Sample Review Questions in Medical and Surgical Nursing 1

 

 1. Which nursing intervention would be most appropriate for promoting the environmental safety of a client with a cognitive disorder?

A. Applying an identification bracelet on the clientB. Maintaining daily routine care for the clientC. Placing a clock and a daily schedule in the client’s roomD. Using short sentences with simple words when speaking with the client

Correct Answer: ARationale: Applying an identification bracelet on the client would be most effective in helping to ensure environmental and client safety should the client wander. Other measures include installing alarms; instituting injury, fire, and poisoning precautions; providing adequate lighting; and keeping the bed in a low position. Maintaining a daily routine would be helpful for ensuring consistency and promoting optimal functioning. Clocks and daily schedules would be helpful for reorienting the client and promoting optimal cognitive function. Using short sentences with simple words would be appropriate for maximizing effective communication.

 2. Which client complaint would lead the nurse to suspect premenstrual syndrome (PMS)?

A. Fatigue and weight gain on the day prior to mensesB. Headache and mood swings occurring about 10 days prior to mensesC. Mood swings and breast tenderness with the onset of mensesD. Painful menstruation and large menstrual flow

Correct Answer: BRationale: Typically, PMS is manifested by complaints of headache, mood swings, irritability, weight gain, fatigue, and full, tender breasts, occurring approximately 10 days before menses in each cycle. Painful menstruation and a large menstrual flow are not associated with PMS.

3. When disposing of the plastic bags, tubing, syringes, and gloves used to administer antineoplastic drugs, the nurse should implement which nursing intervention?

A. Avoiding contact with the equipment by allowing housekeeping to remove itB. Discarding all used equipment in a container marked “isolation”C. Disposing of all equipment in a container marked “bio-health hazard”D. Disposing of all used equipment in the regular trash receptacles

Correct Answer: CRationale: Any disposable equipment and supplies used for chemotherapy must be disposed of in a manner that protects the environment; placing the items in a container marked “bio-health

hazard” is appropriate because these containers can be incinerated at a temperature of 2,200 to 2,500° F so that there is no residue. Only personnel trained in the proper handling of antineoplastic agents should handle the wastes. Infectious waste is incinerated at 1,700 to 1,800° F; residue is possible after incineration at these temperatures, making it an inappropriate method for the disposal of antineoplastic equipment and supplies. Because the equipment has been contaminated with material that is carcinogenic, special precautions are required.

4. Which assessment data for a client who is 1 day postabdominal surgery would warrant immediate nursing intervention? 

A. Blood pressure of 110/70 mm Hg and hematocrit of 42%B. Complaints of abdominal pain as anC. Hypoactive bowel sounds and a serum potassium of 3.7 mEq/LD. Rigid, hard, boardlike abdomen and a white blood cell (WBC) count of 20,000 mm

Correct Answer: DRationale: One day after abdominal surgery, the client’s abdomen should be soft, not rigid or hard. Also, the WBC count may be slightly elevated in response to the surgery, but an elevation of 20,000 mmis highly suggestive of an infectious process. A rigid, boardlike abdomen in conjunction with a seriously elevated WBC count suggests peritonitis and requires immediate intervention. The client’s blood pressure and hematocrit are within normal limits. One day after surgery, abdominal incisional pain would be expected and often is rated as high when using a scale from 1 to 10. The client’s hemoglobin level is within normal limits. Hypoactive bowel sounds would be expected 1 day after abdominal surgery. The client’s potassium level is within normal limits.

 5. The nurse would include which nursing intervention for a client diagnosed with acute diverticulitis?

A. Administration of stimulant laxativesB. Increased fluid intakeC. Continuation of client’s nothing-by-mouth statusD. High-fiber dietCorrect Answer: CRationale: During an acute episode of diverticulitis, measures focus on resting the colon, such as keeping the client on nothing-by-mouth status, administering I.V. fluids, and maintaining nasogastric suctioning and bedrest. Administering stimulant laxatives may be appropriate for restoring the client’s normal bowel elimination, but their use during an acute attack would only serve to irritate the bowel further. Increased fluid intake would be appropriate for diverticulosis. A high-fiber diet would be indicated for diverticulosis, but this type of diet would not be appropriate during an acute attack.

 6. The nurse would include which nursing intervention in the care plan for a client with an L5-S1 intervertebral disc herniation?

A. Assessing the skeletal traction insertion sites for infectionB. Encouraging the client to ambulate as much as possibleC. Positioning the client with his knees slightly flexed and the head of bed elevatedD. Preparing the client for lumbar puncture

Correct Answer: CRationale: Positioning the client with the head of the bed elevated and his knees slightly flexed increases the disc space and may help to decrease the client’s pain. Skeletal traction is not a treatment of choice for a herniated disc. The client with an intervertebral disc herniation should be kept on bedrest. A lumbar puncture is not a diagnostic procedure for intervertebral disc herniation.

 7. A 16-year-old client asks the nurse, “What caused me to have acne?” Which statement would be the nurse’s best response?

A. “Acne is caused by an excess production of sebum.”B. “Acne is caused by not cleaning your face thoroughly every day.”C. “Eating lots of chocolate and candy causes you to have acne.”D. “The exact cause of acne is not really known.”

