Med surg exam 3 practice questions

C. Maintaining fluid and electrolyte balance

****Of the following outcomes for client care after an ileostomy, which has the highest priority? A. Providing relief from constipation B. Assisting the client with self-care activities C. Maintaining fluid and electrolyte balance D. Minimizing odor formation

A. Assess the amount of drainage from the nasogastric (NG) tube

****On the first postoperative day after an open Billroth I procedure a client develops hiccups, 6 on a scale of 10 epigastric pain, and a blood pressure drop. The nurse's initial actions should be to: A. Assess the amount of drainage from the nasogastric (NG) tube B. Notify the client's physician C. Assess the abdominal dressing D. Administer the ordered morphine sulfate 4 mg IV

c) "I can pull out cast padding to scratch inside the cast."

****Which of the following client statements identifies a knowledge deficit about cast care? a) "I'll elevate the cast above my heart initially." b) "I'll exercise my joints above and below the cast." c) "I can pull out cast padding to scratch inside the cast." d) "I'll apply ice for 10 minutes to control edema for the first 24 hours."

a) X-ray of the affected joints

***The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests would the nurse expect the health-care provider to order to R/O osteoarthritis? a) X-ray of the affected joints b) Serum studies for synovial fluid amount c) Serum erythrocyte sedimentation rate (ESR) d) Full body magnetic resonance imaging scan

A. 52-year-old man with a family history of polyposis

***The nurse is conducting a screening for colorectal cancer. The client with the highest risk of colorectal cancer is a: A. 52-year-old man with a family history of polyposis B. 32-year-old woman with a history of skin cancer C. 61-year-old man with a history of gastric ulcers D. 42-year-old man following a low-fat, 1800-calorie diet

A. The client's abdomen is rigid and painful

***Which information about a client admitted with a duodenal ulcer should the nurse report immediately to the physician? A. The client's abdomen is rigid and painful B. The client is complaining of intermittent nausea C. The client's NG drainage has a coffee-ground appearance D. The client reports drinking approximately 10 beers every day

B. Have the client lie down

Fifteen minutes after eating, a client who has had a gastrojejunostomy complains of abdominal cramping and palpitations. Which action should the nurse take? A. Administer prn metoclopramide (Reglan) B. Have the client lie down C. Place the client on NPO status for 24 hours D. Notify the physician

c) Pain upon joint movement

A 60-year-old woman has primary osteoarthritis of the left knee. A finding that the nurse would expect to be present on examination of the patient's knee is: a) Has nodules b) A reddened, swollen joint c) Pain upon joint movement d) Stiffness that increases with movement

C. The client is experiencing a side effect of the aluminum hydroxide

A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client' constipation? A. The client has not been including enough fiber in his diet B. The client needs to increase his daily exercise C. The client is experiencing a side effect of the aluminum hydroxide D. The client has developed a gastrointestinal obstruction

D. Enterostomal nurse therapist

A client is scheduled to have a descending colostomy. He's anxious, and has many questions concerning the surgery, the care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to refer the client to which member of the health care team? A. Social worker B. Registered dietitian C. Occupational therapist D. Enterostomal nurse therapist

a) In an abducted position

A client received a right hip prosthesis after a fall. In the immediate postoperative period, the nurse should maintain the leg: a) In an abducted position b) In an adducted position c) In a neutral position d) With the hip flexed greater than 90 degrees

a) Presence of distal pulse

A client who crashed her motorcycle suffered a tibial fracture that required casting. Approximately 5 hours later, the client begins to complain of increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following would be the nurse's next assessment? a) Presence of distal pulse b) Pain with pain rating scale c) Vital signs change d) Potential for drug tolerance

A. "Can you tell me more about why you are afraid?"

A client who has been diagnosed with gastric cancer tells the nurse, "I am so afraid!" Which response by the nurse is most appropriate? A. "Can you tell me more about why you are afraid?" B. "Do you think that an antianxiety medication would help?" C. "Perhaps talking to a clergyman would help decrease your fear." D. "It is quite common for people with your diagnosis to be fearful."

D. Ineffective coping related to chronic abdominal pain

A client who has unlcerative colitis says to the nurse, "I cannot take this anymore! I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, an appropriate nursing diagnosis of this client would be A. Impaired physical mobility related to fatigue B. Disturbed thought processes related to pain C. Social isolation related to chronic fatigue D. Ineffective coping related to chronic abdominal pain

C. "The bottom part of the stomach is removed and the remainder is attached to the small intestine."

A client who is scheduled for a Billroth II procedure asks the nurse to explain what will be done during the surgery. Which response should the nurse make? A. "The surgeon will explain the procedure to you since the doctor is responsible for obtaining consent." B. "Your stomach is completely removed and the esophagus is connected to the small intestine." C. "The bottom part of the stomach is removed and the remainder is attached to the small intestine." D. "The nerves that go to your stomach are cut and a larger opening is made for stomach emptying."

