Medical Surgical Nursing Review 1

A 49-year-old woman was admitted to a physical rehabilitation unit 2 weeks before surgery for a below-the-knee amputation on her right leg. She asks, "Why do I have to keep wrapping my stump?" The nurse's best response is:
1. "You will have to shrink and shape the residual limb to fit the prosthesis."
2. "You want to increase the size of the residual limb to fit the prosthesis."
3. "You need to because it is what your physical therapist wants."
4. "You need to speak to your doctor."
To prevent flexion contraction of the hip after a below-the-knee amputation, the nurse should encourage the client to be:
1. In supine position with a pillow between the legs
2. In a semi-Fowler's position most of the day
3. In supine position with a pillow under the knees
4. In prone position
After a below-the-knee amputation, a client states, "Please tell me I am not crazy because it still feels like my right foot is still there." The nurse's best response is:
1. "Since your leg is not there, you should not feel anything."
2. "You are experiencing phantom limb sensation, which is normal."
3. "It might be best for you to see a psychiatrist to help you deal with your loss."
4. "Next you will be telling me you can see your toes."
In caring for a residual limb after a below-the-knee amputation, the nurse knows that which of the following statements by the client indicates a need for further teaching? "I should
1. "Inspect the stump for redness and abrasions."
2. Apply lotion or alcohol to the stump."
3. Use a stump sock or Ace bandage."
4. Clean the stump with mild soap."
A 65-year-old man with hypertension has suffered a stroke and has right hemiplegia. When assessing the client, the nurse expects to find:
1. Weakness on one side of the body
2. Paralysis of the lower extremities
3. Total body paralysis
4. Paralysis of one side of the body
A client has dysphagia. The nurse would include in the plan of care which of the following?
1. Promote exercises to decrease facial rigidity
2. Allow extra time for speaking
3. Institute special feeding precautions.
4. Increase light in the environment.
When assessing a client after a stroke, the nurse notes that there is an impairment of the ability to read, write, speak, listen, and comprehend. The nurse identifies this as:
1. Ataxia
2. Aphasia
3. Dysphagia
4. Agnosia
A client's entire posterior chest and buttocks have full-thickness burns. Using the Rule of Nines, the nurse would calculate the BSA burned as:
1. 9
2. 18
3. 27
4. 36
Which of the following is the most characteristic symptom of the disequilibrium syndrome associated with hemodialysis?
1. Seizures
2. Hypertension
3. Chest pain
4. Shortness of breath
A wife whose husband has suffered an MI states, "My husband's favorite foods are fried chicken and frenchfried potatoes. Would it be okay for me to bring him some?" The nurse's best response is:
1. "That's a good idea; he has a hearty appetite."
2. "If you bring him only a small amount, it will be okay."
3. "First let's speak to the dietitian about his diet."
4. "No, you can't bring food into the hospital."
The nurse is preparing a 42-year-old man for hospital discharge after an MI. Which of the following statements indicates the need for further teaching?
1. "I will take my medications as prescribed."
2. "I will follow a low-cholesterol, low-fat diet."
3. "I can exercise as much as I want."
4. "I can have a small glass of wine with the evening meal."
A wife whose husband has suffered a stroke notices that he cries and laughs inappropriately. She asks, "Why does he do that?" The nurse's best response is:
1. "He is experiencing emotional lability, which is common after a stroke."
2. "Ignore him; he likes to play games."
3. "Don't you also cry when something is funny and laugh when it is not?"
4. "I don't know; maybe he needs a psychiatrist."
A 17-year-old girl was injured in a car accident. She now has paraplegia secondary to a T11 spinal cord injury. The nurse identifies the four divisions of the spinal column as:
1. Coccygeal, cranial, thoracic, lumbar
2. Cervical, thoracic, lumbar, sacral
3. Cervical, trochanter, ischial, sacral
4. Thoracic, coccygeal, femur, ulnar
The nurse assesses for which of the following symptoms in a T11 spinal cord injury?
1. Loss of movement in both the upper and lower extremities
2. Loss of bladder control
3. Loss of movement in the upper extremities
4. Loss of respiratory control
Humulin NPH insulin is administered at 7 AM. At what time would the nurse anticipate the peak action to take place?
