Medical Surgical Nursing Answer Key

MEDICAL-SURGICAL NURSING INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item by making the box corresponding to the letter of your choice on the answer sheet provided. Situation: Mrs. de Vera, an 89-year-old widow, is admitted to a hospital because of Dehydration brought about by 2-day-history of LBM and occasional vomiting. She needs to be in bed because of her generalized weakness and occasional confusion and disorientation. 1.

From the knowledge of temperature regulation in the elderly, the nurse should: A. make sure that the environmental temperature is adequately controlled B. palpate the client’s skin periodically to assess for warmth C. place extra blanket at bedside in case she becomes cold especially at night D. do all of the above

2.

Mrs. De Vera is on diaper for urinary incontinence: A. necessitates frequent changes of diaper to preserve skin integrity B. prompts the nurse to request catheterization of the patient C. brings the body toxins out of the gastrointestinal system D. all of the above conditions are probable

3.

The nurse initiates a 2-hourly-turning schedule based on the knowledge that the underlying cause of bedsore formation is: A. altered skin turgor B. nutritional deficiency C. pressure D. vasoconstriction

4.

On diaper change, the nurse noted blister formation on an erythematous background of the sacral area; this is stage ____________of bedsore formation: A. ONE B. TWO C. THREE D. FOUR

Situation: Mr. Castro, a 67-year-old retired carpenter is admitted to the hospital because of anorexia and afternoon fever. 5.

Mr. Castro’s PPD tuberculin test yields an induration of 10mm that indicates that: A. an active disease is present B. he has been exposed to M. tuberculosis C. preventive treatment should be initiated D. reaction is doubtful, a repeat test is necessary

6.

Mr. Castro’s PPD tuberculin test result is confirmed by: A. a chest X-ray B. (+) AFB in sputum smears indurations C. repeat PPD test that yields>10mm D. (+) blood culture for M. tuberculosis

7.

Mr. Castro is started on quadruple drug regimen. Nursing management includes observing for ototoxicity and nephrotoxicity when _____is used: A. ETHAMBUTOL B. ISONIAZID C. RIFAMPICIN D. STREPTOMYCIN

8.

Mr. Castro is informed that he will no longer be considered infectious after: A. 1 week of treatment B. 2-3 weeks of treatment C. 2 months of treatment D. complete 6-9 treatment

Situation: Miko, a 19-year-old student nurse, is admitted to the hospital with a possible diagnosis of appendicitis. He has been vomiting every after meal. 9.

On assessment, the nurse is looking for positive indicators of appendicitis, which includes all of the following except: A. a low grade fever B. abdominal tenderness on palpation C. leukocytosis D. thrombocytopenia

10. The appendix is an accessory part of the: A. colon B. cecum

C. ileum D. Jejunum 11. Rebound tenderness is elicited by: A. palpating the left hypogastrium resulting in right hypogastric tenderness B. hip flexion or internal rotation of the hip joint C. pain relief on palpation and pain on release of pressure D. none of the above is the answer 12. To ensure a patent airway following a tonsillectomy, it is important for the nurse to: A. Place the client in semi-fowlers position B. Begin nasal oxygen at 4 L/min. C. Maintain strict bed rest D. Keep the head of the bed flat 13. To monitor the nutritional status of a total laryngectomy client, the nurse should include which of these actions in the plan of care: A. Monitor WBC count B. Observe activity tolerance C. Assess daily weight D. Monitor bleeding levels 14. The type of breathing pattern commonly seen in children described as hyperpnea with periods of apnea? A. Biot’s B. Apneustic breathing C. Cheyne-Stoke D. Normovesicular 15. The priority nursing diagnosis for a client with a nasal fracture is: A. Body-Image disturbance B. Pain C. Ineffective airway clearance D. Impaired tissue integrity 16. Which of these risk factors is associated with the development of laryngeal cancer? A. Tonsillitis B. Obesity C. Smoking D. Fatty diet 17. All of the following are true in ABG extraction, EXCEPT? A. Heparinize the syringe B. Put pressure dressing on the punctured site C. Aspirate the syringe when collecting blood from the artery D. Use to evaluate gas exchange in the lungs 18. Oxygen is carried by which of these tissues of the body? A. platelets B. WBCs C. lymphocytes D. hemoglobin 19. Which measure should the nurse use to help liquefy and facilitate expectoration of chest secretions in the client with pneumonia? A. Administer frequent oral feedings B. Encourage a fluid intake of at least 2-3 liters a day C. Place the client in supine position D. Administer oxygen as ordered 20. In providing discharge instructions for a client with a new diagnosis of tuberculosis, the nurse should give the highest priority to which nursing diagnosis? A. Knowledge deficit B. Activity intolerance C. Altered nutrition D. Anxiety 21. In preparing a client for a thoracentesis, the nurse should include which of these measures? A. Withhold food and liquids. B. client leaning forward with head and arms supported on an overbed table C. Hold all scheduled medications D. Position the client flat in bed 22. In conducting a physical assessment, which of these findings is most suggestive of pneumonia? A. Clubbing of fingers and toes B. Diminished bowel sounds