C. Cherry gelatin

A client who was admitted with acute gastritis with nausea and vomiting has been NPO (nothing by mouth) for 2 days. The client has a new "diet as tolerated" order. What should the nurse offer to the client? A. Tomato juice B. Tossed salad C. Cherry gelatin D. Nonfat milk

d) Dark, scanty urine

A client with a fracture develops compartment syndrome. Which of the following signs would alert the nurse to impending organ failure? a) Rales b) Jaundice c) Generalized edema d) Dark, scanty urine

a) Crossing the legs while sitting down

A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities would the nurse instruct the client to avoid? a) Crossing the legs while sitting down b) Sitting on a raised commode seat c) Using an abductor splint while lying on the side d) Rising straight from a chair to a standing position

A. An esophagogastroduodenoscopy (EGD)

A client with a history of peptic ulcer disease is admitted to the emergency department with massive vomiting of blood. The nurse prepares for: A. An esophagogastroduodenoscopy (EGD) B. An upper gastrointestinal (GI) tract x-ray series C. Blood testing for Helicobacter pylori D. Stool testing for occult blood

B. Disturbed sleep pattern related to epigastric pain

A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate? A. Imbalanced nutrition: less than body requirements related to anorexia B. Disturbed sleep pattern related to epigastric pain C. Ineffective coping related to exacerbation of duodenal ulcer D. Activity intolerance related to abdominal pain

c) "Fluid won't be allowed to accumulate at the site."

A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, "Why does she have this tube inserted in her hip?" Which of the following responses would be best? a) "The tube helps us to detect a wound infection early on." b) "This way we won't have to irrigate the wound." c) "Fluid won't be allowed to accumulate at the site." d) "We have a way to administer antibiotics into the wound."

c) Encouraging the client to resume activity gradually

After a cast is removed, the best nursing intervention is: a) Placing the limb in a depend position b) Encouraging the client to exfoliate dry skin by scratching c) Encouraging the client to resume activity gradually d) Avoiding emollient on the area that was immobilized

B. Encourage the client to eat smaller amounts more frequently

As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identified Imbalanced nutrition: less than body requirements as a major nursing diagnoses. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions? A. Instruct the client to increase the amount eaten eat each meal B. Encourage the client to eat smaller amounts more frequently C. Explain that if vomiting occurs after a meal, nothing more should be eaten that day D. Inform the client that bland foods are typically less nutritional and should be used minimally

c) Compartment syndrome

The nurse has administered analgesics and elevates the limb for a client complaining of pain to the leg, which is casted. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. This may be a sign of a) Ischemia b) A pressure ulcer c) Compartment syndrome d) Disuse syndrome

C. Consume high-residue, high-fiber foods

Management of clients with intestinal and rectal disorders. Which of the following should be included in client teaching to prevent constipation? A. Establish a bowel routine based upon the fact that the best time for defecation is after dinner B. Exercise may prolong a bowel movement C. Consume high-residue, high-fiber foods D. Resist the urge to defecate until the scheduled time

D. Administer the ordered prn morphine sulfate

On the first day after a gastrectomy, a client complains of incisional pain rated at 8 on a scale of 10. The nurse notes coffee-ground nasogastric drainage and crackles throughout both lungs. Which action should the nurse take first? A. Auscultate for bowel sounds B. Infuse the ordered famotidine (Pepcid) C. Assist the client to cough and breathe deeply D. Administer the ordered prn morphine sulfate

A. Cancer of the colon is associated with a lack of fiber in the diet

The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? A. Cancer of the colon is associated with a lack of fiber in the diet B. Cancer of the colon has a greater incidence among those younger than age 50 years C. Cancer of the colon has no known risk factors D. Cancer of the colon is rare among make clients

A. Watery with blood and mucus

The client arrives in the clinic with a complaint of altered bowel habits and has a family history of ulcerative colitis. The stools of these clients are characteristically: A. Watery with blood and mucus B. Hard and black C. Long and cylinder shaped D. Loose and fatty

C. "I can see you very upset. I'll sit down and we can talk."

The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement would be the nurse's best response? A. "I understand how frustrating this must be for you." B. "You must keep thinking about the good things in your life." C. "I can see you very upset. I'll sit down and we can talk." D. "Are you thinking about doing anything like committing suicide?"