Correct Answer: DRationale: The exact cause of acne is not known, but evidence has shown that acne involves multiple factors, such as genetics, hormonal factors, and bacterial infections. Excess production of sebum results in seborrhea. Uncleanliness and dietary indiscretions, such as eating chocolate and candy, do not cause acne.

 8. Which intervention would most important in the prevention of pressure ulcers?

A. Applying external urine collection devicesB. Helping the client to maintain appropriate body positionC. Massaging reddened areas as soon as they are notedD. Turning the client every 2 hours

Correct Answer: DRationale: Turning the client frequently, such as every 2 hours, is one of the single most important interventions in preventing pressure ulcers because it helps to minimize the effects of pressure on the skin, allowing pressure to be redistributed with each turn. Applying an external urine collection device would be appropriate if the client is incontinent, but this action is not always relevant for every client and thus is not the most important. Helping the client to maintain appropriate body position is important, but it must be done in conjunction with frequent turning; maintaining body position without frequent turning would not be beneficial. Reddened areas should never be massaged because this increases tissue damage.

9. The client with a rectovaginal fistula is at high risk for infection. Which intervention would be the most important aspect of preventative nursing care?

 

A. Administering antibioticsB. Ensuring adequate rest to enhance healingC. Monitoring temperature and white blood cell (WBC) countD. Performing perineal hygiene, including irrigations

Correct Answer: DRationale: The client with a rectovaginal fistula may experience fecal drainage via the vagina; preventing infection by keeping the vaginal area clean with irrigation, douches, and sitz baths would be most important. Administering antibiotics and ensuring adequate rest may be useful in promoting healing, but they are not preventative measures. Monitoring for symptoms of infection is important, but perineal hygiene is more effective as a preventative measure.

 10. The client with a head injury is experiencing increased intracranial pressure (ICP). Which medication would the nurse anticipate administering?

A. Anticholinesterase agentsB. AnticonvulsantsC. Loop diureticsD. Osmotic diuretics

Correct Answer: DRationale: Osmotic diuretics such as mannitol are the preferred diuretic in the management of increased ICP to decrease cerebral edema and, therefore, decrease ICP. Anticholinesterase agents are used in the management of myasthenia gravis and are not helpful in decreasing ICP. Anticonvulsant medications would be used to treat seizure activity and are not helpful in decreasing ICP. Loop diuretics can be given in cases of increased ICP, but they are not a first-line agent.

Sample Review Questions on Medical and Surgical Nursing Part 1

1. Which intervention would the nurse anticipate as the initial action to be included in the care plan for a client experiencing a tension pneumothorax?

A. Application of on occlusive petroleum dressingB. Increasing the ventilator’s tidal volumeC. Obtaining a chest X-rayD. Removal of an occlusive dressing

Correct Answer: DRationale: A tension pneumothorax occurs when the pressure increases in the pleural space. Thus, removing an occlusive dressing will release the increased pressure in the pleural space

and help resolve the tension. Typically, the health care provider will insert a large bore needle initially and then a chest tube to aid in reinflating the lung. Applying an occlusive dressing will increase the pressure in the chest and worsen the tension pneumothorax. An occlusive dressing would be appropriate for an open pneumothorax. Increasing the tidal volume on the ventilator will increase the volume delivered to the chest, worsening the tension pneumothorax. The diagnosis of a tension pneumothorax is based on the client’s clinical presentation. It is a medical emergency that can quickly be fatal. Obtaining a chest X-ray wastes precious minutes that may permit the client to decompensate; it may be performed once the chest tube has been inserted and the initial build of pressure has been relieved.

2. When teaching a group of women about breast health awareness and breast self-examination (BSE) at a local community center, the nurse follows the American Cancer Society (ACS) recommendations. Which recommendation would the nurse include in the teaching program?

A. Bimonthly BSE and yearly mammograms beginning after the woman has had her first childB. Optional monthly BSE, yearly clinical examination, and yearly mammograms after age 40C. Quarterly BSE until the age of 70 after which breast health awareness is no longer necessaryD. Yearly BSE and follow up clinical examinations after onset of menses

Correct Answer: BRationale: The ACS recommends a yearly clinical examination and yearly mammograms in clients older than age 40. Monthly self-breast examination is an option for women starting in their 20s. The risk of breast cancer increases with age. At age 80, there is a 1 in 8 risk of developing breast cancer.

3. When providing postoperative care after a bowel resection to a client with a pre-existing history of chronic obstructive pulmonary disease (COPD) with frequent exacerbations, for which complication should the nurse be alert?

A. Acute respiratory failureB. Airway obstructionC. AtelectasisD. Pneumothorax

Correct Answer: ARationale: The client is at high risk for developing acute respiratory failure because of his history of chronic lung disease requiring frequent intubations, the anesthesia used during surgery, and the experience of surgery. Airway obstruction and atelectasis are postoperative complications, but there is no evidence that this client would be at greater risk for these complication than anyone else. The operative procedure and the client’s medical history would not place this client at a greater risk for postoperative pneumothorax as compared to any other postoperative client.

4. The nurse is doing preoperative teaching for a client about to have a mechanical valve replacement. Which client statement indicates effective teaching?