C. Red, scratchy throat D. Rales over the affected lung area 23. Which of these is an abnormal finding in a client with a chest tube connected to a closed water-seal drainage system? A. Drainage collection of 10-20 ml per hour during the first 24 hours of chest-tube placement for a client with a hemothorax B. Diminished breath sounds to the affected lung area C. Periodic bubbling in the water-seal chamber D. Continuous bubbling in the water-seal chamber 24. Which of these assessment findings is characteristic of a client experiencing asthma? A. audible chest wheezing B. normal breath sounds C. dry skin and pink nail beds D. chest tightness 25. Which of these client responses indicates that postural drainage has been effective? A. “My upset stomach is better.” B. “My cough is better.” C. “I coughed up a lot of sputum.” D. “My fever has dropped.” 26. To assess the possibility of an adverse drug effect in a client receiving streptomycin injections for TB, the nurse would ask which of these questions? A. “How do you hear me?” B. “What color is your sputum?” C. “How is your appetite?” D. “Is your cough better?” 27. Which action should the nurse first implement with the dislodgement of a chest tube? A. Turn the suction drainage system off. B. Apply occlusive dressing to the chest-tube insertion site and tape on three sides C. Call the physician D. Order new chest-tube insertion equipment and Supplies 28. Which of these measures is correct in the administration of an intradermal (PPD=Purified protein derivative) test? A. Inject 1.0ml of PPD into the dorsal aspect of the forearm B. Assess and record the diameter of redness to the site C. Inject 0.1ml of PPD into the dorsal aspect of the forearm D. Read the test 48-72 hours after injection 29. To reduce the recurrence of bronchitis, the nurse should emphasize the importance of which of these long term measures? A. increasing oral fluid intake B. smoking cessation C. Taking cough suppressant to facilitate rest D. Taking Tylenol to relieve discomfort 30. In managing the care of a client taking isoniazid (INH), it is important for the nurse to monitor which of these laboratory test? A. Urine osmolality B. Cholesterol C. Liver function studies D. Sedimentation 31. A nursing diagnosis appropriate for a client with Ulcerative Colitis: A. Abdominal pain related to decreased peristalsis B. Diarrhea related to hyperosmolar intestinal content C. Fluid volume excess related to increased water absorption by intestinal mucosa D. Activity intolerance related to fatigue 32. Which of the following enzymes is most accurate in assessing liver function? A. AST B. ALT C. LDH D. ALP 33. The client with Liver Cirrhosis experiences Ascites. This is due to: A. Elevated serum ammonia level B. Impaired excretion of bilirubin C. Portal hypertension, hyperaldosteronism, hypoalbuminemia D. Inability of the liver to metabolize nutrients and store fat soluble vitamins 34. The purpose of administering Neomycin SO4 to the client with Liver Cirrhosis is to: A. Reduce colonic bacterial flora and inhibit ammonia formation