A. Check the client's glucose level

The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? A. Check the client's glucose level B. Administer an oral hypoglycemic C. Assess the peripheral intravenous site D. Monitor the client's oral food intake

D. Empty the pouch when it is one-third to one-half full

The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? A. The stoma should be a white, blue, or purple color B. Limit ambulation to prevent the pouch from coming off C. Take pain medication when the pain level is at an "8" D. Empty the pouch when it is one-third to one-half full

D. Aspiration of gastric contents

The client with GERD complains of a chronic cough. The nurse understands that in a client GERD this symptom may be indicative of which of the following conditions? A. Development of laryngeal cancer B. Irritation of the esophagus C. Esophageal scar tissue formation D. Aspiration of gastric contents

d) Instruct the client to push the residual limb against a pillow

The client with a right AKA is being taught how to toughen the residual limb? Which intervention should the nurse implement? a) Demonstrate how to apply an elastic bandage around the residual limb b) Encourage the client to apply vitamin B12 to the surgical incision c) Teach the client to elevate the residual limb at least three times a day d) Instruct the client to push the residual limb against a pillow

B. Assess the client for a rigid abdomen

The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate? A. Reassure the client that the nasoenteric tube is functioning B. Assess the client for a rigid abdomen C. Administer narcotic as ordered D. Reposition the client on the left side

B. To reduce intestinal peristalsis

The client with ulcerative colitis following orders for bed rest with bathroom privileges. What would be the primary rationale for this activity restriction? A. To relieve pain B. To reduce intestinal peristalsis C. To promote rest and comfort D. To prevent injury

c) Prepares for probable intubation

The nurse hears crackles and wheezes in an elderly patient who was admitted for multiple bone fractures. The patient appears apprehensive with and oxygen saturation of 84% on 3 L/min nasal cannula. The nurse stays with the patient and: a) Puts the patient in Trendelenburg position b) Begins chest compressions c) Prepares for probable intubation d) Administers intravenous fluids

A. "I'll avoid lying down after a meal"

The nurse instructs the client on health maintenance activities to help control symptoms from her hiatal hernia. Which of the following statements would indicate that the client has understood the instructions? A. "I'll avoid lying down after a meal" B. "I can still enjoy my potato chips and cola at bedtime" C. "I wish I did not have to give up swimming" D. "If I wear a girdle, I'll have more support for my stomach"

b) Inability to move

The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity? a) Decreased distal pulse b) Inability to move c) Diminished capillary refill d) Coolness to the touch

B. Tofu

The nurse is assisting a client admitted with inflammatory bowel disease with menu selections. Which of the following menu selections is the best choice for this client? A. Taco B. Tofu C. Multigrain bagel D. Blueberries

A. Can perforate an intestinal abscess

The nurse is aware that diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema A. Can perforate an intestinal abscess B. Would greatly increase the client's pain C. Is of minimal diagnostic value in diverticulitis D. Is too lengthy a procedure for the client to tolerate

B. The client has a temperature of 100°F D. The client complains of epigastric pain E. The client experiences hematemesis

The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply A. The client complains of a sore throat B. The client has a temperature of 100°F C. The client appears drowsy following the procedure D. The client complains of epigastric pain E. The client experiences hematemesis

b) The client with a total knee replacement who is complaining of a cold foot

The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first? a) The client diagnosed with osteoarthritis who is complaining of stiff joints b) The client with a total knee replacement who is complaining of a cold foot c) The client who needs to receive a scheduled intravenous antibiotic d) The client diagnosed with back pain who is scheduled for a lumbar myelogram

A. Changing central venous line dressing daily

The nurse is developing a plan for care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions would the nurse exclude? A. Changing central venous line dressing daily B. Weighting the client daily C. Monitoring the intravenous infusion rate hourly D. Taping all intravenous tubing connections securely

C. The nurse checks for residual amounts every 4 hours

The nurse manager observes a new nurse caring for a client who has a jejunal feeding tube. Which action by the new nurse indicates a need for more education about jejunal feedings? A. The nurse instills 100 mL of water into the tube B. The nurse leaves the tube insertion site open to air C. The nurse checks for residual amounts every 4 hours D. The nurse auscultates the client's abdomen for bowel sounds

A. Ropes and pulleys are in straight alignment

The nurse monitors the traction of a client with a fractured hip who is being prepared for surgery. The nurses know that tractions is being maintained upon finding that the: A. Ropes and pulleys are in straight alignment B. Client's affected leg is in external rotation C. Client's unaffected leg is touching the end of the bed D. Ropes are all the same length, and knots are securely tied

