Medical Surgical Nursing Multiple Choice Identify the choice that BEST completes the statement or answers the

question. ____ 1. Ms. Baker has decided to have surgical correction of her stenosed valve at this time because her subjective complaints of dyspnea, hemoptysis, orthopnea, and paroxysmal nocturnal dyspnea have become unmanageable. These complaints are probably due to: a. b. ____ thickening of the pericardium right heart failure c. d. pulmonary hypertension left ventricular hypertrophy

2. SITUATION: Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking in midsentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA. Upper motor neuron disease may be manifested in WHICH of the following clinical signs? a. b. c. d. spastic paralysis, hyperreflexia, presence of babinski reflex flaccid paralysis, hyporeflexia muscle atrophy, fasciculations decreased or absent voluntary movement

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3. A thorough history reveals that hormonal changes associated with menstruation may have triggered Julies migraine attack. In investigating Julies history what factors would be LEAST significant in migraine? a. b. seasonal ALLergies trigger foods such as alcohol, MSG, chocolate c. d. family history of migraine warning sign of onset, or aura

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4. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one hour preoperatively. WHICH nursing actions follow the giving of the preop medication? a. b. c. d. have her void soon after receiving the medication ALLow her family to be with her before the medication takes effect bring her valuables to the nursing station reinforce preop teaching

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5. Mrs. Hogan returns to your clinical unit following discharge from the recovery room. Her vital signs are stable and her family is with her. Postoperative leg exercises SHOULD be inititated: a. after the physician writes the order c. if Mrs. Hogan will NOT be ambulated early

b. ____

after the family leaves

d.

stat

6. If breath sounds are only heard on the right side after intubation: a. b. Extubate, ventilate for 30 seconds then try again. The patient probably only has one lung, the right. c. d. You have intubated the stomach. Pull the tube back and listen again.

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7. Diabetes insipidus involves a dysfunction of: a. Glucose b. ADH

c. Insulin production d. FSH

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8. The nurse is caring for a client who recently underwent a tracheostomy. The FIRST priority when caring for a client with a tracheostomy is: a. helping him communicate. b. keeping his airway patent. c. encouraging him to perform activities of daily living. d. preventing him from developing an infection.

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9. The nurse is caring for a client experiencing acute addisonian crisis. WHICH laboratory data would the nurse expect to find? a. Hyperkalemia c. Hypernatremia b. Reduced blood urea nitrogen (BUN) d. Hyperglycemia

____ 10. The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse SHOULD FIRST administer: a. I.M. or subcutaneous glucagon. b. an I.V. bolus of dextrose 50%. c. 15 to 20 g of a fast-acting carbohydrate such as orange juice. d. 10 U of fast-acting insulin. ____ 11. When a client is scheduled for a thyroid test, the nurse must determine if the client has taken any medication containing iodine, WHICH would alter test results. WHICH of the following medications contain iodine? a. Acetaminophen and aspirin b. Estrogen and amphetamines c. Insulin and oral antidiabetic agents d. Contrast media, topical antiseptics, and multivitamins ____ 12. One of these statements is true about the glomerulus? a. It can filter blood for approximately 125 cc/min. b. It reabsorbs filtrates. c. It receives blood from the renal arteries and later on returns it to the same blood vessel. d. ALL of the above ____ 13. A client has undergone subtotal thyroidectomy. Postoperatively, the nurse continues to assess for signs and symptoms of hypocalcemia. WHICH of the following are more indicative of tetany? a. Abdominal cramping and convulsions c. Positive Chvosteks and Trousseaus signs b. Dyspnea and cyanosis d. Muscular flaccidity and hypotension ____ 14. A male client is diagnosed to have acute glomerulonephritis. WHICH of the following is the pathophysiologic alteration that occurs with this disease? a. CrystALLization in the distal tubules of the kidney due to an untoward effect of antipyretic medication. b. Destruction of glomeruli due to the trapping of circulating antigen-antibody complexes.