B. Lower pH of the colon and inhibit formation of alkaline ammonia C. Remove digested blood from the colon D. Reduce serum potassium levels 35. Which of the following manifestations of the client with Liver Cirrhosis should alert the nurse? A. Jaundice B. Petechiae C. Asterixis D. Telangiectasia 36. The client wit Cholelithiasis experiences flatulence. This is primarily due to: A. Incomplete digestion of fats B. Absence of stercobilin in the colon C. Mechanical pressure within the gallbladder wall D. Inadequate absorption of vitamin K 37. Which description of pain would be most characteristic of a duodenal ulcer? A. Aching in the epigastric area that awakens a patient from sleep B. RUQ pain that increases after meal C. Sharp pain in the epigastric area that radiates to the right shoulder D. A sensation of painful pressure in the midsternal area 38. In comparing duodenal ulcer and gastric ulcer, duodenal ulcer is characterized as? A. Usually affected are people with Type A blood B. It is aggravated with the intake of food C. More tendency for malignancy D. Has a higher frequency of H. pylori 39. What instructions should the patient be given before undergoing a Paracentesis? A. NPO 12 hours before procedure B. Empty bladder before procedure C. Strict bed rest following procedure D. Empty bowel before procedure 40. If your patient has an elevated conjugated bilirubin, which of the following statement should be true? A. The patient is diagnosed with obstruction of part of the biliary tract B. The patient is diagnosed with a distress affecting red blood cell production C. The patient is diagnosed with liver disease D. The patient is diagnosed with renal disease 41. What is the pathophysiologic change in gallstone formation? A. High levels of cholesterol causes the formation of excess bile causing the formation of stone B. Over saturation and increasing concentration with stagnation of bile causes the formation C. Associated infection causes bacterial colonization causing the formation of stone D. The presence of calcium oxalates causes the formation of stone on the GB 42. Which of the following laboratory results would NOT be expected with the diagnosis of cirrhosis? A. Decreased serum albumin B. Decreased platelet and increased Bilirubin C. Decreased PT and leukocytes D. Elevated ALT, AST and LDH 43. In doing paracentesis, what is the most important responsibility of the nurse? A. Monitor the patient’s BP B. Bring the fluid sample for laboratory work-up C. Monitor fluid drainage after the procedure D. Observe for any signs of respiratory distress 44. What laboratory parameter would indicate the presence of acute Pancreatitis? A. Serum trypsin B. Serum amylase C. Pancreatic lipase D. Leukocytosis 45. What is the physiologic cause of hepatic encephalopathy? A. The presence of colonic bacteria that increases the NH4 in the blood B. The presence of renal problem decreasing the urine output and increasing NH4 concentration C. The inability of the liver to convert NH3 to NH4 D. The toxic effect of NH4 in the brain due to increased CHON diet

46. When a patient complains of pain, your initial response is:

A. B. C. D.

Record description of pain Verbally acknowledge the pain Refer patient’s complaint to the doctor Change to a more comfortable position

47. Her doctor ordered cholecystogram. This will: A. Determine the bacterial content of the gallbladder B. Facilitate visualization of the gallbladder C. Facilitate visualization of stone in the bile ducts and gallbladder D. Determine the cause of cholelithiasis 48. What is the key test in diagnosing IBD? A. barium enema B. barium swallows C. gastroscopy D. colonoscopy 49. Early sign of developing cancer of the colon? A. diarrhea B. constipation C. decreased size of stool D. change in bowel habits 50. Which type of IBD has a higher risk to progress in CANCER? A. Conn’s Disease B. Crohns Disease C. Ulcerative Colitis D. Diverticulitis 51. The etiology of COPD? A. cigarette smoking B. air pollution C. occupational exposure D. all of the above 52. Which of the following diseases most commonly leads to Coronary Artery Diseases? A. Diabetes Mellitus B. Atherosclerosis C. Myocardial Infarction D. Renal Failure 53. It is a chronic dilatation of the bronchi and bronchioles due to inflammation and destruction of the walls? A. bronchiectasis B. bronchitis C. atelectasis D. COPD 54. Acute Respiratory Failure is characterized by the following except: A. acidemia B. hypercapnea C. hypoxemia D. none of the above 55. To evaluate effectiveness of Theophylline, the nurse would anticipate: A. suppression of respiratory infection B. relaxation of bronchial smooth muscles C. thinning of tenacious purulent sputum D. decrease in bronchial secretions 56. When teaching a client with COPD to conserve energy, the nurse should teach the client to lift objects: A. while inhaling through an open mouth B. while exhaling through pursed lips C. after exhaling D. while taking a deep breath and holding it 57. After leg amputation, which emergency equipment must be on the bedside? A. emergency cart B. suction machine C. tourniquet D. all of the above

