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MEDICAL SURGICAL ASSESSMENT A
100% CORRECT & VERIFIED ANSWERS
"A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? A) "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates" B) "The HbA1c test can help detect the presence of ketones in my body" C) "I will have my HbA1c checked twice per year"
D) "I will plan to fast before I have my HbA1c tested" - CORRECT ANSWER C) "I will have my HbA1c
checked twice per year" An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose." "A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? A) The client asks questions each time the nurse stops talking. B) The client stops the nurse and asks for pain medication. C) While the nurse is speaking, the client refers to the written materials.
D) A family member who is present asks the client to repeat important points. - CORRECT ANSWER B)
The client stops the nurse and asks for pain medication. The nurse should identify that a client who is in pain will not be able to concentrate, which can interfere with his ability to learn." "A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? A) "Your partner will not require treatment for this infection" B) "You can resume sexual activity as soon as you begin treatment" C) "You are at risk for infertility with this infection, regardless of treatment"
D) "You will not be at further risk for this infection following treatment" - CORRECT ANSWER C) "You
are at risk for infertility with this infection, regardless of treatment"
The nurse should inform the client that there is a risk for infertility as a result of this infection." "A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? A) "I should call my doctor if I get a headache" B) "I may develop gastric reflux" C) "I may develop excessive bruising"
D) "I should call my doctor if my ankles swell" - CORRECT ANSWER D) "I should call my doctor if my
ankles swell" Swelling of the ankles can indicate heart failure. The client should report this finding to the provider." "A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend? A) Ketchup B) Mayonnaise C) Soy sauce
D) Lemon juice - CORRECT ANSWER D) Lemon juice
The nurse should recommend that the client use lemon juice to flavor his food because it is low in sodium." "A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? A) "I will perform the exam before I shower" B) "I will check my testicles every 6 months" C) "I understand that testicular cancer is painless"
D) "I understand that pea-sized lumps are normal" - CORRECT ANSWER C) "I understand that testicular
cancer is painless" Clients should report a lump that is not painful because testicular cancer is typically painless." "A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? A) Sodium 136 mEq/L B) Potassium 4.8 mEq/L C) Creatinine 1.9 mg/dL
D) Calcium 10 mg/dL - CORRECT ANSWER C) Creatinine 1.9 mg/dL
Listening to soft music can help the client to relax and reduces environmental stressors." "A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? A) Collect a sputum culture B) Administer ceftriaxone by intermittent IV bolus C) Initiate oxygen at 4 L/min via nasal cannula
D) Obtain blood cultures - CORRECT ANSWER C) Initiate oxygen at 4 L/min via nasal cannula
When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body." "A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? A) Determine the client's daily elimination habits. B) Administer a suppository to the client 30 min prior to defecation time. C) Offer the client 4 oz of warm prune juice to promote elimination.
D) Provide dietary bulk to the client to ease the passage of stool. - CORRECT ANSWER A) Determine
the client's daily elimination habits. The first action the nurse should take using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time." "A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all) A) Monitor the insertion site for bleeding B) Position the affected extremity at a 45 degree angle C) Restrict the client's fluid intake D) Maintain the pressure dressing
E) Check the client's peripheral pulses - CORRECT ANSWER A) Monitor the insertion site for bleeding
The nurse should monitor the client's insertion site for manifestations of hemorrhaging. D) Maintain the pressure dressing.
The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. E) Check the client's peripheral pulses. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion." "A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? A) Expect decreased sensation for the first postoperative week. B) Avoid lying on the operative side. C) Obtain a raised toilet seat.
D) Cross legs at the ankles. - CORRECT ANSWER C) Obtain a raised toilet seat.
The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation." "A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? A) Administer epinephrine. B) Monitor the client's vital signs. C) Monitor the client's oxygen saturation level.
D) Administer an antihistamine. - CORRECT ANSWER A) Administer epinephrine.
The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema." "A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? A) Perform pin site care daily B) Remove the overbed trapeze C) Remove the boot every 2 hr
D) Keep the weights on a stable, flat surface - CORRECT ANSWER A) Perform pin site care daily
The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection."
D) Give the client liquids with increased viscosity. - CORRECT ANSWER D) Give the client liquids with
increased viscosity. Thickened liquids are easier for the client to swallow and can prevent aspiration." "A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? A) Gown B) Mask C) Sterile gloves
D) Protective eyewear - CORRECT ANSWER B) Mask
The nurse should identify that a client who has Meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 3 feet of the client." "A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? A) "Can I get you something for the pain?" B) "You should talk about this with your family." C) "Tomorrow will be a better day."
D) "Tell me more about the way you are feeling." - CORRECT ANSWER D) "Tell me more about the way
you are feeling." The nurse is establishing a trusting relationship by seeking clarification and encouraging the client to verbalize feelings." "A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? A) Wound infection B) Pulmonary embolism C) Thrombophlebitis
D) Paralytic ileus - CORRECT ANSWER B) Pulmonary embolism
Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea." "A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? A) Offer sips of water to the client following oral care.
