Med Surge Practice Questions

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply.) A. Use antimicrobial ointment on the peristomal skin B. Empty the bag when it is one-third to one-half full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water E. Apply the skin barrier while slightly moist.

Ans: BCD Allowing the bag to become too full can cause leakage. The client should cut an opening that is about 1/16 to 1/8 larger than the stoma to avoid applying any constricting pressure to the stoma. The client should avoid moisturizing soaps because lubricants can affect adhesion of the appliance. Incorrect Answers: A. Oil-based ointments on the skin disrupt adhesion, and antimicrobials are not necessary unless prescribed by the provider to treat an infection. E. The skin must be dry before applying the skin barrier since the pouch will not adhere to moist skin.

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestation of the client's skin should the nurse expect? A) Confluent, honey-colored, crusted lesions. B) A large, tender nodule located on a hair follicle C) Unilateral, localized, nodular skin lesions D) A fluid-filled vesicular rash in the genital region

Ans: C Herpes zoster, or shingles, results from the reactivation of dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. Infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces localized, nodular skin lesions. A) Confluent, honey-colored, crusted lesions: associated with impetigo B) A large, tender nodule located on a hair follicle: this describes furuncle or bacterial infection on hair follicle. D) A fluid-filled vesicular rash in the genital region: this manifest d=genital herpes, which is caused by herpes simplex virus.

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to take methotrexate, even if I'm in remission." B. " I am thankful that this type of lupus only affects the skin" C. "Each day, I should apply a sunblock with a sun protection factor of 15." D. " A mild fever is common with SLE and usually does not require medical intervention. "

Correct Answer: A. "I will need to take methotrexate, even if I'm in remission." The nurse should inform the client that SLE is an autoimmune disorder characterized by exacerbations and remissions. It affects the skin, joints, organs, and any structure in the body that contains connective tissue. Methotrexate is an immunosuppressive medication given during remission to help prevent exacerbation. The medication is also given when exacerbations occur to reduce the severity of manifestations. Incorrect Answers: B. Discoid lupus erythematosus only affects the skin; however, SLE affects the skin, joints, organs, and any structure in the body that contains connective tissue. C. The client should be encouraged to protect the skin from sun exposure to reduce the incidence of exacerbations. The nurse should recommend using a sunblock with a sun protection factor of at least 30. D. An elevated temperature is an indication of an exacerbation. The client should report this finding to the provider immediately.

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? A. Lymph nodes B. Maxillary Sinuses C. Intercostal spaces D. Salivary glands

Correct Answer: B. Maxillary sinuses Transillumination is a procedure that allows the passage of light, often bright halogen light, through body tissues. Occluded sinuses prevent the passage of light rays through the sinus air sacs. Clear sinus air spaces allow transillumination. Incorrect Answers: A. Transillumination cannot help the provider evaluate lymph nodes, which are tiny organs throughout the body that collect tissue fluid. C. Transillumination cannot help the provider evaluate intercostal spaces, which are the areas between the ribs. D. Transillumination cannot help the provider evaluate salivary glands, which are tiny organs that secrete saliva to aid the digestive process.

A nurse is performing a preoperative assessment of a client about to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods? A. Cabbage B. Oatmeal C. Milk D. Bananas

Correct Answer: D. Bananas An allergy to bananas is a risk factor that indicates the client could also be allergic to latex. Other cross-reactive foods include avocados, kiwi, chestnuts, mangoes, pineapple, and passion fruit. The health care team should wear non-latex gloves and use only latex-free supplies when caring for this client. Incorrect Answers: There is no known association between a latex allergy and a allergy to the other options.

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the client's perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infections

Correct Answer: B. Addressing the client's perception of the disease process and what might have triggered past attacks The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's current knowledge.

A nurse is monitoring the EKG of a client who has hypocalcemia. Which of the following findings should the nurse expect? A) Flattened T waves B) Prolonged QT intervals C) Shortened QT intervals D) Widened QRS complexes

Correct Answer: B. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea. Incorrect Answers: A. Hypokalemia causes flattened T waves and cardiac dysrhythmias. C. Hypercalcemia shortens QT intervals. D. Hyperkalemia widens QRS complexes.

