excitability) to prevent atrial fibrillation. He also has kidney disease. The nurse is aware that this drug, when given to a client with kidney disease, may a. Cause cardiac arrest b. Cause hypotension c. Produce mild bradycardia d. Be very toxic even in small doses Answer: a Rationale: Kidney disease interferes with metabolism and excretion of Quinidine, resulting in higher drug concentrations in the body. Quinidine can depress myocardial myocardial excitability enough to cause cardiac arrest. 6. A client is about to be discharged on the drug bishydroxycoumarin (Dicumarol). Of the principles below, which one is the most important to teach the client before discharge? a. He should be sure to take the medication before meals b. He should shave with an electric razor c. If he misses a dose, he should double the dose at the next scheduled time d. It is the responsibility of the physician to do the teaching for this medication Answer: b Rationale: Dicumarol is an anticoagulant drug and one of the dangers involved is bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be given at the same time daily but not related to meals. Due to danger of bleeding, missed doses should not be made up. 7. A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be to a. Wait until the client's lab work is done b. Not administer oxygen unless ordered by the physician c. Administer oxygen at 2 liters flow per minute d. Administer oxygen at 10 liters flow per minute and check the client's nail beds Answer: c Rationale: Administer oxygen at 2 liters per minute and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function 8. A client with a diagnosis of gout will be taking colchicine and allopurinol bid to prevent recurrence. The most common early sign of colchicine toxicity that the nurse will assess for is a. Blurred vision b. Anorexia c. Diarrhea
excitability) to prevent atrial fibrillation. He also has kidney disease. The nurse is aware that this drug, when given to a client with kidney disease, may a. Cause cardiac arrest b. Cause hypotension c. Produce mild bradycardia d. Be very toxic even in small doses Answer: a Rationale: Kidney disease interferes with metabolism and excretion of Quinidine, resulting in higher drug concentrations in the body. Quinidine can depress myocardial myocardial excitability enough to cause cardiac arrest. 6. A client is about to be discharged on the drug bishydroxycoumarin (Dicumarol). Of the principles below, which one is the most important to teach the client before discharge? a. He should be sure to take the medication before meals b. He should shave with an electric razor c. If he misses a dose, he should double the dose at the next scheduled time d. It is the responsibility of the physician to do the teaching for this medication Answer: b Rationale: Dicumarol is an anticoagulant drug and one of the dangers involved is bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be given at the same time daily but not related to meals. Due to danger of bleeding, missed doses should not be made up. 7. A cyanotic client with an unknown diagnosis is admitted to the emergency room. In relation to oxygen, the first nursing action would be to a. Wait until the client's lab work is done b. Not administer oxygen unless ordered by the physician c. Administer oxygen at 2 liters flow per minute d. Administer oxygen at 10 liters flow per minute and check the client's nail beds Answer: c Rationale: Administer oxygen at 2 liters per minute and no more, for if the client is emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will cease to function 8. A client with a diagnosis of gout will be taking colchicine and allopurinol bid to prevent recurrence. The most common early sign of colchicine toxicity that the nurse will assess for is a. Blurred vision b. Anorexia c. Diarrhea
d. Fever Answer: c Rationale: Diarrhea is by far the most common early sign of colchicine toxicity. When given in the acute phase of gout, the dose of colchicine is usually 0.6 mg (PO) q hr (not to exceed 10 tablets) until pain is relieved or gastrointes gastrointestinal tinal symptoms ensue. 9. A client has chronic dermatitis involving the neck, face and antecubital creases. She has a strong family history of varied allergy disorders. disorders. This type of dermatitis is probably best described as a. Contact dermatitis b. Atopic dermatitis c. Eczema d. Dermatitis medicamentosa Answer: b Rationale: Atopic dermatitis dermatitis is chronic, pruritic and allergic in nature. Typically it has a longer course than contact dermatitis and is aggravate aggravated d by commerc commercial ial face or body lotions, emotional stress, and, in some instances, particular foods. 12. The nurse would expect to find an improvement in which of the blood values as a result of dialysis treatment? a. High serum creatinine levels b. Low hemoglobin c. Hypocalcemia d. Hypokalemia Answer: a Rationale: High creatinine levels will be decreased. Anemia is a result of decreased production of erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base bicarbonate levels are present in renal failure clients. 13. A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. Insert sterile packing into the nares and remove in 24 hours Answer: b
Rationale: The halo or "bull's eye" sign seen when drainage from the nose or ear of a head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated contraindicat ed because brain tissue may be inadvertently removed at the same time or other tissue damage may result. 14. A 24-year-old male is admitted with a possible head injury. His arterial blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that a. Edema has resulted from a low pH state b. Acidosis has caused vasoconstriction vasoconstriction of cerebral arterioles c. Cerebral edema has resulted from a low oxygen state d. Cerebral blood flow has decreased Answer: c Rationale: Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation vasodilatat ion particularly in response to a decrease in the PaO2 below 60 mmHg. 16. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is a. That it is reversible b. Amnesia will occur c. Loss of consciousne consciousness ss may be transient d. Laceration of the brain may occur Answer: d Rationale: Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousne consciousness, ss, retrograde amnesia, and is generally reversible. 17. A client with tuberculosis is given the drug pyrazinamide (Pyrazinamide). Which one of the following diagnostic tests would be inaccurate if the client is receiving the drug? a. Liver function test b. Gall bladder studies c. Thyroid function studies d. Blood glucose Answer: a Rationale: Liver function tests can be elevated in clients taking pyrazinamide. This drug is used when primary and secondary antitubercular drugs are not effective. Urate levels may be increased and there is a chemical interference with urine ketone levels if these