A. “I need to make sure I have someone to care for me after this same-day surgery procedure.”B. “I will always need to take anticoagulants to prevent the formation of blood clots.”C. “I will need to take several days of steroids each time I have major dental work done.”D. “Because my valve is from a pig, I need to take precautions to prevent rejection of the valve.”

Correct Answer: BRationale: Following mechanical valve replacement surgery, clients need to be educated about the need for lifelong oral anticoagulant therapy. (Povine or bovine valve replacements do not require anticoagulants.) Valve replacement surgery is not performed as a day surgery procedure; it requires that the client be admitted to a critical care unit for constant monitoring due to the potential for complications. Prophylactic antibiotics, not steroids, are needed after valve replacement surgery. Rejection of the artificial valve is not a major problem associated with valve replacement surgery.

5. Which collaborative intervention would be included in the care plan for a client with a venous stasis ulcer to assist with healing?

A. Antiembolism stockingsB. Plaster cast sockC. Transcutaneous electrical nerve stimulator (TENS)D. Unna boot

Correct Answer: DRationale: An Unna boot is medicated gauze applied to the affected limb from the toes to the knees after the ulcer is cleaned. The boot is then wrapped in plastic wrap and hardens like a cast promoting venous return and preventing stasis. Antiembolism stockings are fit tightly and can traumatize an ulcer when applied. A plaster cast sock is usually applied to a residual limb following amputation to reduce edema. TENS is used as a pain relief measure; it would have no effect on healing.

6. A client with pulmonary edema is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). When explaining to a student about the rationale for using PEEP, the nurse would indicate which rationale as its major purpose?

A. Allows the client to obtain needed restB. Increases pulmonary capillary pressureC. Improves area available for gas exchangeD. Increases the client’s carbon dioxide

Correct Answer: CRationale: PEEP helps keep the alveoli expanded, increasing the area available for gas exchange, thus improving the client’s oxygenation. PEEP has no effect on the client’s ability to rest, decreases pulmonary capillary pressure, and decreases the client’s carbon dioxide level by increasing the area for gas exchange.

7. The nurse teaches a client about residual limb care following an amputation and assesses that he understood the teaching when he demonstrates which behavior?

A. Applies lotions to keep the skin from crackingB. Elevates the residual limb on a pillow following surgeryC. Lies prone for several hours each dayD. Wraps the residual limb in adhesive bandages

Correct Answer: CRationale: Lying prone for several hours each day helps prevent hip contractures and demonstrates compliance with the treatment regimen. Using lotions keeps the skin soft; however, following an amputation, the skin needs to become tough. New guidelines recommend elevating the foot of the bed because a pillow can cause flexion contractures of the hip. Adhesive bandages irritate the skin, leading to sores, breakdown, and infection.

8. A client with a history of bigeminy who is on a lidocaine drip complains of light-headedness. Which intervention would the nurse implement

A. Calling the health care provider and getting a stat electrocardiogram (ECG)B. Checking the rhythm strip and assessing blood pressureC. Decreasing the lidocaine and instituting seizure precautionsD. Having the client lie down and administering atropine

Correct Answer: BRationale: Before doing anything else, the nurse needs to check the rhythm strip and assess the client’s blood pressure to determine the possible cause of the client’s complaints and gather additional data so that a full report can be made to the health care provider. An ECG is not needed for diagnosis of arrhythmia when a rhythm strip will suffice. The client is not exhibiting signs of lidocaine toxicity and, in fact, the lidocaine may need to be increased. Atropine is the drug of choice for sinus bradycardia, not premature ventricular contractions.

9. The nurse knows a client with chronic obstructive pulmonary disease (COPD) understands the discharge teaching when he makes which statement?

A. “I need to drink at least 2 liters of fluid every day.”B. “I need to take a sleeping pill every night so I wake up rested.”C. “I should do everything in the morning so I can rest later on.”D. “I should smoke only when I am not having difficulty breathing.”

Correct Answer: ARationale: Secretions are often very thick and difficult to expectorate for clients with COPD; drinking at least 2 liters of fluid per day will help to thin the secretions and aid in expectoration. Hypnotics and sedatives such as sleeping pills depress respirations and should be avoided. The client needs to pace himself and his activities to minimize energy expenditures and prevent exertion. The client should eliminate exposure to irritants such a smoking.

10. Which assessment finding indicates that furosemide (Lasix), a loop-diuretic, ordered for an elderly client is achieving its intended results?

A. +4 pitting edema in both legsB. Nontender calf muscles on palpationC. Relief of nocturnal leg crampingD. Systolic blood pressure of 150 mm Hg

Correct Answer: DRationale: Furosemide is commonly used as an initial step in treating hypertension. For the elderly client, a systolic blood pressure of 150 mm Hg would be considered normal and thus indicative that the drug therapy is effective. Pitting edema of +4 indicates that the drug is not achieving its intended result because fluid is still present; the client’s medication regime needs to be adjusted or changed. Furosemide has no effect on calf muscle; relief of tenderness in the calf is seen in deep vein thrombosis. Loop diuretics do not typically relieve cramps

Sample Review Questions on Medical and Surgical Nursing Part 2

1. When caring for a client with arterial occlusive disease of the extremities, what would the nurse include in the client’s teaching plan?