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts

Correct Answer: B. Retinal detachment A flash of light and a sudden loss of vision are manifestations of retinal detachment. Clients report the event of vision loss as sudden and painless. Incorrect Answers: A. Manifestations of glaucoma include sudden, severe pain around the eyes. The pain often radiates over the face, and the client reports a headache, halos around lights, and sudden blurred vision. C. Manifestations of macular degeneration include a decline of central vision leading to a total loss. Clients often report mild blurring and distortion. D. Manifestations of cataracts include blurred vision and decreased color perception at first, followed by a lens of cloudiness that continues gradually until a loss of vision occurs in all visual fields.

A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? A. Amylase B. Lipase C. Steapsin D. Pepsin

Correct Answer: D. Pepsin Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body. Incorrect Answers: A. Amylase is an enzyme secreted by the pancreas and intestine that breaks down starches into glucose. B. Lipase is an enzyme secreted by the pancreas that breaks down triglycerides into monoglycerides. C. Steapsin is an enzyme secreted by the gastric mucosa that breaks down triglycerides into monoglycerides.

A nurse is assessing a client who is recovering from a thyroidectomy and has a harsh, high-pitched sound. Which of the following actions should the nurse take? A) Hyperextend the client's neck B) Prepare for a tracheostomy C) Lower the HOB D) Administer morphine

Ans: B The nurse should notify the provider immediately and prepare for a tracheostomy. Laryngeal stridor is a high-pitched, harsh breathing sound that indicates respiratory distress due to swelling, tetany, and laryngeal spasms. Do not hyperextend neck as it can place tension on the incision and cause bleeding. Elevate HOB promotes ventilation. Morphine can cause respiratory depression.

A Charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A) Leaving soiled lines in a containers in the client's room B) Instructing visitors to remain 6 feet away from the client C) Borrowing a dosimeter film badge from another nurse before entering the client's room D) Removing an extra IV pole from the client's room to be sued for another client

Ans: C A nurse should never borrow a film badge form another staff member. The badge measures the radiation exposure that the nurse is receiving, and each film badge will indicate the nurse's cumulative radiation exposure. Linen's and dressings should be kept in the room until after radiation has been discontinued. Visitors limited to 30 mins per day and stay 6 feet away from client. Equipment can be removed and does not posed a problem because it is not emitting radiation.

A nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. For which of the following complications of the rewarming process should the nurse monitor the client? A) Acidosis B) Infection C) Hypertension D) Cardiac tamponade

Correct Answer: A. Acidosis Metabolic acidosis associated with hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than 1°C (1.8°F) per hour. Incorrect Answers: B. The client could develop an infection following CABG surgery, but this is not the result of rewarming. Infection can be a result of surgical incisions or invasive tubes and procedures. C. Hypothermia promotes vasoconstriction, which puts the client at risk of hypertension. Rewarming the client reduces this risk. D. Cardiac tamponade results from bleeding inside the pericardium or blood backing up in mediastinal tubes and compressing the heart. Rewarming does not contribute to cardiac tamponade.

A nurse is caring for a client who has a demand pacemaker inserted with a set rate of 72/min. Which of the following findings should the nurse expect? A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes. B. Premature ventricular complexes at 12/min. C. Telemetry monitoring showing pacing spikes with no QRS complexes D/ Hiccups

Correct Answer: A. Telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes The nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min because the client's intrinsic rate overrides the set rate of the pacemaker. Incorrect Answers: B. The nurse should report frequent premature ventricular complexes because this complication can indicate a lead wire is displaced in the ventricle. C. The nurse should report pacer spikes without QRS complexes because this complication can indicate noncapture of the pacemaker. D. The nurse should report hiccups because this complication can indicate a lead wire is displaced and is stimulating the diaphragm.

A nurse is providing discharge teaching to a client following an open radical prostatectomy. The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching? A. " I will be able to take a tub bath in 1 week" B. " I will change the catheter drainage bag once each week" C. "I will use suppositories to prevent constipation" D. " I will regain my bladder control once the catheter is removed"

Correct Answer: B. "I will change the catheter drainage bag once each week." The nurse should teach the client how to change the catheter drainage bag and explain the importance of changing the bag at least once each week. Incorrect Answers: A. The nurse should instruct the client to shower rather than take a tub bath for 2 to 3 weeks following an open radical prostatectomy. C. The nurse should instruct the client to use stool softeners rather than suppositories to control constipation. D. The nurse should inform the client that bladder control might not return immediately and to practice Kegel exercises, which can relieve incontinence. Urinary incontinence can last for 1 to 2 years following surgery.

A nurse is providing teaching about disease management to a client who has rheumatoid arthritis. Which of the following responses by the client indicates an understanding of the teaching? A. " I will take a hot bath every morning to decrease my stiffness." B " When my arthritis acts up, I will rest all day and avoid exercise." C. " I will have handrails installed in my bathroom and hall." D. " I will avoid taking naps so I sleep better at night."