B) Massage the client's lower extremities with lotion every 2 hr. C) Encourage the client to use an incentive spirometer every hour while awake.
D) Place one or two pillows beneath the client's knees while he is in bed. - CORRECT ANSWER C)
Encourage the client to use an incentive spirometer every hour while awake. The nurse should assist the client to use the incentive spirometer in addition to coughing and deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve ventilation to prevent postoperative pneumonia." "A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? A) Use a traction boot to keep the client's right leg internally rotated. B) Have the client sit in a reclining chair when out of bed. C) Maintain abduction of the client's right leg while in bed.
D) Encourage the client to perform passive range-of-motion exercises. - CORRECT ANSWER C)
Maintain abduction of the client's right leg while in bed. The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed." "A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? A) Position pillows between the bony prominences B) Check for incontinence every 3 hr C) Massage reddened areas of the skin
D) Elevate the head of the bed to 45 degrees - CORRECT ANSWER A) Position pillows between the
bony prominences The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure ulcer development." "A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? A) Keep the skin dry and free of perspiration. B) Use hot water and antibacterial soap to bathe the client. C) Massage the skin over bony prominences to promote circulation.
D) Limit the use of moisturizers on the skin over bony prominences. - CORRECT ANSWER A) Keep the
skin dry and free of perspiration.
B) Encourage the client to express his feelings. C) Allow the client's family to stay with him.
D) Provide music as a distraction. - CORRECT ANSWER A) Determine the client's understanding of the
procedure. Using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to provide necessary teaching, which can help manage his anxiety." "A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? A) Minimize the time the head of the bed is elevated. B) Apply a sterile gauze dressing to the site. C) Massage the site with moisturizing lotion.
D) Place a donut-shaped cushion under the client's sacral area. - CORRECT ANSWER A) Minimize the
time the head of the bed is elevated. The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area." "A nurse is collecting data from a 55 yr old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? A) 5 yr history of menopause manifestations B) History of treatment for blood clots C) Topiramate use for migraine headaches
D) Increased serum cholesterol levels - CORRECT ANSWER B) History of treatment for blood clots
Estrogen increases the risk of blood clots. Therefore, a woman who has a history of blood clots should not receive HRT." "A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? A) Scaly patches B) Silvery white plaques C) Irregular borders
D) Raised edges - CORRECT ANSWER C) Irregular borders
The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma."
"A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? A) Polyuria B) Constipation C) Anorexia
D) Bradycardia - CORRECT ANSWER D) Bradycardia
The client who has hyperkalemia can have an irregular, slow heart rate, known as bradycardia." "A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? A) Muscle weakness B) Dysrhythmia C) Abdominal pain
D) Lethargy - CORRECT ANSWER B) Dysrhythmia
When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia." “A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? A) "I apply rubbing alcohol to my feet every day to prevent infection" B) "I will wear clean, knee-high wool socks everyday to help improve my circulation" C) "I use hot water bottles to keep my feet warm at night"
D) "I don't cross my legs anymore" - CORRECT ANSWER D) "I don't cross my legs anymore"
"A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? A) Halitosis B) Hemorrhoids C) Rebound tenderness
D) Small liquid stools - CORRECT ANSWER D) Small liquid stools
Small liquid stools can be the result of fecal material being expelled around an impaction." "A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?
Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract." "A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? A) Blurred vision B) Insomnia C) Bradycardia
D) Weight loss - CORRECT ANSWER C) Bradycardia
The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate." "A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? A) Albumin B) Phosphorus C) TSH
D) BUN - CORRECT ANSWER D) BUN
BUN levels indicate kidney function. Contrast media used during cardiac catheterization can cause renal failure. The nurse should review this laboratory level to determine if the client can tolerate the IV contrast dye during the procedure." "A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? A) Keep the door of the client's room closed at all times. B) Remove gloves after leaving the client's room. C) Wear a mask when working within 1 m (3 feet) of the client.
D) Have a designated stethoscope in the client's room. - CORRECT ANSWER D) Have a designated
stethoscope in the client's room. The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room." "A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan?
A) Use a commercial mouthwash before taking the medication. B) Instruct the client to swish the medication in her mouth. C) Discontinue the medication as soon as the lesions are healed.
D) Combine the medication with applesauce. - CORRECT ANSWER B) Instruct the client to swish the
medication in her mouth. The nurse should instruct the client to place half the dose in each side of her mouth, swish the medication, and then swallow. This action will allow the medication to coat the entire oral mucosa and treat the fungal infection." "A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? A) Encourage abdominal breathing B) Direct the client to inhale with pursed lips C) Set the oxygen therapy at 5L/min
D) Instruct the client to lean back while coughing - CORRECT ANSWER A) Encourage abdominal
breathing The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes." "A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include? A) Place moist heat pads on the extremities. B) Perform manual massage of the affected extremities. C) Dangle the extremities off the side of the bed.