tests are done while the client is on the drug. 18. Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the client's ear? a. Artificial nails b. Vasodilation c. Hypothermia d. Movement of the head Answer: c Rationale: Hypothermia or fever may lead to an inaccurate reading. Artificial nails may distort a reading if a finger probe is used. Vasoconstriction can cause an inaccurate reading of oxygen saturation. Arterial saturations have a close correlation with the reading from the pulse oximeter as long as the arterial saturation is above 70 percent. 19. While on a camping trip, a friend sustains a snake bite from a poisonous snake. The most effective initial intervention would be to a. Place a restrictive band above the snake bite b. Elevate the bite area above the level of the heart c. Position the client in a supine position d. Immobilize the limb Answer: a Rationale: A restrictive band 2 to 4 inches above the snake bite is most effective in containing the venom and minimizing lymphatic and superficial venous return. Elevation of the limb or immobilization would not be effective i nterventions. 20. There is a physician's order to irrigate a client's bladder. Which one of the following nursing measures will ensure patency? a. Use a solution of sterile water for the irrigation b. Apply a small amount of pressure to push the mucus out of the catheter tip if the tube is not patent c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to remain for 10 hour, and then siphon it out d. Irrigate with 20mL's of normal saline to establish patency Answer: d Rationale: Normal saline is the fluid of choice for irrigation. It is never advisable to force fluids into a tubing to check for patency. Sterile water and aqueous Zephiran will affect the pH of the bladder as well as cause irritation. 21. A female client has orders for an oral cholecystogram. Prior to the test, the nursing intervention would be to a. Provide a high fat diet for dinner, then NPO
b. Explain that diarrhea may result from the dye tablets c. Administer the dye tablets following a regular diet for dinner d. Administer enemas until clear Answer: b Rationale: Diarrhea is a very common response to the dye tablets. A dinner of tea and toast is usually given to the client. Each dye tablet is given at 5 minute intervals, usually with 1 glass of water following each tablet. The number of tablets prescribed will vary, because it is based on the weight of the client. 22. The physician has just completed a liver biopsy. Immediately following the procedure, the nurse will position the client a. On his right side to promote hemostasis b. In Fowler's position to facilitate ventilation c. Supine to maintain blood pressure d. In Sims' position to prevent aspiration Answer: a Rationale: Placing the client on his right side will allow pressure to be placed on the puncture site, thus promoting hemostasis and preventing hemorrhage. The other positions will not be effective in achieving these goals. 23. When a client has peptic ulcer disease, the nurse would expect a priority intervention to be a. Assisting in inserting a Miller-Abbott tube b. Assisting in inserting an arterial pressure line c. Inserting a nasogastric tube d. Inserting an IV Answer: c Rationale: An NG tube insertion is the most appropriate intervention because it will determine the presence of active gastrointestinal bleeding. A Miller-Abbott tube is a weighted, mercury-filled ballooned tube used to resolve bowel obstructions. There is no evidence of shock or fluid overload in the client; therefore, an arterial line is not appropriate at this time and an IV is optional. 25. In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include a. Walking several times each day as a part of an exercise routine b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation
Answer: b Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful in preventing vasoconstriction, but TED hose would not be therapeutic. Walking will most likely increase pain. 26. When a client asks the nurse why the physician says he "thinks" he has tuberculosis, the nurse explains to him that diagnosis of tuberculosis can take several weeks to confirm. Which of the following statements supports this answer? a. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis, even if one negative sputum is obtained b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the bacillus c. Because small lesions are hard to detect on chest x-rays, x-rays usually need to be repeated during several consecutive weeks d. A client with a positive smear will have to have a positive culture to confirm the diagnosis Answer: b Rationale: Answer b is correct because the culture takes 3 weeks to grow. Usually even very small lesions can be seen on x-rays due to the natural contrast of the air in the lungs; therefore, chest x-rays do not need to be repeated frequently (c). Clients may have positive smears but negative cultures if they have been on medication (d). A positive skin test indicates the person only has been infected with tuberculosis but may not necessarily have active disease (a). 27. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition leads to a. Blindness b. Myopia c. Retrolental fibroplasia d. Uveitis Answer: a Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and leads eventually to blindness. 28. A nursing assessment for initial signs of hypoglycemia will include a. Pallor, blurred vision, weakness, behavioral changes b. Frequent urination, flushed face, pleural friction rub c. Abdominal pain, diminished deep tendon reflexes, double vision d. Weakness, lassitude, irregular pulse, dilated pupils
Answer: a Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common symptoms when there is too much insulin or too little food - hypoglycemia. The signs and symptoms in answers (b) and (c) are indicative of hyperglycemia. 29. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then a. Discarded, then the collection begins b. Saved as part of the 24-hour collection c. Tested, then discarded d. Placed in a separate container and later added to the collection Answer: a Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours. 30. Following an accident, a client is admitted with a head injury and concurrent cervical spine injury. The physician will use Crutchfield tongs. The purpose of these tongs is to a. Hypoextend the vertebral column b. Hyperextend the vertebral column c. Decompress the spinal nerves d. Allow the client to sit up and move without twisting his spine Answer: b Rationale: The purpose of the tongs is to decompress the vertebral column through hyperextending it. Both (a) and (c) are incorrect because they might cause further damage (d) is incorrect because the client cannot sit up with the tongs in place; only the head of the bed can be elevated. 31. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown b. Set alarms on the oximeter to at least 100 percent c. Identify if the client has had a recent diagnostic test using intravenous dye d. Remove the sensor between oxygen saturation readings Answer: c Rationale: Clients may experience inaccurate readings if dye has been used for a diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings.
32. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to a. Check that a hemostat is at the bedside b. Monitor IV fluids for the shift c. Regularly assess respiratory status d. Check that the balloon is deflated on a regular basis Answer: c Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention. 33. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. The client's activity at this time should be a. Ambulation as desired b. Bedrest in supine position c. Up ad lib and right side-lying position in bed d. Bedrest in Fowler's position Answer: d Rationale: The pain of pancreatitis is made worse by walking and supine positioning. The client is more comfortable sitting up and leaning forward. 34. Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is a. pH 7.49, HCO3 24, PCO2 46 b. pH 7.49, HCO3 14, PCO2 30 c. pH 7.26, HCO3 24, PCO2 46 d. pH 7.26, HCO3 14, PCO2 30 Answer: d Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45; HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg. 35. A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to a. Correct the hyperglycemia that occurs with acute renal failure b. Facilitate the intracellular movement of potassium
c. Provide calories to prevent tissue catabolism and azotemia d. Force potassium into the cells to prevent arrhythmias Answer: b Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed. This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also added to the infusion. 38. A client has had a cystectomy and ureteroileostomy (ileal conduit). The nurse observes this client for complications in the postoperative period. Which of the following symptoms indicates an unexpected outcome and requires priority care? a. Edema of the stoma b. Mucus in the drainage appliance c. Redness of the stoma d. Feces in the drainage appliance Answer: d Rationale: The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum which has been resected from its anatomical position and now functions as a reservoir or conduit for urine. The proximal and distal ileal borders can be resumed. Feces should not be draining from the conduit. Edema and a red color of the stoma are expected outcomes in the immediate postoperative period, as is mucus from the stoma. 39. A nursing care plan for a client with a suprapubic cystostomy would include a. Placing a urinal bag around the tube insertion to collect the urine b. Clamping the tube and allowing the client to void through the urinary meatus before removing the tube c. Catheter irrigations every 4 hours to prevent formation of urinary stones d. Limiting fluid intake to 1500 mL per day Answer: b Rationale: Allowing the client to void naturally will be done prior to removal of the catheter to ensure adequate emptying of the bladder. Irrigations are not recommended, as they increase the chances of the client developing a urinary tract infection. Any time a client has an indwelling catheter in place, fluids should be encouraged (unless contraindicated) to prevent stone formation. 40. For a client who has ataxia, which of the following tests would be
performed to assess the ability to ambulate? a. Kernig's b. Romberg's c. Riley-Day's d. Hoffmann's Answer: b Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction, is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh. 41. A client admitted to a surgical unit for possible bleeding in the cerebrum has vital signs taken every hour to monitor to neurological status. Which of the following neurological checks will give the nurse the best information about the extent of bleeding? a. Pupillary checks b. Spinal tap c. Deep tendon reflexes d. Evaluation of extrapyramidal motor system Answer: a Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches as it becomes displaced by blood, tumor, etc. 42. Assessing for immediate postoperative complications, the nurse knows that a complication likely to occur following unresolved atelectasis is a. Hemorrhage b. Infection c. Pneumonia d. Pulmonary embolism Answer: c Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated along with vigorous treatment for atelectasis. Hemorrhage and infection are not related to this condition. Pulmonary embolism could result from deep vein thrombosis. 43. A young client is in the hospital with his left leg in Buck's traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to a. Anchor the traction b. Prevent footdrop c. Keep the client from sliding down in bed d. Prevent pressure areas on the foot
Answer: b Rationale: The purpose of the footplate is to prevent footdrop while the client is immobilized in traction. This will not anchor the traction, keep the client from sliding down in bed, or prevent pressure areas.