58. In DVT the possibility of dislodging the thrombi increases if necessary precautions are not observed. You will suspect that possible complication is/are: A. arterial occlusion and gangrene B. air embolism C. pulmonary embolism D. all of the above 59. Digitalis toxicity will increase if there is: A. low potassium B. high potassium C. low calcium D. high calcium 60. The primary reason of pursed-lip-breathing in a client with Emphysema is: A. to promote O2 intake B. to promote carbon dioxide excretion C. to promote lung expansion D. to prevent lung collapse 61. When developing a discharge plan to client with COPD, the nurse would anticipate? A. the client will develop infections easily B. the client will require less oxygen C. the client will show permanent improvement D. all of the above 62. In assessing the correct placement of an endotracheal tube, the nurse would: A. auscultate lung sounds bilaterally B. monitor respiratory rate C. assess for crackles D. all of the above 63. Signs of digitalis toxicity include which of the following? A. skin rash over the chest and the back B. anorexia and visual disturbances such as seeing yellow spots C. elevate blood pressure and respiratory distress D. increased appetite and diarrhea 64. Contraindication to administration of tissue plasminogen activator includes which of the following? A. age greater than 60 B. cigarette smoking C. history of cerebral hemorrhage D. history of CHF 65. During the acute phase of MI, the nurse should make the client bed by: A. changing the top linen from top to bottom without lowering the head part B. lift the client when changing the linen to limit activity C. changing the top linen and only the necessary bottom linen D. sliding the client onto the stretcher, remake the bed without delay then return the patient to bed immediately 66. The nurse has been assigned to a client with a history of PVD who has symptoms of claudication. This symptom result when? A. oxygen supply exceeds the demand of muscles B. oxygen is absent C. oxygen demand by the muscle exceeds the supply D. all of the above 67. A client has edema on the day and disappears at night. The client states it is not painful and is located in the lower extremities. The nurse should suspect: A. pulmonary edema B. right ventricular failure C. left ventricular failure D. myocardial infarction 68. What is the potential side effect of Metaproterenol, a bronchodilator drug? A. palpitations B. tremors C. diaphoresis D. all of the above

69. A 60 year old male client comes into the ER with complaints of crushing sub-sternal chest pain that radiates to his shoulder and left arm. The admitting diagnosis acute myocardial infarction. Immediate admission orders include oxygen by nasal cannula 4L/min, blood works, a chest radiograph, a 12 lead ECG and 2 mg morphine sulfate intravenously. The nurse should first: A. administer the morphine B. obtain ECG C. obtain blood work D. order the chest radiograph 70. In obtaining apical pulse, correct landmark would be: A. left fifth ICS, midclavicular line B. right fifth ICS, midclavicular line C. left fourth ICS, midclavicular line D. right fourth ICS, midclavicular line 71. Classic sign of Pulmonary Edema? A. bi-basilar crackles B. atelectasis C. pink tinged frothy sputum D. all of the above 72. Anasarca or generalized edema is best manifested by: A. periorbital edema B. edema +4 C. distention of neck veins D. any of the above 73. Which of the following is an appropriate Nursing diagnosis for Asthma? A. altered breathing pattern B. decreased tissue perfusion C. ineffective airway clearance D. decreased lung expansion 74. Crackles heard on lung auscultation indicate which of the following? A. cyanosis B. bronchospasm C. airway narrowing D. fluid filled alveoli 75. What is the primary reason of taking oral Furosemide in the morning? A. prevent electrolyte imbalance B. reduce rapid drug absorption C. excrete excessive fluids accumulated during the night D. prevent sleep disturbance during the night 76. Which of the following is the primary function of osteoblast activity: A. Bone Formation B. Bone Destruction C. Estrogen Function D. Hematopoiesis 77. Which of the following would the nurse most likely assess as an early manifestation of Rheumatoid Arthritis? A. Limited motion of joints B. Deformed joints of the hand C. Early morning stiffness D. Rheumatoid Nodules 78. Heberden’s nodes are a common sign of OA. What is the correct statement about this deformity? A. It appears only in men B. It appears on the distal interphalangeal joint C. It appears on the proximal interphalangeal joint D. It appears on the metatarso phalangeal joint 79. The primary consideration when caring for a client with Rheumatoid Arthritis is? A. Surgery B. Comfort C. Education D. Motivation 80. A physician tells a client diagnosed with Gout that her X-rays are normal. Which if the following responses would be the most appropriate when the client asks if she still has Gout? A. No, you’re cured B. Yes, X-rays are unreliable C. Yes, X-rays are normal in the early stages of gout.