c. Inhibition of antibodies resulting from an invading microorganisms. d. Sensitivity of toxins resulting from an invading microorganisms. ____ 15. To control diabetes mellitus, proper treatment and diet SHOULD go hand in hand. The MOST important factor in the success of a diabetic diet is: a. the accuracy of the food exchange list to be given to the patient b. the appropriateness of the drug or insulin to be prescribed to the patient c. the patients willingness to adhere it consistently d. the age of the patient ____ 16. WHICH of the following disease processes is caused by an absence of insulin or inadequate amount of insulin, resulting in hyperglycemia and leading to a series of biochemical disorders? a. Diabetes insipidus c. Diabetic ketoacidosis b. Hyperaldosteronism d. HHNK syndrome ____ 17. Mrs. Cruise is to undergo laboratory examinations. The purpose of oral glucose tolerance test is: a. determine the amount of glucose in the blood when fasting b. measure the blood sugar following a meal c. determine persons response to a measured dose of glucose d. any of these purposes. ____ 18. If fluid intake is limited in a client with diabetes insipidus, WHICH of the following complications will he be at risk for developing? a. Hypertension and bradycardia c. Glucosuria and weight gain b. Peripheral edema and weight gain d. Severe dehydration and hypernatremia ____ 19. WHICH of the following statements would the nurse identify as the BEST indication of a 50-year-old client's developmental concerns at this time in his life? a. It is time to reevaluate life's goals b. selection of a career is important c. Leisure-time activities are a center of focus d. Stress associated with illness precipitates a need to "settle down ____ 20. When developing a teaching plan for a sexuality class at a community center about human immunodeficiency virus (HIV) transmission, the nurse would include WHICH of the following behaviors as a measure to greatly reduce the risk of transmission? a. Avoiding inhalant drugs b. Avoiding prolonged sex c. Using latex condoms with sexual intercourse d. Douching before and after sexual intercourse ____ 21. When developing the plan of care for a client with aplastic anemia, WHICH of the following goals would be MOST appropriate to include? a. Perform activities of daily living without excessive fatigue or dyspnea b. Learn how to administer weekly vitamin B injections c. Correctly demonstrate how to take prescribed anticoagulant drug therapy d. Describe self-care behaviors to prevent the transmission to family members ____ 22. When developing the plan of care for a client with full-thickness burns over 35% of his body, the nurse would anticipate WHICH of the following? a. Using oral analgesics because full-thickness burns are painless owing to nerve destruction. b. Relying on nonpharmacologic measures to avoid respiratory depression c. Sedating the client to an unconscious state to decrease awareness of pain d. Administering intravenous opioid analgesics such as morphine

____ 23. The nurse performs a cardiovascular assessment on an elderly client, WHICH reveals a BP of 162/86. The nurses assessment finding is MOST likely a result of a. Less muscle mass c. Dehydration b. Calcification of the arteries d. Impaired lung capacity ____ 24. WHICH nursing care measure is NOT appropriate for client with deep vein thrombosis? a. Careful leg massages c. Elevating the legs b. Elastic stockings d. Leg exercises ____ 25. A client has thrombophlebitis. Heparin SC Q 8hr is prescribed. Nursing interventions related to the administration of heparin include: a. Monitoring the clients UO c. Checking the clients Ecchymosis b. Checking the clients INR before administration d. Informing the client that NSAIODS may be taken for discomfort ____ 26. The nurse is caring for patients on the medical unit. A patient is admitted with a diagnosis of deep vein thrombosis (DVT). Admission orders include heparin 2,000 units per hour in 5% dextrose in water. The nurse SHOULD have WHICH of the following available? a. Propanolol (Inderal) c. Protamine sulfate b. Protamine zinc d. Vitamin K ____ 27. The nurse observes a nursing assistant positioning the clients leg on a pillow. The client is diagnosed with arterial insufficiency of the lower extremities. The nurse SHOULD: a. Go to the clients room and remove the pillow from c. Go into the clients room and demonstrate proper the clients leg immediately positioning in front of the nursing assistant b. CALL the nursing assistants attention and explain d. Ignore the nursing assistants action the position is wrong ____ 28. WHICH of the following is a cardinal symptom of a patient with peripheral arterial occlusive disease? a. Thrombophlebitis c. Edema and pain b. Positive human sign d. Intermittent claudication ____ 29. If a patient develops a pyrogenic reaction to a blood transfusion, the patient would MOST likely have WHICH of the following symptoms? a. Pounding headache c. Chill and fever b. Urticaria d. Flank pain ____ 30. WHICH of these observations of a patient who has pernicious anemia would indicate that the goal of care has been achieved? a. The patients skin has no petechiae c. The patient has no dependent edema b. The patients tongue has lost its beefy red color d. The patient has good appetite ____ 31. An 88-year old female patient is on IV therapy dehydration. The nurse would assess the effectiveness of this treatment by: a. Pinching the skin over the sternum c. Checking the patients tongue b. Pinching the skin over the hand d. Looking at the patients conjunctiva ____ 32. A patient scheduled for surgery asks the nurse How long before surgery SHOULD I stop taking aspirin? The nurses BEST response would be: a. 24 hours c. 8 hours b. 48 hours d. 3 days ____ 33. A 24-year-old patient has a long-leg cast applied to the left leg following a fracture sustained in an accident. WHICH of these measures would be MOST important to include in the patients care plan initiALLy? a. Maintaining the leg in external rotation c. Determining the capillary refill in the toes of the affected leg