Medical and Surgical Nursing Practice Questions with Rationale 1. Which nursing intervention would be most appropriate for promoting the environmental safety of a client with a cognitive disorder? A. Applying an identification bracelet on the client B. Maintaining daily routine care for the client C. Placing a clock and a daily schedule in the client’s room D. Using short sentences with simple words when speaking with the client Correct Answer: A Rationale: Applying an identification bracelet on the client would be most effective in helping to ensure environmental and client safety should the client wander. Other measures include installing alarms; instituting injury, fire, and poisoning precautions; providing adequate lighting; and keeping the bed in a low position. Maintaining a daily routine would be helpful for ensuring consistency and promoting optimal functioning. Clocks and daily schedules would be helpful for reorienting the client and promoting optimal cognitive function. Using short sentences with simple words would be appropriate for maximizing effective communication. 2. Which client complaint would lead the nurse to suspect premenstrual syndrome (PMS)? A. Fatigue and weight gain on the day prior to menses B. Headache and mood swings occurring about 10 days prior to menses C. Mood swings and breast tenderness with the onset of menses D. Painful menstruation and large menstrual flow Correct Answer: B Rationale: Typically, PMS is manifested by complaints of headache, mood swings, irritability, weight gain, fatigue, and full, tender breasts, occurring approximately 10 days before menses in each cycle. Painful menstruation and a large menstrual flow are not associated with PMS. 3. When disposing of the plastic bags, tubing, syringes, and gloves used to administer antineoplastic drugs, the nurse should implement which nursing intervention? A. Avoiding contact with the equipment by allowing housekeeping to remove it B. Discarding all used equipment in a container marked “isolation” C. Disposing of all equipment in a container marked “bio-health hazard” D. Disposing of all used equipment in the regular trash receptacles Correct Answer: C Rationale: Any disposable equipment and supplies used for chemotherapy must be disposed of in a manner that protects the environment; placing the items in a container marked “bio-health hazard” is appropriate because these containers can be incinerated at a temperature of 2,200 to 2,500° F so that there is no residue. Only personnel trained in the proper handling of antineoplastic agents should
handle the wastes. Infectious waste is incinerated at 1,700 to 1,800° F; residue is possible after incineration at these temperatures, making it an inappropriate method for the disposal of antineoplastic equipment and supplies. Because the equipment has been contaminated with material that is carcinogenic, special precautions are required. 4. Which assessment data for a client who is 1 day postabdominal surgery would warrant immediate nursing intervention? A. Blood pressure of 110/70 mm Hg and hematocrit of 42% B. Complaints of abdominal pain as an C. Hypoactive bowel sounds and a serum potassium of 3.7 mEq/L D. Rigid, hard, boardlike abdomen and a white blood cell (WBC) count of 20,000 mm Correct Answer: D Rationale: One day after abdominal surgery, the client’s abdomen should be soft, not rigid or hard. Also, the WBC count may be slightly elevated in response to the surgery, but an elevation of 20,000 mmis highly suggestive of an infectious process. A rigid, boardlike abdomen in conjunction with a seriously elevated WBC count suggests peritonitis and requires immediate intervention. The client’s blood pressure and hematocrit are within normal limits. One day after surgery, abdominal incisional pain would be expected and often is rated as high when using a scale from 1 to 10. The client’s hemoglobin level is within normal limi ts. Hypoactive bowel sounds would be expected 1 day after abdominal surgery. The client’s potassium level is within normal limits. 5. The nurse would i nclude which nursing intervention for a client diagnosed with acute diverticulitis? A. Administration of stimulant laxatives B. Increased fluid intake C. Continuation of client’s nothing-by-mouth status D. High-fiber diet Correct Answer: C Rationale: During an acute episode of diverticulitis, measures focus on resting the colon, such as keeping the client on nothing-by-mouth status, administering I.V. fluids, and maintaining nasogastric suctioning and bedrest. Administering stimulant laxatives may be appropriate for restoring the client’s normal bowel elimination, but their use during an acute attack would only serve to irritate the bowel further. Increased fluid intake would be appropriate for diverticulosis. A high-fiber diet would be indicated for diverticulosis, but this type of diet would not be appropriate during an acute attack. 6. The nurse would include which nursing intervention in the care plan for a client with an L5-S1 intervertebral disc herniation? A. Assessing the skeletal traction insertion sites f or infection B. Encouraging the client to ambulate as much as possible C. Positioning the client with his knees slightly flexed and the head of bed elevated D. Preparing the client for lumbar puncture Correct Answer: C Rationale: Positioning the client with the head of the bed elevated and his knees slightly flexed increases the disc space and may help to decrease the client’s pain. Skeletal traction is not a treatment of choice for a herniated disc. The client with an intervertebral disc herniation should be kept on bedrest. A lumbar puncture is not a diagnostic procedure for intervertebral disc herniation.