A. Changing positions frequently and elevating the legs above the heart to promote venous return in the legsB. Elevating the arm on a pillow with the elbow higher than the shoulder and the hand higher than the elbowC. Elevating the foot of the bed about 6″ (15.2 cm) while the client is sleeping to promote venous returnD. Keeping the legs in a dependent position in relationship to the heart to improve peripheral blood flow

Correct Answer: DRationale: The client with arterial occlusive disease needs to enhance the blood supply to the body parts affected; keeping legs in a dependent position in relationship to the heart to improve peripheral blood flow enhances the blood flow to the extremities. Changing positions frequently and elevating the legs above the heart to promote venous return in the legs should be included in teaching for the client with varicose veins. Elevating the arm on a pillow with the elbow higher than the shoulder and hand higher than the elbow helps to promote lymphatic drainage. Elevating the foot of the bed about 6″ while the client is sleeping to promote venous return is appropriate for the client with deep vein thrombosis.

2. While caring for a client with a new amputation, the dressing inadvertently comes off the stump. Which intervention should the nurse implement  first?

A. Bedside application of a large tourniquet to prevent massive hemorrhageB. Elevation of the limb above heart level to promote venous return

C. Maintenance of the client in a supine position to improve peripheral blood flowD. Immediate application of an elastic compression bandage wrapped around the limb

Correct Answer: DRationale: Because excessive edema will develop in a short time, resulting in delays in rehabilitation, the nurse should wrap the limb with an elastic compression bandage immediately. Before a tourniquet would be applied, the nurse would need to assess the client for signs and symptoms of bleeding because applying a tourniquet could compromise the circulatory and neurologic status of the limb. Elevating the limb above heart level could cause contractures; in this case, venous return is not a major concern. The supine position is contraindicated. The nurse needs to keep the stump elevated by raising the foot of the bed.

3. Which assessment finding would the nurse expect to assess in a client with emphysema?

A. Copious sputumB. Cor pulmonaleC. AnemiaD. Distant breath sounds

Correct Answer: DRationale: With emphysema, air trapping and chronic hyperexpansion of the lungs lead to distant breath sounds. Copious amounts of sputum are produced with chronic bronchitis; with emphysema, sputum production is usually scant. Cor pulmonale (right-sided heart failure) is more commonly associated with chronic bronchitis than emphysema. Polycythemia, an increase in red blood cells, may occur, but emphysema does not lead to anemia.

4. Following a thoracentesis, which assessment finding would warrant immediate intervention by the nurse?

A. Auscultation of crackles bilaterallyB. Complaints of pain at the needle insertion siteC. Prolonged periods of uncontrolled coughingD. Symmetrical respirations

Correct Answer: CRationale: Uncontrolled coughing in the client following a thoracentesis may indicate the development of pulmonary edema that requires immediate attention. Bilateral crackles may indicate underlying inflammation or congestion, but immediate attention is not necessary. Complaints of pain at the needle insertion site and symmetrical respirations are normal findings.

5. A client arrives in the emergency department following a motor vehicle accident with multiple injuries to the head, chest, and extremities with minimal bleeding. Which would the nurse assess first?

A. Airway statusB. Blood pressure

C. Level of consciousnessD. Quality of peripheral pulses

Correct Answer: A

Rationale: When dealing with an emergency, the ABCs — airway, breathing, and circulation — are the priorities and must be maintained first. Blood pressure, neurological, and neurovascular assessments are important, but in this case, airway is the priority.

6. A client receiving nasogastric tube feedings for the past 48 hours develops a hacking cough, a fever of 100.6° F (38.1° C), and is moderately dyspneic. Which complication would the nurse suspect?

A. Aspiration pneumoniaB. Chronic obstructive pulmonary disease (COPD)C. Pleural effusionD. Pneumoconioses

Correct Answer: ARationale: Nasogastric tube feedings may result in aspiration leading to pneumonia, suggested by the hacking cough, low-grade fever, and moderate dyspnea. Clients with COPD have a chronic cough and usually are afebrile. Clients with pleural effusion usually have no cough and are afebrile. Clients with pneumoconioses present with chronic cough and progressive dyspnea.

7. A client is admitted to the health care facility with a diagnosis of acute arterial occlusion. While performing a physical assessment, what would the nurse expect to observe?

A. CrampingB. ElephatismC. Phantom painD. Pulselessness

Correct Answer: DRationale: Pulselessness is one of the common manifestations of acute arterial occlusion secondary to cessation of blood flow distal to the occlusion. Cramping is a common complaint associated with varicose veins. Elephantism is an indication of secondary lymphedema. Phantom pain is pain noted following a limb amputation.

8. A client with leukemia is undergoing radiation therapy to the brain and spinal cord. In planning care for this client, the nurse would include which nursing intervention?

A. A scalp ointment to prevent dryness B. Avoiding washing off the target’s marksC. Not allowing the client to use a hat or scarfD. A dandruff shampoo twice daily

Correct Answer: BRationale: The marks made by the radiation oncologist guide the technician in configuring the external beam to irradiate the area in question without causing damage to other tissues. These marks must remain in place and should not be washed off. Ointments, which are petroleum-based, could cause a radiation burn to the area. The client should be encouraged to use a hat or scarf when in the sun to prevent damage to the scalp skin and at night to prevent loss of body heat through the scalp; hats and scarves also help to foster a positive body image. Dandruff shampoo includes harsh chemicals that could damage already fragile skin; the area being irradiated should be washed with water and the skin patted dry.