b. Monitoring the femoral pulses

d. Encouraging exercise of the unaffected leg

____ 34. An 80 years old female who sustained an unstable fracture of hip when she fell from a kitchen ladder is brought to the ER. WHICH of the following clinical findings would be MOST significant in the initial assessment of the patient? a. Deformity c. Localized swelling b. Ecchymoses d. Pain ____ 35. The nurse is evaluating the care given to a client who has had a total hip replacement. WHICH position indicates the client has been position appropriately a. The affected leg is abducted and externALLy c. The affected leg is abducted and internALLy rotated rotated b. The affected leg is adducted and externALLy d. The affected leg is adducted and internALLy rotated rotated ____ 36. The client with a spinal cord injury at the level of C5 has a weakened respiratory effort, ineffective cough, and is using accessory neck muscles in breathing. The nurse carefully monitors the client and formulates WHICH of the following diagnosis? a. Ineffective breathing pattern c. Risk for aspiration b. Impaired gas exchange d. Risk for injury ____ 37. A swimmer sustains a spinal cord injury at the level of C6-C7 following a diving accident. WHICH of the following would be the MOST important for the nurse to have readily available at the bedside? a. A lumbar puncture tray c. A chest tube insertion tray b. A tracheostomy set d. A gastric lavage/suction kit ____ 38. WHICH of the following nursing diagnosis would have the highest priority for a patient with diagnosis of Guillain-Barre syndrome? a. Potential for impaired physical mobility c. Potential for ineffective breathing patterns b. Potential for altered nutrition d. Potential for altered elimination; bowel/bladder ____ 39. A nurse is caring for a client with Guillain-Barre syndrome. WHICH of the following strategies is of MOST importance in the plan of care? a. Range of motion exercises three to four times per c. Use of artificial tears day b. Frequent measurement of vital capacity d. Starting an enteral feeding ____ 40. A client has been diagnosed with Bells palsy (cranial nerve 7 disorder). One of the instructions the nurse needs to review with the client is: a. Chew foods on affected side to strengthen facial c. Massaged effected side of the face vigorously muscles b. Perform simple exercises such as blinking the eye d. Apply protective eye shield over affected eye ____ 41. The client has dysfunction of the cochlear division of the vestibulcochlear cochlear nerve (cranial nerve VIII). The nurse evaluates that the client is adequately adapting to this problem if the client states a plan to obtain a a. Hearing aid c. Pair of eye glasses b. Walker d. Bath thermometer ____ 42. The client is admitted with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the clients history of a. Hypertension c. Heart failure b. Chronic obstructive pulmonary disease d. Prosthetic valve replacement

____ 43. The nurse is caring for a patient 4 hours after intracranial surgery. WHICH of the following actions SHOULD the nurse take immediately? a. Turn. Cough, and deep-breathe the patient c. Perform passive range of motion exercise b. Place the patient with the neck flexed and d. Move the client to the head of the bed using head turned to the side a turning sheet ____ 44. Patient has right-sided CVA. What does the nurse need to do when feeding this patient? a. Give the patient sips of water between each bite c. Avoid thickened fluids and food with texture b. Place the food in the left side of the patients mouth d. Position patient upright with the head tilted slightly forward ____ 45. A client has had a cerebral vascular accident (CVA). The nurse establishes a nursing diagnosis of alteration in nutrition related to dysphagia. WHICH of the following actions might make swallowing easier for the client? a. Stroking the posterior neck to promote c. Positioning the client upright with the head and swALLowing neck positioned forward and flexed b. Feeding the client thin liquids, such as clear soups, d. Placing about one teaspoonful of liquid in the front coffee, and tea of the mouth ____ 46. The client with CVA has residual dysphagia. When a diet order is initiated, the nurse avoids doing WHICH of the following? a. Giving the client thin liquids c. Placing the food on the unaffected side of the mouth b. Thickening liquids to the consistency of oatmeal d. ALLowing plenty of time for chewing and swALLowing ____ 47. A tracheostomy was performed and mechanical ventilation instituted on an adult. Tracheal suctioning by the nurse SHOULD include a. Wearing clean gloves, goggles, and a mask c. Hyperoxygenating the client with 100% O2 only after the procedure is completed b. Applying a constant suction while inserting the d. Applying intermittent suction and rotating the catheter catheter as the suction catheter is drawn from the tracheostomy tube ____ 48. You are caring for the patient with water sealed drainage. WHICH of the following is NOT a proper intervention or observation? a. b. Do NOT clamp the tubing during transport or ambulation Observe the water fluctuate with inspiration and expiration c. d. Keep the drainage equipment below the level of the patients chest Observe that continuous bubbling occurs in the fluid where the water seal is maintained

____ 49. WHICH assessment is MOST useful in assessing the adequacy of O2 therapy of patient with COPD? a. Respiratory rate c. Pulmonary function tests b. Color mucous membranes d. Arterial blood gases ____ 50. A client is on a ventilator. The ventilator alarm goes off. The nurse assesses the patient and observes increased respiratory rate, use of accessory muscles, and agitation. The nurses BEST initial action is to a. Remove the client from the ventilator and ambu c. notify the physician bag the patient, while continuing to assess to determine the cause of the clients distress b. CALL the respiratory therapy to check the d. Turn off the alarm ventilator