7. A 16-year-old client asks the nurse, “What caused me to have acne?” Which statement would be the nurse’s best response? A. “Acne is caused by an excess production of sebum.” B. “Acne is caused by not cleaning your face thoroughly every day.” C. “Eating lots of chocolate and candy causes you to have acne.” D. “The exact cause of acne is not really known.” Correct Answer: D Rationale: The exact cause of acne is not known, but evidence has shown that acne involves multiple factors, such as genetics, hormonal factors, and bacterial infections. Excess production of sebum results in seborrhea. Uncleanliness and dietary indiscretions, such as eating chocolate and candy, do not cause acne. 8. Which intervention would most important in the prevention of pressure ulcers? A. Applying external urine collection devices B. Helping the client to maintain appropriate body position C. Massaging reddened areas as soon as they are noted D. Turning the client every 2 hours Correct Answer: D Rationale: Turning the client frequently, such as every 2 hours, is one of the single most important interventions in preventing pressure ulcers because it helps to minimize the effects of pressure on the skin, allowing pressure to be redistributed with each turn. Applying an external urine collection device would be appropriate if the client is incontinent, but this action is not always relevant for every client and thus is not the most important. Helping the client to maintain appropriate body position is important, but it must be done in conjunction with frequent turning; maintaining body position without frequent turning would not be beneficial. Reddened areas should never be massaged because this increases tissue damage. 9. The client with a rectovaginal fistula is at high risk for infection. Which intervention would be the most important aspect of preventative nursing care? A. Administering antibiotics B. Ensuring adequate rest to enhance healing C. Monitoring temperature and white blood cell (WBC) count D. Performing perineal hygiene, including irrigations Correct Answer: D Rationale: The client with a rectovaginal fistula may experience fecal drainage via the vagina; preventing infection by keeping the vaginal area clean with irrigation, douches, and sitz baths would be most important. Administering antibiotics and ensuring adequate rest may be useful in promoting healing, but they are not preventative measures. Monitoring for symptoms of infection is important, but perineal hygiene is more effective as a preventative measure. 10. The client with a head injury is experiencing increased intracranial pressure (ICP). Which medication would the nurse anticipate administering? A. Anticholinesterase agents B. Anticonvulsants
C. Loop diuretics D. Osmotic diuretics Correct Answer: D Rationale: Osmotic diuretics such as mannitol are the preferred diuretic in the management of increased ICP to decrease cerebral edema and, therefore, decrease ICP. Anticholinesterase agents are used in the management of myasthenia gravis and are not helpful in decreasing ICP. Anticonvulsant medications would be used to treat seizure activity and are not helpful in decreasing ICP. Loop diuretics can be given in cases of increased ICP, but they are not a fi rst-line agent. Sample Review Questions on Medical and Surgical Nursing Part 1 1. Which intervention would the nurse anticipate as the initial action to be included in the care plan f or a client experiencing a tension pneumothorax? A. Application of on occlusive petroleum dressing B. Increasing the ventilator’s tidal volume C. Obtaining a chest X-ray D. Removal of an occlusive dressing Correct Answer: D Rationale: A tension pneumothorax occurs when the pressure increases in the pleural space. Thus, removing an occlusive dressing will release the increased pressure in the pleural space and help resolve the tension. Typically, the health care provider will insert a large bore needle initially and then a chest tube to aid in reinflating the l ung. Applying an occlusive dressing will increase the pressure in the chest and worsen the tension pneumothorax. An occlusive dressing would be appropriate for an open pneumothorax. Increasing the tidal volume on the ventil ator will increase the volume delivered to the chest, worsening the tension pneumothorax. The diagnosis of a tension pneumothorax is based on the client’s clinical presentation. It is a medical emergency that can quickly be fatal. Obtaining a chest X-ray wastes precious minutes that may permit the client to decompensate; it may be performed once the chest tube has been inserted and the initial build of pressure has been relieved. 2. When teaching a group of women about breast health awareness and breast self-examination (BSE) at a local community center, the nurse follows the American Cancer Society (ACS) recommendations. Which recommendation would the nurse include in the teaching program? A. Bimonthly BSE and yearly mammograms beginning after the woman has had her first child B. Optional monthly BSE, yearly clinical examination, and yearly mammograms after age 40 C. Quarterly BSE until the age of 70 after which breast health awareness is no longer necessary D. Yearly BSE and follow up clinical examinations after onset of menses Correct Answer: B Rationale: The ACS recommends a yearly clinical examination and yearly mammograms in clients older than age 40. Monthly self-breast examination is an option for women starting in their 20s. The risk of breast cancer increases with age. At age 80, there is a 1 in 8 risk of developing breast cancer. 3. When providing postoperative care after a bowel resection to a client with a pre-existing history of chronic obstructive pulmonary disease (COPD) with frequent exacerbations, for which complication should the nurse be alert? A. Acute respiratory failure B. Airway obstruction