9. Which intervention would the nurse include in the teaching plan for a client diagnosed with gastroesophageal reflux disease (GERD)?

A. Avoiding eating within 2 hours of bedtimeB. Eating a high-fat, low-fiber dietC. Completing all antibioticsD. Sleeping with the head of the bed flat

Correct Answer: ARationale: Clients with GERD should avoid eating prior to retiring or lying down to decrease the incidence of reflux. The client with GERD will be prescribed a low-fat, high-fiber diet. Antibiotics are not used to treat GERD, although antibiotics are used for clients with <i>Helicobacter pylori</i> infection and peptic ulcer disease. The client with GERD should elevate the head on pillows or use blocks under the head of the bed to minimize reflux.

10. Which would the nurse include in the discharge teaching plan for an elderly client diagnosed with pneumonia?

A .Demonstration of postural drainage techniquesB. Demonstration of pursed lip breathingC. Discussion of proper use of oxygen therapyD. Instructions about increasing fluid intake

Correct Answer: DRationale: Pneumonia typically causes thick secretions that may be difficult for the elderly client to expectorate; increasing fluid intake will help thin secretions, ultimately aiding in their removal. Postural drainage usually is recommended for clients diagnosed with bronchitis and emphysema. Pursed lip breathing and oxygen therapy usually are recommended for clients with chronic obstructive pulmonary disease. A client with pneumonia typically does not require oxygen at home.

Sample Review Questions on Medical and Surgical Nursing Part 3

1. For a client receiving oral anticoagulant therapy for chronic atrial fibrillation, the nurse would be correct in withholding the medication if which assessment data is present?

A. Apical heart rate below 60 beats per minuteB. Elevated erythrocyte sedimentation rate (ESR)C. International Normalized Ratio (INR) above 5D. Partial thromboplastin time (PTT) of 25 seconds

Correct Answer: CRationale: The INR value for a client with chronic atrial fibrillation receiving oral anticoagulants should be kept between 2 and 3; any value above 3 would place the client at risk for hemorrhage, especially if anticoagulant therapy was continued. Anticoagulant therapy is given to prevent clots from forming in the atria. It should not be held related to heart rate. (Digoxin is sometimes held for heart rates below 60 beats per minute.) ESR is not an indicator of anticoagulant effectiveness and has no bearing on whether or not the drug should be held. Prothrombin time, not PTT, is used to monitor the effectiveness of oral anticoagulants; also, a PTT value of 25 seconds is considered within the normal range.

2. Which discharge teaching would be most appropriate to promote vasodilation in a client with arterial occlusion?

A. Mechanically squeezing the affected tissue

B. Using antiembolism stockingsC. Using warm water when bathingD. Walking with a heel-toe gait

Correct Answer: CRationale: Using warm water when bathing is helpful because heat causes vessels to dilate, thereby increasing blood flow; make sure that the client knows not to use hot water because of his decreased temperature sensation. Mechanical squeezing of the tissues is performed for lymphedema. Antiembolism hose are not indicated for use with arterial occlusions and should be avoided. Walking with a heel-toe gait is suggested for clients with deep vein thrombosis.

3. Which intervention should the nurse include in the discharge plan for a client who has experienced a myocardial infarction (MI)?

A. Assisting the client in planning for retirement activitiesB. Encouraging the client’s family to take a cardiopulmonary resuscitation (CPR) courseC. Instructing the client to have cardiac enzymes checked monthlyD. Teaching the client about food choices for a high-fiber, high-protein diet

Correct Answer: BRationale: Encouraging the client’s family to take a CPR course is important to ensure that the family is prepared to give CPR should the client experience another MI. The client should participate in a cardiac rehabilitation program, not plan for retirement activities. The nurse

should discuss ways to prevent complications secondary to coronary artery disease, but monthly testing of cardiac enzymes is unnecessary. Typically, a low-sodium, low-cholesterol, and low-fat diet is recommended after an MI. Although high fiber is encouraged to minimize straining with stool, protein intake does not need to be increased.

4. Which client statement would indicate a possible problem with peripheral vascular function?

A. “I can feel my heart beating in my abdomen when I am lying down.”B. “I get pain in my legs when I walk down the street more than two blocks.”C. “I often have pain near my upper right rib and back after eating a heavy meal.”D. “I stopped smoking last year, but I still have difficulty breathing sometimes.”

Correct Answer: BRationale: Complaints of pain in the legs with activity are a cardinal sign of arterial insufficiency. Reports of feeling the heart beating in the abdomen when lying down are commonly seen with aortic aneurysm. Complaints of pain in the right upper rib region and back, especially after eating a heavy meal, suggest biliary colic. Difficulty breathing even after smoking cessation may suggest pulmonary problems that are unrelated to peripheral vascular function.

5. A client diagnosed with pneumonia is experiencing pleuritic pain located on the right side of his chest. Which nursing intervention would be most appropriate for relieving the pain?