D) Apply support stockings before getting out of bed. - CORRECT ANSWER C) Dangle the extremities
off the side of the bed. The nurse should include in the plan of care to have the client dangle the lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow." "A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? A) Collaborate with a dietitian. B) Provide nutritional supplements. C) Recommend a referral for a speech language pathologist.
D) Inform assistive personnel about proper positioning. - CORRECT ANSWER C) Recommend a referral
for a speech language pathologist.
"A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? A) Thrombophlebitis B) Infiltration C) Hematoma
D) Venous spasms - CORRECT ANSWER A) Thrombophlebitis
The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis." "A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? A) Polyuria B) Abdominal cramps C) Renal insufficiency
D) Insomnia - CORRECT ANSWER B) Abdominal cramps
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication." "A nurse is monitoring a client who recently has a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? A) Report of a dull, throbbing pain B) Extremities that are cool bilaterally C) Capillary refill of 3 seconds in the nail beds of the toes
D) Lack of sensation between the first and second toes - CORRECT ANSWER D) Lack of sensation
between the first and second toes Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. The nurse should notify the provider immediately." "A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? A) Administer doxazosin. B) Palpate the abdomen. C) Insert an indwelling urinary catheter.
D) Notify the primary care provider. - CORRECT ANSWER B) Palpate the abdomen.
When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention." "A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which
of the following locations should the nurse place the V1 electrode? (Hotspots A,B,C,D) - CORRECT
ANSWER C is correct.
The nurse should identify that the V1 electrode should be placed in the 4th intercostal space just to the right of the sternum. Correct placement of the electrodes is vital in obtaining accurate information about the electrical activity of the heart." "A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? A) Apply a mask on the client if transport is needed B) Wear a mask when working within 4 feet of the client C) Don a gown when visiting the client
D) Wear a N95 mask when entering the client's room - CORRECT ANSWER A) Apply a mask on the
client if transport is needed The nurse should apply a mask to the client who has manifestations of pertussis during transport to prevent exposure to others." "A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? Elevated sodium Elevated blood pressure Decreased potassium
Decreased urine output - CORRECT ANSWER Decreased potassium
The nurse should notify the provider immediately of a decreased potassium level because potassium is lost when a diuretic such as furosemide is administered, which can cause hypokalemia." "A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to
the nearest tenth. Use a leading zero is it applies. Do not use a trailing zero. - CORRECT ANSWER
7mg/10 mg *1mL= 0.7 mL" "A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider?
A) Place the client on a low-calorie diet to prevent weight gain B) Remind the client to avoid watching her feet when walking C) use small area rugs in the client's home for traction
D Instruct the client to take tub baths instead of showers - CORRECT ANSWER B) Remind the client to
avoid watching her feet when walking The nurse should instruct the client's family to frequently remind the client to maintain correct posture and prevent falls by not watching her feet when walking." "A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? A) "You may cross your legs in 60 days" B) "Avoid lying on your operative side" C) "Avoid bending your hips more than 90 degrees"
D) You may sleep on a soft mattress" - CORRECT ANSWER C) "Avoid bending your hips more than 90
degrees" The nurse should instruct the client to avoid bending her hips more than 90° to prevent dislocation of the replacement hip." "A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? A) Administer an analgesic following wound care. B) Irrigate the wound with povidone iodine. C) Cleanse the wound with a cotton-tipped applicator.
D) Report purulent drainage to the provider. - CORRECT ANSWER D) Report purulent drainage to the
provider. The nurse should remind the family member to report signs of infection, including purulent drainage." "A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? A) Avoid liquids at mealtimes B) Exclude eating starchy vegetables C) Avoid eating high-protein meals
D) Plan to increase intake of sweetened fruits - CORRECT ANSWER A) Avoid liquids at mealtimes
The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly."
"A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? A) "You can take acetaminophen for pain" B) "Consume a diet high in animal protein" C) "Sleep lying flat on your back"
D) "Consume foods low in sodium" - CORRECT ANSWER D) "Consume foods low in sodium"
The nurse should instruct the client to consume foods low in sodium to reduce the development of edema and ascites." "A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take with communicating with the client? A) Rephrase client instructions when not understood B) Cup hands around the mouth and direct speech toward the client C) Accentuate vowel sounds by using a higher pitch when speaking
D) Sit to the side of the client and speak instructions into her best eat - CORRECT ANSWER A) Rephrase
client instructions when not understood When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood." "A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals? A) Butter B) Coconut Oil C) Olive Oil
D) Shortening - CORRECT ANSWER C) Olive Oil
The nurse should instruct the client who has cardiovascular disease to consume foods which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or other vegetable oils, rather than foods that are high in saturated fat. The nurse should reinforce that oils high in monounsaturated fats help decrease the client's cardiovascular risk by lowering LDL cholesterol and triglyceride levels." "A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? A) "I should wait at least 2 hours after eating before going to bed." B) "I should eat three meals a day without eating snacks between meals." C) "I should season my food with garlic."