C. Atelectasis D. Pneumothorax Correct Answer: A Rationale: The client is at high risk for developing acute respiratory failure because of his history of chronic lung disease requiring frequent intubations, the anesthesia used during surgery, and the experience of surgery. Airway obstruction and atelectasis are postoperative complications, but there is no evidence that this client would be at greater risk for these complication than anyone else. The operative procedure and the client’s medical history would not place this client at a greater risk for postoperative pneumothorax as compared to any other postoperative client. 4. The nurse is doing preoperative teaching for a client about to have a mechanical valve replacement. Which client statement indicates effective teaching? A. “I need to make sure I have someone to care f or me after this same-day surgery procedure.” B. “I will always need to take anticoagulants to prevent the formation of blood clots.” C. “I will need to take several days of steroids each time I have major dental work done.” D. “Because my valve is from a pig, I need to take precautions to prevent rejection of the valve.” Correct Answer: B Rationale: Following mechanical valve replacement surgery, clients need to be educated about the need for lifelong oral anticoagulant therapy. (Povine or bovine valve replacements do not require anticoagulants.) Valve replacement surgery is not performed as a day surgery procedure; it requires that the client be admitted to a critical care unit for constant monitoring due to the potential for complications. Prophylactic antibiotics, not steroids, are needed after valve replacement surgery. Rejection of the artificial valve is not a major problem associated with valve replacement surgery. 5. Which collaborative intervention would be included in the care plan for a client with a venous stasis ulcer to assist with healing? A. Antiembolism stockings B. Plaster cast sock C. Transcutaneous electrical nerve stimulator (TENS) D. Unna boot Correct Answer: D Rationale: An Unna boot is medicated gauze applied to the affected limb from the toes to the knees after the ulcer is cleaned. The boot is then wrapped in plastic wrap and hardens like a cast promoting venous return and preventing stasis. Antiembolism stockings are fit tightly and can traumatize an ulcer when applied. A plaster cast sock is usually applied to a residual limb following amputation to reduce edema. TENS is used as a pain relief measure; it would have no effect on healing. 6. A client with pulmonary edema is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). When explaining to a student about the rationale for using PEEP, the nurse would indicate which rationale as its major purpose? A. Allows the client to obtain needed rest B. Increases pulmonary capillary pressure C. Improves area available for gas exchange D. Increases the client’s carbon dioxide
Correct Answer: C Rationale: PEEP helps keep the alveoli expanded, increasing the area available for gas exchange, thus improving the client’s oxygenation. PEEP has no effect on the client’s ability to rest, decreases pulmonary capillary pressure, and decreases the client’s carbon dioxide level by increasing the area for gas exchange. 7. The nurse teaches a client about residual limb care following an amputation and assesses that he understood the teaching when he demonstrates which behavior? A. Applies lotions to keep the skin from cracking B. Elevates the residual limb on a pillow following surgery C. Lies prone for several hours each day D. Wraps the residual limb in adhesive bandages Correct Answer: C Rationale: Lying prone for several hours each day helps prevent hip contractures and demonstrates compliance with the treatment regimen. Using lotions keeps the skin soft; however, following an amputation, the skin needs to become tough. New guidelines recommend elevating the foot of the bed because a pillow can cause flexion contractures of the hip. Adhesive bandages irritate the skin, leading to sores, breakdown, and infection. 8. A client with a history of bigeminy who is on a lidocaine drip complains of light-headedness. Which intervention would the nurse implement A. Calling the health care provider and getting a stat electrocardiogram (ECG) B. Checking the rhythm strip and assessing blood pressure C. Decreasing the lidocaine and instituting seizure precautions D. Having the client lie down and administering atropine Correct Answer: B Rationale: Before doing anything else, the nurse needs to check the rhythm strip and assess the client’s blood pressure to determine the possible cause of the client’s complaints and gather additional data so that a full report can be made to the health care provider. An ECG is not needed for diagnosis of arrhythmia when a rhythm strip will suffice. The client i s not exhibiting signs of lidocaine toxicity and, in fact, the lidocaine may need to be increased. Atropine is the drug of choice for sinus bradycardia, not premature ventricular contractions. 9. The nurse knows a client with chronic obstructive pulmonary disease (COPD) understands the discharge teaching when he makes which statement? A. “I need to drink at least 2 liters of fluid every day.” B. “I need to take a sleeping pill every night so I wake up rested.” C. “I should do everything in the morning so I can rest later on.” D. “I should smoke only when I am not having difficulty breathing.” Correct Answer: A Rationale: Secretions are often very thick and difficult to expectorate for clients with COPD; drinking at least 2 liters of fluid per day will help to thin the secretions and aid in expectoration. Hypnotics and sedatives such as sleeping pills depress respirations and should be avoided. The client needs to pace himself and his activiti es to minimize energy expenditures and prevent exertion. The client should eliminate exposure to irritants such a smoking.