C. Rectal bleeding

Then nurse is preparing a teaching plan for a community presentation on the prevention and early detection of colon cancer. Which of the following would the nurse identify to the audience as the most common symptom of colon cancer? A. Abdominal pain B. Diarrhea C. Rectal bleeding D. Abdominal distention

d) Assess the pin insertion site every 8 hours

To prevent the complication of skin breakdown in a client with skeletal traction, the nurse should implement which of the following preventive measures? a) Do not remove the crusting around the pin insertion site b) Encourage the client to push up with the elbows when repositioning c) Encourage the client to perform ankle and calf muscle exercises once a shift d) Assess the pin insertion site every 8 hours

D. Decrease the carbohydrate content of meals

To reduce the risk of dumping syndrome, the nurse should teach the client which of the following interventions? A. Sit upright for 30 minutes after meals B. Drink liquids with meals, avoiding caffeine C. Avoid milk and other dairy products D. Decrease the carbohydrate content of meals

c) The area distal to the fracture

When admitting a client with a fractured extremity the nurse would first focus the assessment on which of the following? a) The area proximal to the fracture b) The actual fracture site c) The area distal to the fracture d) The opposite extremity for baseline comparison

C. Clients should experiment to find the diet that is best for them

When planning diet teaching for the client with a colostomy, the nurse would develop a plan that emphasizes which of the following dietary instructions? A. Foods containing roughage should not be eaten B. Liquids are best limited to prevent diarrhea C. Clients should experiment to find the diet that is best for them D. A high-fiber diet will produce a regular passage of stool

B. Managing diarrhea

Which goal for the client's care should take propriety during the first days of hospitalization for an exacerbation of ulcerative colitis? A. Promoting self-care independence B. Managing diarrhea C. Maintaining adequate nutrition D. Promoting rest and comfort

d) Keep the injury immobilized and elevated for 24 to 48 hours

Which information should the nurse teach the client regarding sports injuries? a) Apply hear intermittently for the first 48 hours b) An injury is not serious if the extremity can be moved c) Only return to health-care provider if the foot becomes cold d) Keep the injury immobilized and elevated for 24 to 48 hours

B. The client will explain the rationale for eliminating alcohol from the diet

Which of following would be an expected outcome for a client with peptic ulcer disease? A. The client will demonstrate appropriate use of analgesics to control pain B. The client will explain the rationale for eliminating alcohol from the diet C. The client will verbalize the importance of monitoring hemoglobin and hematocrit every 3 months D. The client will eliminate contact sports from his or her lifestyle

b) Absence of feeling, capillary refill of 4-5 seconds, and cool skin

Which of the following assessment findings may indicate peripheral neurovascular dysfunction to the nurse? a) Pale, warm skin with a capillary refill of 1-2 seconds b) Absence of feeling, capillary refill of 4-5 seconds, and cool skin c) Pain, increased motion, and redness of the skin d) Jaundiced skin, weakness in motion, and capillary refill of 3 seconds

A. Eating small, frequent meals

Which of the following dietary measures would be useful in preventing esophageal reflux? A. Eating small, frequent meals B. Increasing fluid intake C. Avoiding air swallowing with meals D. Adding a bedtime snack to the dietary plan

C. Deficient fluid volume related to nausea and vomiting

Which of the following nursing diagnoses would be most appropriate for a client with an intestinal obstruction? A. Impaired swallowing related to NPO status B. Urinary retention related to deficient fluid volume C. Deficient fluid volume related to nausea and vomiting D. Chronic pain related to abdominal distention

D. Achieve optimal nutritional status through oral or parenteral feedings

Which of the following would be an expected nutritional outcome for a client who has undergone a subtotal gastrectomy for cancer? A. Regain weight loss within 1 month after surgery B. Resume normal dietary intake of three meals a day C. Control nausea and vomiting through regular use of antiemeics D. Achieve optimal nutritional status through oral or parenteral feedings

c) Shortening of affected leg

Which of the following would the nurse assess in a client with an intracapsular hip fracture? a) Internal rotation b) Muscle flaccidity c) Shortening of affected leg d) Absence of pain in the fracture area

B. "I should have my big meal at lunchtime."

Which statement by a client who has received education about gastroesophageal reflux disease (GERD) indicates that the nurse may need to provide additional teaching? A. "I will take antacids before I eat." B. "I should have my big meal at lunchtime." C. "I am going to quit smoking today." D. "I should use two pillows to sleep on at night."

B. The client asks about the supplies used during the dressing change

While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following? A. The client ask what time the doctor will visit that day B. The client asks about the supplies used during the dressing change C. The client talks about something she read in the morning newspaper D. The client complains about the way the night nurse changed the dressing