A. Administrating oxygen during episodes of painB. Encouraging the client to cough and deep-breatheC. Encouraging the client to lay on the right sideD. Giving an ordered opioid analgesic around the clock

Correct Answer: CRationale: Splinting the affected side, such as by having the client lie on the right side, restricts expansion and reduces friction between pleurae, which helps decrease the pain. Oxygen will not help relieve pain, but it will help to relieve dyspnea and hypoxemia. Coughing and deep-breathing is necessary, but these typically will increase the client’s pain, not relieve it. Opioid analgesics should be administered with caution to prevent depression of the cough reflex and respiratory drive.

6. Which electrocardiogram change would the nurse expect to assess in a client complaining of chest pain and experiencing myocardial ischemia?

A. Inverted T wavesB. Prolonged PR intervalsC. ST-segment elevationD. Widening QRS complexes

Correct Answer: ARationale: Inverted T waves are a sign of ischemic changes. Prolonged PR intervals signal a

delay in atrioventricular junction. ST-segment elevation suggests cardiac muscle injury. Widened QRS complexes suggest bundle-branch blocks and ventricular beats.

7. Which data would the nurse expect to assess in a client admitted with right-sided heart failure?

A. Heart sound and tachycardiaB. Decreased urinary output and restlessnessC. Nausea and anorexiaD. Orthopnea and crackles

Correct Answer: CRationale: In right-sided heart failure, the viscera and peripheral tissues become congested. Venous engorgement and venous stasis in the abdominal organs lead to nausea and anorexia in right-sided heart failure. A heart sound, tachycardia, decreased blood flow to the kidneys causing decreased urinary output, and restlessness due to impaired gas exchange and tissue oxygenation occur with left-sided heart failure. Congestion in the lungs in left-sided heart failure produces orthopnea and crackles.

8. Two days following insertion of a temporary demand pacemaker set at 60 beats per minute, the nurse assesses the client’s heart rate at 85 beats per minute. Which intervention should the nurse implement?

A. Further monitoring of the client’s vital signs as orderedB. Getting an electrocardiogram (ECG) to verify pacemaker captureC. Increasing the pacemaker setting to 70 beats per minuteD. Notifying the health care provider of possible pacer malfunction

Correct Answer: ARationale: The client’s pacemaker is a demand type pacemaker that senses the heart’s intrinsic rhythm; it will only function if the client’s own heart rate falls below the predetermined set rate. There is nothing wrong in this situation. Nothing should be changed and there is no need to contact the health care provider. Because the client’s heart rate is 85, the pacemaker will not fire and there will be no pacemaker spikes to see on an ECG. (However, if a problem occurs, the nurse would not change any settings without the health care provider’s order.)

9. Which instruction would the nurse include when teaching clients diagnosed with irritable bowel syndrome (IBS)?

A. Decrease fluid intake during meals.B. Eat a bland diet.C. Eat high-fiber, low gas-forming foods.D. Take antianxiety agents.

Correct Answer: CRationale: Clients with IBS should eat a high-fiber, low gas-producing diet and increase, not decrease, their fluid intake. No supportive evidence exists that a bland diet helps to alleviate the

symptoms of IBS. Stress can cause exacerbations of IBS, but administration of antianxiety agents is usually not necessary.

10. A client has a diagnosis of hypertension based on three systolic blood pressure readings above 90 mm Hg. Which data would the nurse expect to find on assessment?

A. Ankle edemaB. Bluish-white skinC. Chronic swollen limbsD. No abnormal symptoms

Correct Answer: DRationale: Hypertension usually produces no symptoms until vascular changes occur. Ankle edema is typically seen with varicose veins. Bluish-white skin is typically seen with frostbite. Chronic swollen limbs are associated with chronic venous insufficiency

Sample Review Question for Medical and Surgical Nursing Part 5

1. When auscultating the breath sounds of a client with bacterial pneumonia, the nurse would expect to find which assessment data?

A. Adventitious breath sounds with crackles and wheezesB. Bronchial breath sounds over consolidated lung fieldsC. Decreased breath sounds with crackles and a pleural friction rubD. Wheezing with expiration more prolonged than inspiration

Correct Answer: BRationale: In normal, clear lungs, bronchial breath sounds would be heard over the large airways and vesicular breath sounds would be heard over the clear lungs. With pneumonia, exudate fills the air spaces producing consolidation and bronchial breath sounds over these areas. Adventitious breath sounds, including crackles and wheezes, would be indicative of acute respiratory failure. Decreased breath sounds with crackles and a pleural friction rub would suggest a pulmonary embolism. Wheezing with expiration that is more prolonged than inspiration is indicative of chronic obstructive pulmonary disease.

2. When documenting the assessment finding of a client with emphysema who has an increase in the anteroposterior diameter of the chest, which term would the nurse use?

A. Barrel chestB. Flail chestC. Funnel chestD. Pigeon chest

Correct Answer: ARationale: Barrel chest is a term that refers to an increase in the anteroposterior diameter of the chest, resulting from overinflation of the lungs. A flail chest results from fractured ribs when a portion of the chest pulls inward upon inspiration. A funnel chest refers to a depression of the lower part of the sternum. A pigeon chest refers to an anterior displacement of the sternum protruding beyond the abdominal plane.