10. Which assessment finding indicates that furosemide (Lasix), a loop-diuretic, ordered for an elderly client is achieving its intended results? A. +4 pitting edema in both legs B. Nontender calf muscles on palpation C. Relief of nocturnal leg cramping D. Systolic blood pressure of 150 mm Hg Correct Answer: D Rationale: Furosemide is commonly used as an ini tial step in treating hypertension. For the elderly client, a systolic blood pressure of 150 mm Hg would be considered normal and thus indicative that the drug therapy is effective. Pitting edema of +4 indicates that the drug is not achieving its intended result because fluid is still present; the client’s medication regime needs to be adjusted or changed. Furosemide has no effect on calf muscle; relief of tenderness in the calf is seen in deep vein thrombosis. Loop diuretics do not typically relieve cramping. Sample Review Questions on Medical and Surgical Nursing Part 2 1. When caring for a client with arterial occlusive disease of the extremities, what would the nurse include in the client’s teaching plan? A. Changing positions frequently and elevating the legs above the heart to promote venous return in the legs B. Elevating the arm on a pillow with the elbow higher than the shoulder and the hand higher than the elbow C. Elevating the foot of the bed about 6″ (15.2 cm) while the client is sleeping to promote venous return D. Keeping the legs in a dependent position in relationship to the heart to improve peripheral blood flow Correct Answer: D Rationale: The client with arterial occlusive disease needs to enhance the blood supply to the body parts affected; keeping legs in a dependent position in relationship to the heart to improve peripheral blood flow enhances the blood flow to the extremities. Changing positions frequently and elevating the legs above the heart to promote venous return in the legs should be included in teaching for the client with varicose veins. Elevating the arm on a pillow with the elbow higher than the shoulder and hand higher than the elbow helps to promote lymphatic drainage. Elevating the foot of the bed about 6″ while the client i s sleeping to promote venous return is appropriate for the client with deep vein thrombosis. 2. While caring for a client with a new amputation, the dressing inadvertently comes off the stump. Which intervention should the nurse implement first? A. Bedside application of a large tourniquet to prevent massive hemorrhage B. Elevation of the limb above heart level to promote venous return C. Maintenance of the client in a supine position to improve peripheral blood flow D. Immediate application of an elastic compression bandage wrapped around the limb Correct Answer: D Rationale: Because excessive edema will develop in a short time, resulting in delays in rehabilitation, the nurse should wrap the limb with an elastic compression bandage immediately. Before a tourniquet would be applied, the nurse would need to assess the client for signs and symptoms of bleeding
because applying a tourniquet could compromise the circulatory and neurologic status of the limb. Elevating the limb above heart level could cause contractures; in this case, venous return is not a major concern. The supine position is contraindicated. The nurse needs to keep the stump elevated by raising the foot of the bed. 3. Which assessment finding would the nurse expect to assess in a client with emphysema? A. Copious sputum B. Cor pulmonale C. Anemia D. Distant breath sounds Correct Answer: D Rationale: With emphysema, air trapping and chronic hyperexpansion of the l ungs lead to distant breath sounds. Copious amounts of sputum are produced with chronic bronchitis; with emphysema, sputum production is usually scant. Cor pulmonale (right-sided heart failure) is more commonly associated with chronic bronchitis than emphysema. Polycythemia, an increase in red blood cells, may occur, but emphysema does not lead to anemia. 4. Following a thoracentesis, which assessment finding would warrant immediate intervention by the nurse? A. Auscultation of crackles bilaterally B. Complaints of pain at the needle insertion site C. Prolonged periods of uncontrolled coughing D. Symmetrical respirations Correct Answer: C Rationale: Uncontrolled coughing in the client following a thoracentesis may indicate the development of pulmonary edema that requires immediate attention. Bilateral crackles may indicate underlying inflammation or congestion, but immediate attention is not necessary. Complaints of pain at the needle insertion site and symmetrical respirations are normal findings. 5. A client arrives in the emergency department following a motor vehicle accident with multiple injuries to the head, chest, and extremities with minimal bleeding. Which would the nurse assess first? A. Airway status B. Blood pressure C. Level of consciousness D. Quality of peripheral pulses Correct Answer: A Rationale: When dealing with an emergency, the ABCs — airway, breathing, and circulation — are the priorities and must be maintained first. Blood pressure, neurological, and neurovascular assessments are important, but in this case, airway is the priority. 6. A client receiving nasogastric tube feedings for the past 48 hours develops a hacking cough, a fever of 100.6° F (38.1° C), and is moderately dyspneic. Which complication would the nurse suspect? A. Aspiration pneumonia B. Chronic obstructive pulmonary disease (COPD)
C. Pleural effusion D. Pneumoconioses Correct Answer: A Rationale: Nasogastric tube feedings may result in aspiration leading to pneumonia, suggested by the hacking cough, low-grade fever, and moderate dyspnea. Clients with COPD have a chronic cough and usually are afebrile. Clients with pleural effusion usually have no cough and are afebrile. Clients with pneumoconioses present with chronic cough and progressive dyspnea. 7. A client is admitted to the health care facility with a diagnosis of acute arterial occlusion. While performing a physical assessment, what would the nurse expect to observe? A. Cramping B. Elephatism C. Phantom pain D. Pulselessness Correct Answer: D Rationale: Pulselessness is one of the common manifestations of acute arterial occlusion secondary to cessation of blood flow distal to the occlusion. Cramping is a common complaint associated with varicose veins. Elephantism is an indication of secondary lymphedema. Phantom pain is pain noted following a limb amputation. 