D. Yes, x-rays changes are only seen with acute attacks 81. The nerve involved in Carpal Tunnel syndrome is: A. medial nerve B. ulnar nerve C. median nerve D. radial nerve 82. To achieve the desired outcome of functional healing of a fracture, which nursing goal should receive the highest priority? A. Maintain immobilization and alignment B. Provide optimal nutrition and hydration C. Promote independence in ADL D. Provide relief from pain and discomfort 83. What is the best position after HIP surgery? A. abduction and prevent external rotation B. Adduction and prevent internal rotation C. prevent internal and external rotation D. all of the above 84. In advanced Gout, Urate crystal deposits develop on the hands, knees, feet , forearms, ears, and Achilles tendon. Which of the following terms refer to these deposits? A. Arthralgia B. Gout Nodules C. Pinna D. Tophi 85. Following Spinal surgery the nurse would assess for which of the following? A. bowel and bladder movement B. ability to wiggle the toes C. lower extremities must be checked for sensory and motor functioning D. any of the above 86. Which of the following statement made by the client about cast care would require further health teachings? A. “I will elevate the cast above my heart initially” B. “I will exercise my joints above and below the cast” C. “I can pull out cast padding to scratch inside the cast” D. “I will apply ice for ten minutes to control edema for the 1st 24 hours 87. Common type of ARTHRITIS? A. OA B. GA C. RA D. all of the above 88. PANNUS formation is seen in? A. OA B. GA C. RA D. all of the above 89. Action of COLCHICINE? A. anti-inflammatory B. analgesic C. inhibits uric acid formation D. promote excretion of uric acid 90. PHANTOM LIMB pain must be treated with? A. placebo B. antibiotics C. steroids D. narcotics 91. Standing drug to combat rheumatoid arthritis? A. ASA B. GOLD compounds C. steroids D. all of the above 92. Key test in diagnosing HIP DYSPLASIA? A. positive Ortolani’s B. positive Barlow’s C. x-ray D. all of the above

93. In managing ADVANCED Osteomyelitis the management of choice is? A. amputation B. IV antibiotics C. debridement D. all of the above 94. During rehab of SPINAL CORD INJURY highest priority is? A. bowel and bladder program B. stone formation C. pressure sore D. all of the above 95. Common contrast medium used in x-ray? A. iodide B. gallium C. thallium D. technetium 96. Specific test in diagnosing Rheumatoid Arthritis? A. elevated ANA B. elevated RF C. elevated ESR D. all of the above 97. Classic sign of OSTEOMYELITIS? A. sequestration and involucrum B. pannus and granuloma C. heberden’s and bouchard’s D. crepitus and contracture 98. PAGET’s disease is best manifested by? A. skull enlargement and hearing loss B. dyspnea in relation to head drop C. kyphosis and bowing of legs D. all of the above 99. Rickets and osteomalacia is mainly due to? A. lack of vitamin D and sunlight exposure B. FAT malabsorption C. Chronic Renal Failure D. all of the above 100. Primary Osteoporosis is due to? A. aging and menopausal effects B. menopausal and lack of calcium C. aging and calcium D. any of the above