3. When caring for a client with a chest tube inserted in the right chest wall, which assessment data would lead the nurse to suspect that the client is experiencing a tension pneumothorax?

A. A cough with purulent sputumB. Frothy pink-tinged sputumC. Markedly decreased ventilation in the left lungD. Subcutaneous emphysema in the chest wall

Correct Answer: CRationale: Decreased ventilation in the opposite lung is indicative of a mediastinal shift, which leads to a tension pneumothorax. A cough with purulent sputum is usually seen in clients diagnosed with pneumonia. Hemoptysis is indicative of lung disease, such as pulmonary embolism and lung cancer. Subcutaneous emphysema, air accumulation in the tissues giving a crackling sensation when palpitated, is usually associated with chest trauma.

4. When evaluating risk for developing cancer, which client would the nurse identify as having the highest risk?

A. An asphalt road construction worker who eats meats and potatoesB. A new breast-feeding mother who works in a bankC. An oncology nurse who takes vitamins C and E dailyD. A vegetarian who works at a convenience store

Correct Answer: ARationale: Exposure to certain chemicals such as tar, soot, asphalt, oils, and sunlight put this occupation at the highest risk. Also, meats and potatoes are low in fiber, contributing to the risk of cancer. Plus, some processed meats contain chemicals that have been implicated in the development of cancer. Breast-feeding does not increase the client’s risk of developing cancer. Office work also is not considered a risk factor. Working with cancer clients does not increase a person’s risk for developing cancer. Vitamins C and E have been shown to demonstrate preventative attributes. A vegetarian diet is considered to be a healthier diet for deduction of cancer risk because it provides increased fiber. Cruciferous vegetables have been shown to be preventative. Working in a convenience store does not increase risk.

5. A client with a history of coronary artery disease begins to experience chest pain. After putting the client on bedrest and administering a nitroglycerin tablet sublingually, which intervention should the nurse implement first?

A. Calling the health care providerB. Checking the heart’s creatine kinase MB (CK-MB) levelC. Getting a 12-lead electrocardiogram (ECG)D. Preparing the client for angioplasty

Correct Answer: CRationale: For the client experiencing chest pain, obtaining a 12-lead ECG is a priority to reveal possible changes occurring during an acute anginal attack that will be helpful in treatment. Before calling the health care provider, the nurse should obtain the results of the 12-lead ECG so that these results can be communicated to him. A CK-MB level may be ordered later and the client may need angioplasty in the near future, but getting the 12-lead ECG during the chest pain is the most important priority.

6. Which signs and symptoms would alert the nurse to the possibility of a major complication in a client with pericarditis?

A. Crushing chest pain and diaphoresisB. Dyspnea and copious blood-tinged, frothy sputumC. Hypotension and muffled heart soundsD. Tachycardia and oliguria

Correct Answer: CRationale: A major complication associated with pericarditis is pericardial effusion or cardiac tamponade manifested by hypotension and muffled heart sounds. Crushing chest pain and diaphoresis are signs of myocardial infarction. Dyspnea and copious blood-tinged, frothy sputum are signs of acute pulmonary edema, a complication of left-sided heart failure. Tachycardia and oliguria are signs of hemorrhagic shock.

7. Which assessment finding would the nurse identify as indicative of a client’s altered peripheral vascular function?

A. Ankle arm index pressure of 0.4B. Capillary refill time of less than 3 secondsC. Diastolic blood pressure of 84 mm HgD. Pulses graded as being +4

Correct Answer: ARationale: The ankle arm index is an objective indicator of arterial disease. Normal value is 1.0. Values less than 0.5 indicate ischemic rest pain. A capillary refill time of less than 3 seconds is considered normal. A diastolic blood pressure of 84 mm Hg is considered within the normal range. Pulses graded as +4 are considered normal.

8. Which valvular disorder would the nurse suspect in a client presenting with fatigue, hemoptysis, and dyspnea on exertion?

A. Aortic insufficiencyB. Aortic stenosisC. Mitral insufficiencyD. Mitral stenosis

Correct Answer: DRationale: Mitral stenosis is an obstruction of blood flowing from the left atrium into the left ventricle, commonly manifested by progressive fatigue due to low cardiac output, hemoptysis, and dyspnea on exertion secondary to pulmonary venous hypertension. Aortic insufficiency refers to the backflow of blood from the aorta into the left ventricle during diastole; most clients are asymptomatic, except for a complaint of a forceful heartbeat. Aortic stenosis refers to a narrowing of the orifice between the left ventricle and the aorta; many clients experience no symptoms early on, but eventually develop exertional dyspnea, dizziness, and fainting. Mitral insufficiency refers to the backflow of blood from the left ventricle and aorta; many clients experience no symptoms early on, but eventually develop exertional dyspnea, dizziness, and fainting.

9. When developing a teaching plan for clients with chronic obstructive pulmonary disease (COPD) about the prevention of acute exacerbations, which topic should be included?