Correct Answer: C. "I will have handrails installed in my bathroom and hall." The nurse should instruct the client to have handrails installed in the bathroom and hall to promote safety as the disease progresses. Incorrect Answers: A. The nurse should instruct the client to take a hot shower to decrease morning stiffness. Getting in and out of a bathtub is a safety risk for a client who has rheumatoid arthritis. B. Immobility will further hinder joint movement and should be avoided. Gentle exercise of the affected extremities should be performed, even when joints are painful and inflamed. A physical therapy regimen might be required. D. The client should balance activity with rest by taking 1 or 2 naps during the day.

A nurse names 3 objects for the client to remember, asks the client to repeat them, and tells the client he will have to repeat them again in a few minutes. After 5 min, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory? A. Remote B. Sensory C. Immediate D. Recall

Correct Answer: C. Immediate The nurse tests the client's immediate or new memory by following the 3-object protocol. A client without cognitive decline should be able to recall and name the 3 objects 5 minutes later. Incorrect Answers: A. The nurse tests remote or long-term memory by asking about information from the client's past that family or friends can verify later. B. Sensory memory is a momentary perception of some form of stimuli from the environment. Recalling 3 objects 5 minutes later does not test sensory memory. D. The nurse tests recall or recent memory by asking questions about recent activities that can be verified in the client's medical record, such as how the client got to the facility or the time of admission.

A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temperature C. Sudden oliguria D. Decreased respirations

Correct Answer: C. Sudden oliguria The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs. Incorrect Answers: A. Hypotension due to circulatory shock is an indication of an intravascular hemolytic reaction. B. A fever is an indication of an intravascular hemolytic reaction. D. Tachypnea as a compensatory mechanism due to circulatory shock is an indication of an intravascular hemolytic reaction.

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr.? A. Ineffective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

Correct Answer: C. Ventricular dysrhythmias After a myocardial infarction, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infarction can also interfere with the normal conduction patterns of the heart's electrical system. Incorrect Answers: A. Infective endocarditis occurs when bacteria invade the endothelial surface of the heart. Infective endocarditis is usually seen in clients who have prosthetic heart valves or pacemakers. B. Pericarditis can occur from 10 days to 2 months following a myocardial infarction. Pericarditis is an inflammation of the pericardial sac that surrounds the heart and is usually a result of infection, connective tissue disorders, or trauma. D. Pulmonary emboli occur if the client develops heart failure following a myocardial infarction. Pulmonary emboli are found more commonly with valvular disorders, atrial fibrillation, or deep-vein thrombosis.

A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A) Avoid foods containing protein B) Drink liquids during each meal C) Eat foods that contain simple sugars D) Maintain supine position after meals

Correct Answer: D. Maintain a supine position after meals The nurse should instruct the client to lie supine after eating to help slow the rapid emptying of food into the small intestine. A client who has dumping syndrome should decrease the amount of food eaten at once, eat small meals more frequently, and eliminate fluids at mealtime. Fluid shifts occur in the upper gastrointestinal tract when food contents and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine and decreasing blood volume, which causes the client to experience nausea and vomiting, sweating, syncope, palpitations, increased heart rate, and hypotension. Incorrect Answers: A. The nurse should instruct the client to include foods containing protein at each meal and only to eat 1 or 2 foods from each food group at once. Protein, fats, and complex carbohydrates are better tolerated by a client who recently had gastric bypass surgery. B. The nurse should instruct the client to avoid drinking liquids during meals and to wait 30 to 60 minutes after eating solid foods to drink liquids. Drinking liquids with meals increases the motility of the gastrointestinal tract. C. The nurse should instruct the client to avoid eating foods that contain simple sugars. Simple sugars increase the hypertonicity of the gastrointestinal tract, which increases the movement of the food bolus.

A nurse is assessing a client who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? A. <0.5 mL/Kg of urine output for 12 hr. B. No urine output for 12 hr. C. No urine output without renal replacement therapy for 4 to 12 weeks. D. No urine output without renal replacement therapy for more than 3 months.

Correct Answer: D. No urine output without renal replacement therapy for more than 3 months In the RIFLE classification, R stands for Risk, I stands for Injury, F stands for Failure, L stands for Loss, and E stands for End-stage kidney disease. No urine output without renal replacement therapy for more than 3 months indicates end-stage kidney disease.