."
D) "These coverings protect you from getting an infection from me." B
Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result,
health care workers who prepare or give these drugs, especially nurses and pharmacists, are at
risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect
health. The Oncology Nursing Society and the Occupational Safety and Health Administration
(OSHA) have specific guidelines for using caution and wearing protective clothing whenever
preparing, giving, or disposing of chemotherapy drugs.
The earliest and most sensitive assessment finding that would indicate an alteration in
intracranial regulation would be:
A) change in level of consciousness.
B) unequal pupil size.
4|Page
MEDICAL SURGICAL ASSESSMENT PREPARATION /
MEDIC, Exams of Nursing
A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the
perimeter, and bone is exposed. Which is the nurse's best action?
A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy. C
A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue
necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present.
When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential
intervention consists of débridement of the necrotic tissue and a possible graft to promote
healing.
The nurse is preparing to administer tube feedings through a client's new Salem sump
nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the
feeding. Which is the priority action of the nurse?
A) Start the tube feeding as ordered and check the residual in 30 minutes.
B) Inject air into the nasogastric tube while auscultating the client's epigastric area.
C) Lower the head of the client's bed and attempt to aspirate fluid again.
D) Obtain orders for a chest x-ray to confirm placement before starting the feeding. D
The nurse must verify tube placement before beginning any tube feeding or administering any
medications through a tube. The most accurate way to determine placement is via chest x-ray.
The nurse could cause the client to aspirate if she or he started the feeding then checked later
for placement. Insufflation does not provide accurate results and should not be used to verify
tube placement. The nurse must keep the client's head elevated at least 30 degrees.
A client has a urinary tract infection. Which assessment by the nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries C
1|Page
,Clients who are severely immune compromised or who have diabetes mellitus are more prone
to fungal urinary tract infection. The nurse should assess for these factors. A physical
examination and a post-void residual may be needed, but not until further information is
obtained. Travel to foreign countries probably would not be as important, because even if
exposed, the client needs some degree of immune compromise to develop a fungal urinary
tract infection.
When a diabetic patient asks about maintaining adequate blood glucose levels, which of the
following statements by the nurse relates most directly to the necessity of maintaining blood
glucose levels no lower than about 74 mg/dl?
A) "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce
ATP."
B) "The presence of glucose in the blood counteracts the formation of lactic acid and prevents
acidosis."
C) "The central nervous system cannot store glucose and needs a continuous supply of glucose
for fuel."
D) "Glucose is the only type of fuel used by body cells to produce the energy needed for
physiologic activity." C
The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply
from the body's circulation is needed to meet the fuel demands of the central nervous system.
The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks.
The client states that she is hungry all the time and doesn't understand why. Which assessment
finding could explain the client's weight gain and hunger?
A) The client's glycosylated hemoglobin level is 6%.
B) The client started taking dexamethasone (Decadron) daily.
C) The client started taking naproxen sodium (Naprosyn) daily.
D) The client's thyroxine (T4) level is 8 mcg/dL. B
Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid
metabolism, predisposing the client to obesity when taken on a long-term basis. In addition,
corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric
upset and ulceration and decreased appetite and weight loss. The client's glycosylated
hemoglobin and thyroid levels are within normal limits and would not explain the hunger and
weight gain.
2|Page
,The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which
interventions are appropriate? (Select all that apply.)
A) Use a rubber ring to decrease sacral pressure when up in the chair.
B) Place a small pillow between bony surfaces.
C) Keep the heels off the bed surfaces.
D) Use a lift sheet to assist with repositioning.
E) Reposition the client who is in a chair every 2 hours.
F) Elevate the head of the bed to 45 degrees.
G) Limit fluids and proteins in the diet. B,C,D
A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases
friction and shear, and heels have poor circulation and are at high risk for pressure sores, so
they should be kept off hard surfaces. Head of the bed elevation greater than 30 degrees
increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining
tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring
impairs capillary blood flow, increasing the risk for a pressure sore.
A client who first experienced symptoms related to a confirmed thrombotic stroke 2 hours ago
is brought to the intensive care unit. Which prescribed medication does the nurse prepare to
administer?
A) Tissue plasminogen activator
B) Heparin sodium
C) Warfarin (Coumadin)
D) Gabapentin (Neurontin) A
The client who has had a thrombotic stroke has a 3-hour time frame from the onset of
symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the cerebral
artery occlusion and re-establish blood flow. Clients must meet eligibility criteria for
administration of this therapy. The other medications do not assist in the re-establishment of
blood flow for a client with a confirmed thrombotic stroke.
A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension.
Which is the priority nursing intervention?
A) Place the client in Trendelenburg position to facilitate blood flow to the heart.
B) Take the client's apical pulse for 1 full minute before drug administration.
C) Instruct the client to drink 3 L of fluid daily when taking this medication.
D) Educate the client to sit on the side of the bed for a few minutes before rising. D
3|Page
, Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension
with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a
few minutes to prevent hypotension-induced falls. No indication is known for assessment of the
apical pulse for 1 full minute before taking captopril. Placing the client in a Trendelenburg
position is not indicated. In case of a precipitous drop in blood pressure, a modified
Trendelenburg position may be used. Adequate fluid intake is necessary but is not the priority in
this situation.
A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse
monitor for in this client?
A) New-onset confusion
B) Repeated syncope
C) Abdominal distention
D) Spontaneous ecchymosis D
Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver
dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums,
and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention.
A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask,
gloves, and gown while administering drugs to the client. What is the nurse's best response?
A) "I am preventing the spread of infection from you to me or any other client here."
B) "The clothing protects me from accidentally absorbing these drugs."
C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask."
D) "These coverings protect you from getting an infection from me." B
Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result,
health care workers who prepare or give these drugs, especially nurses and pharmacists, are at
risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect
health. The Oncology Nursing Society and the Occupational Safety and Health Administration
(OSHA) have specific guidelines for using caution and wearing protective clothing whenever
preparing, giving, or disposing of chemotherapy drugs.
The earliest and most sensitive assessment finding that would indicate an alteration in
intracranial regulation would be:
A) change in level of consciousness.
B) unequal pupil size.
4|Page