A. Administration of antibioticsB. Administration of oxygen as neededC. Performance of deep-breathing and coughing exercisesD. Elimination of exposure to pulmonary irritants

Correct Answer: DRationale: One aspect of exacerbation prevention focuses on eliminating the causes and contributory factors associated with COPD, such as pulmonary irritants (e.g., smoke, air pollution, occupational irritants, and allergies). Prevention would focus on eliminating these irritants. Antibiotics are used to treat bronchial infection during exacerbations, but they are not used prophylactically. Although oxygen is used in managing acute exacerbations, it is not a preventative measure. Coughing and deep breathing may help clients clear their airways and prevent further atelectasis, but they will not prevent exacerbation.

10. Which medication would the nurse expect the health care provider to order immediately for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD)?

A. A bronchodilatorB. A corticosteroidC. An anticoagulantD. An antitussive agent

Correct Answer: ARationale: Initially, for the client newly diagnosed with COPD, the health care provider would order a bronchodilator to open the airways and ease dyspnea. Corticosteroids may be ordered for the client with COPD, but they are usually used for acute exacerbations, not as an initial

drug. Anticoagulants interfere with the clotting cascade and would be ordered for a client with an embolic disorder such as pulmonary embolism. An antitussive agent would be used for the client with coughing, such as that occurring with pneumonia.

Sample questions in board. (Dec 2009)

1. A client is admitted to the hospital with findings of liver failure with ascites. The health care provider orders spironolactone (Aldactone). What is the pharmacological effect of this medication?

A)     Promotes sodium and chloride excretionB)     Increases aldosterone levelsC)     Depletes potassium reservesD)     Combines safely with antihypertensives

The correct answer is A: Promotes sodium and chloride excretionSpironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. It had no effect on ammonia levels.

2. A client has had a positive reaction to purified protein derivative (PPD). The client asks the nurse what this means. The nurse should indicate that the client has

A)     active tuberculosisB)     been exposed to mycobacterium tuberculosisC)     never had tuberculosisD)     never been infected with mycobacterium tuberculosis

The correct answer is B: been exposed to mycobacterium tuberculosisThe PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests are needed to determine if active tuberculosis is present.

3. The feeling of trust can best be established by the nurse during the process of the development of a nurse-client relationship by which of these characteristics?

A)     Reliability and kindnessB)     Demeanor and sincerityC)     Honesty and consistencyD)     Sympathy and appreciativeness

The correct answer is C: Honesty and consistencyCharacteristics of a trusting relationship include respect, honesty, consistency, faith and caring.

4. The nurse is providing care to a newly a hospitalized adolescent. What is the major threat experienced by the hospitalized adolescent?

A)     Pain managementB)     Restricted physical activityC)     Altered body imageD)     Separation from family

The correct answer is C: Altered body imageThe hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance during this developmental stage.

5. A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. What is the nurse’s best response?

A)     ”Your doctor will advise you about your risks.”B)     ”Unless you had previous problems, every 2 years is best.”C)     ”Once a woman reaches 50, she should have a mammogram yearly.”D)     ”Yearly mammograms are advised for all women over 35.”The correct answer is C: “Once a woman reaches 50, she should have a mammogram yearly.”

The American Cancer Society recommends a screening mammogram by age 40, every 1 – 2 years for women 40-49, and every year from age 50. If there are family or personal health risks, other assessments may be recommended.

6. In discharge teaching, the nurse should emphasize that which of these is a common side effect of clozapine (Clozaril) therapy?

A)     Dry mouthB)     RhinitisC)     Dry skinD)     Extreme salivation

The correct answer is D: Extreme salivationA significant number of clients receiving Clozapine (Clozaril) therapy experience extreme salivation.

7. A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to

A)     add dietary fiberB)     reduce ammonia levelsC)     stimulate peristalsisD)     control portal hypertension

The correct answer is B: reduce ammonia levelsLactulose blocks the absorption of ammonia from the GI tract and secondarily stimulates bowel elimination.

8. The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed?

A)     Ambivalence, dependence, demandingB)     Denial, projection, regressionC)     Intellectualization, rationalization, repressionD)     Identification, assimilation, withdrawal

The correct answer is B: Denial, projection, regressionHelplessness and hopelessness may contribute to regressive, dependent behavior which often occurs at any age with hospitalization. Denying or minimizing the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.

9. The nurse is caring for a client with a new order for bupropion (Wellbutrin) for treatment of depression. The order reads “Wellbutrin 175 mg. BID x 4 days.” What is the appropriate action?

A)     Give the medication as orderedB)     Question this medication doseC)     Observe the client for mood swingsD)     Monitor neuro signs frequently

The correct answer is B: Question this medication doseBupropion (Wellbutrin) should be started at 100mg BID for three days then increased to 150mg BID. When used for depression, it may take up to four weeks for results. Common side effects are dry mouth, headache, and agitation. Doses should be administered in equally spaced time increments throughout the day to minimize the risk of seizures.

10. A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is

A)     ”Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK.”

B)     ”The food has been prepared in our kitchen and is not poisoned.”C)     ”Let’s see if your partner could bring food from home.”D)     ”If you don’t eat, I will have to suggest for you to be tube fed.”

The correct answer is C: “Let’’s see if your partner could bring food from home.”Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise. Option D offers a logical response to a primarily affective concern. When the client’s condition has improved, gentle negation of the delusional premise can be employed.