1. 9 AM
2. 12 noon
3. 5 PM
4. 11 PM
While the client is in the prone position, which site is most likely to develop a pressure area?
1. Occiput
2. Buttocks
3. Heels
4. Toes
When performing endotracheal suctioning, suctioning should be limited to how many seconds?
1. 5
2. 10
3. 20
4. 30
A 56-year-old man is walking down the hall and complains of chest pain. Before administering nitroglycerin sublingually, what action should be performed first?
1. Call for a stat 12 lead ECG.
2. Lower the head of the bed.
3. Start oxygen with a nasal cannula.
4. Tell client to stop and rest.
Which position facilitates the greatest expansion of the lungs for the client restricted to bed rest?
1. High-Fowler's
2. Low-Fowler's
3. Sims'
4. Trendelenburg
For adults, the diastolic BP is recorded when:
1. The first sound is heard during cuff deflation
2. The muffled sound is heard during cuff deflation
3. The muffled sound is heard during cuff inflation
4. The last sound is heard during cuff deflation
When teaching a female client the proper technique for cleaning the perineum before intermittent self-catheterization, the nurse would teach her to separate the labia and:
1. Wipe from back to front
2. Wipe in a circular motion
3. Wipe from side to side
4. Wipe from front to back
When administering which medication does the nurse frequently obtain peak-and-trough levels?
1. Digoxin
2. Heparin
3. Aminophylline
4. Vancomycin
What is the minimum time established for a health-care worker to properly wash the hands?
1. 10 seconds
2. 30 seconds
3. 45 seconds
4. 60 seconds
Which of the following is a common symptom of constipation?
1. Increase in appetite
2. Suprapubic distention
3. Vomiting
4. Firm abdomen
What directions should the nurse give a client who has just been given a suppository for complaints of constipation?
1. Get up and go to the toilet immediately.
2. Wait 5-10 minutes before going to the toilet.
3. Wait 20-30 minutes before going to the toilet.
4. Remain in the prone position before getting up and going to the toilet.
The physician has ordered povidone-iodine (Betadine) for wound care. When pouring povidone-iodine onto the 4 × 4 bandages, the nurse should:
1. Hold the bottle with the label facing the sterile field.
2. Pour while holding the bottle high over the sterile field.
3. Pour 1-2 mL into another container before pouring onto the sterile bandages.
4. Pour some into a cap and then over the sterile bandages
The major cause of nosocomial infection in the hospital setting is:
1. Excessive use of disposable equipment
2. Proximity of beds in a semiprivate room
3. Infrequent handwashing
4. Excessive use of oral antibiotics
A surgical incision has become infected and now requires wound care every 8 hours. When packing the incision with saline-soaked 4 × 4 bandages, the nurse accidentally drops the dressing on the client's chest. The nurse should:
1. Use the bandage if the client has just bathed.
2. Resoak the bandage in sterile saline and place it in the incision.
3. Discard that bandage and prepare a fresh one.
4. Use the bandage on top of other sterile bandages.
The nurse knows the best place to assess for pallor in a very dark-skinned person is:
1. Sclera
2. Nailbed
3. Mucous membranes
4. Lips
While charting, the nurse makes an error while writing in the nurse's notes. The nurse should:
1. Write with erasable ink to correct the entry easily.
2. Draw lines through the entry until the entry is no longer readable.
3. Draw one straight line through the erroneous entry, initial it, and write "error."
4. Draw one straight line through the erroneous entry and initial it.
Your client has left-leg weakness and needs to use a cane. You observe proper ambulation with the cane when the client:
1. Keeps one point of support on the floor at all times
2. Keeps two points of support on the floor at all times
3. Leans slightly to the left with the cane in the left hand
4. Uses the proper-length cane-the top of the cane should be at waist level
To measure BP accurately, the nurse should:
1. Position the client's arm above the level of the heart.
2. Position the cuff at least 2 inches above the site of the radial artery pulsation.
3. Position the client's arm extended, with the palm down.
4. Center the arrow marker on the cuff over the brachial artery pulsation.
The most accurate technique used to assess the apical pulse is:
1. Inspection
2. Palpation
3. Auscultation
4. Percussion
The nurse is giving discharge instructions to a client who will be receiving oxygen at home, including placing a "No Smoking" sign at all entrances to the home. The rationale for using the sign is:
1. Oxygen can cause a fire to ignite.
2. Oxygen can cause an explosion.
3. The sign alerts visitors to enter the home at their own risk.
4. Smoking causes lung cancer.
The nurse plans to give a complete bed bath to a 70-year-old woman. When cleansing the face area, the nurse should use:
1. Warm water only
2. Tissues instead of a washcloth
3. Liquid soap on all areas except the eyes and lips
4. The client's preference of facial soap and warm water
While receiving a soapsuds enema, the client complains of abdominal cramps. The nurse should:
1. Temporarily stop the flow of the enema.
2. Tell the client to breathe slowly through the mouth.
3. Raise the height of the enema container.
4. Clamp the tubing and withdraw the rectal tube.
The nurse auscultates a BP of 180/99 mm Hg in the right arm and decides to double-check the reading. Before reinflating the cuff, the nurse should wait:
1. 10 seconds
2. 30 seconds
3. 1 minute
4. 2 minutes
The nurse obtains a report from the laboratory stating her client's serum potassium is 4.3 mEq/L. Which action should she perform next?
1. Notify the doctor immediately, because the value is dangerously low.
2. Note the value in her notes, and notify the doctor when he makes rounds.
3. This is a panic value. The level is dangerously high, and the doctor must be notified immediately.
4. Offer the client potassium-rich foods such as orange juice and bananas.
Postoperatively, a client has not voided in more than 8 hours. The nurse feels the lower abdomen and finds it to be distended. The method of physical examination used by the nurse is termed:
1. Auscultation
2. Percussion
3. Palpation
4. Inspection
A sterile specimen would be obtained from an indwelling Foley catheter by:
1. Taking urine from the urinometer
2. Taking urine from the drainage bag
3. Disconnecting the catheter from the drainage tubing
4. Withdrawing urine from the latex port
The nurse knows that an enteric-coated oral medication:
1. Dissolves rapidly when placed under the tongue
2. Needs to be shaken before being administered
3. Does not dissolve until it reaches the small intestine
4. Needs to be chewed and taken with a full glass of water
A client is ordered to receive an IM injection by the Z-track method. The rationale for the use of this method is that it:
1. Prevents the drug from irritating the skin
2. Allows faster absorption of the drug
3. Eliminates discomfort caused by the needle
4. Allows slower absorption of the drug
Medications are absorbed most rapidly through which of the following routes?
1. Topical
2. IV
3. IM
4. Oral
After abdominal surgery, your client has a Salem sump tube that is draining excessive amounts of fluid. Which acid-base disturbance is most likely to occur?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
Your client is being discharged and has been instructed how to lift objects to avoid lower back strain. Which of the following statements made by the client is correct? "I must
1. Narrow my base of support.
2. Move away from the object to be lifted.
3. Position my center of gravity high above the object to be lifted
4. Maintain alignment of the head, neck, and back while lifting
The nurse knows that evaluation is:
1. The final phase of the nursing process
2. Not related to client goals of care
3. The first phase of the nursing process
4. A continuous and ongoing process
To administer oral care to an unconscious client, the nurse should:
1. Use a toothbrush and floss after every meal.
2. Squirt 30 mL of mouthwash into the mouth and then suction the oral cavity.
3. Scrape secretions from inside the mouth with a tongue blade
4. Use a padded tongue blade to keep the mouth open.
According to the American Heart Association (AHA), which of the following is the most prevalent form of cardiovascular disease?
1. Stroke
2. Coronary artery disease (CAD)
3. Hypertension
4. Rheumatic heart disease
A 65-year-old man is admitted to the hospital with the diagnosis of congestive heart failure (CHF). Which of the following is an expected symptom of CHF?
1. Shortness of breath
2. Decrease in tissue turgor
3. Flat neck veins
4. Left upper quadrant abdominal tenderness
Which of the following would be an appropriate nursing intervention for a client in CHF?
1. Assess daily weight.
2. Encourage fluids.
3. Position the head of the bed lt;30 degrees upright.
4. Teach the importance of a diet enriched with sodium.

Medical Surgical Nursing Review 1

Quiz