8. A client with l eukemia is undergoing radiation therapy to the brain and spinal cord. In planning care for this client, the nurse would include which nursing intervention? A. A scalp ointment to prevent dryness B. Avoiding washing off the target’s marksC. Not allowing the client to use a hat or scarf D. A dandruff shampoo twice daily Correct Answer: B Rationale: The marks made by the radiation oncologist guide the technician in configuring the external beam to irradiate the area in question without causing damage to other tissues. These marks must remain in place and should not be washed off. Ointments, which are petroleum-based, could cause a radiation burn to the area. The client should be encouraged to use a hat or scarf when in the sun to prevent damage to the scalp skin and at night to prevent loss of body heat through the scalp; hats and scarves also help to foster a positive body image. Dandruff shampoo includes harsh chemicals that could damage already fragile skin; the area being irradiated should be washed with water and the skin patted dry. 9. Which intervention would the nurse include in the teaching plan for a client diagnosed with gastroesophageal reflux disease (GERD)? A. Avoiding eating within 2 hours of bedtime B. Eating a high-fat, low-fiber diet C. Completing all antibiotics D. Sleeping with the head of the bed flat Correct Answer: A Rationale: Clients with GERD should avoid eating prior to retiring or lying down to decrease the incidence of reflux. The client with GERD will be prescribed a low-fat, high-fiber diet. Antibiotics are not used to treat GERD, although antibiotics are used for clients with Helicobacter pylori
infection and peptic ulcer disease. The client with GERD should elevate the head on pillows or use blocks under the head of the bed to minimize reflux. 10. Which would the nurse include i n the discharge teaching plan for an elderly client diagnosed with pneumonia? A .Demonstration of postural drainage techniques B. Demonstration of pursed lip breathing C. Discussion of proper use of oxygen therapy D. Instructions about increasing fluid intake Correct Answer: D Rationale: Pneumonia typically causes thick secretions that may be difficult for the elderly client to expectorate; increasing fluid intake will help thin secretions, ultimately aiding in their removal. Postural drainage usually is recommended for clients diagnosed with bronchitis and emphysema. Pursed lip breathing and oxygen therapy usually are recommended for clients with chronic obstructive pulmonary disease. A client with pneumonia typically does not require oxygen at home. Sample Review Questions on Medical and Surgical Nursing Part 3 1. For a client receiving oral anticoagulant therapy for chronic atrial fibrillation, the nurse would be correct in withholding the medication if which assessment data is present? A. Apical heart rate below 60 beats per minute B. Elevated erythrocyte sedimentation rate (ESR) C. International Normalized Ratio (INR) above 5 D. Partial thromboplastin time (PTT) of 25 seconds Correct Answer: C Rationale: The INR value for a client with chronic atrial fibrillation receiving oral anticoagulants should be kept between 2 and 3; any value above 3 would place the client at risk for hemorrhage, especially if anticoagulant therapy was continued. Anticoagulant therapy is given to prevent clots from forming in the atria. It should not be held related to heart rate. (Digoxin is sometimes held for heart rates below 60 beats per minute.) ESR is not an indicator of anticoagulant effectiveness and has no bearing on whether or not the drug should be held. Prothrombin time, not PTT, is used to monitor the effectiveness of oral anticoagulants; also, a PTT value of 25 seconds is considered within the normal range. 2. Which discharge teaching would be most appropriate to promote vasodilation in a client with arterial occlusion? A. Mechanically squeezing the affected tissue B. Using antiembolism stockings C. Using warm water when bathing D. Walking with a heel-toe gait Correct Answer: C Rationale: Using warm water when bathing is helpful because heat causes vessels to dilate, thereby increasing blood flow; make sure that the client knows not to use hot water because of his decreased temperature sensation. Mechanical squeezing of the tissues is performed for lymphedema.
Antiembolism hose are not indicated for use with arterial occlusions and should be avoided. Walking with a heel-toe gait is suggested for clients with deep vein thrombosis. 3. Which intervention should the nurse include in the discharge plan for a client who has experienced a myocardial infarction (MI)? A. Assisting the client in planning for retirement activities B. Encouraging the client’s family to take a cardiopulmonary resuscitation (CPR) course C. Instructing the client to have cardiac enzymes checked monthly D. Teaching the client about f ood choices for a high-fiber, high-protein diet Correct Answer: B Rationale: Encouraging the client’s family to take a CPR course is important to ensure that the family is prepared to give CPR should the client experience another MI. The client should participate in a cardiac rehabilitation program, not plan for retirement activities. The nurse should discuss ways to prevent complications secondary to coronary artery disease, but monthly testing of cardiac enzymes is unnecessary. Typically, a low-sodium, low-cholesterol, and low-fat diet is recommended after an MI. Although high fiber is encouraged to minimize straining with stool, protein intake does not need to be increased. 4. Which client statement would indicate a possible problem with peripheral vascular function? A. “I can feel my heart beating in my abdomen when I am lying down.” B. “I get pain in my legs when I walk down the street more than two blocks.” C. “I often have pain near my upper right rib and back after eating a heavy meal.” D. “I stopped smoking last year, but I still have difficulty breathing sometimes.” Correct Answer: B Rationale: Complaints of pain in the legs with activity are a cardinal sign of arterial insufficiency. Reports of feeling the heart beating in the abdomen when lying down are commonly seen with aortic aneurysm. Complaints of pain in the right upper rib region and back, especially after eating a heavy meal, suggest biliary colic. Difficulty breathing even after smoking cessation may suggest pulmonary problems that are unrelated to peripheral vascular function. 5. A client diagnosed with pneumonia is experiencing pleuritic pain located on the right side of his chest. Which nursing intervention would be most appropriate for relieving the pain? A. Administrating oxygen during episodes of pain B. Encouraging the client to cough and deep-breathe C. Encouraging the client to lay on the right side D. Giving an ordered opioid analgesic around the clock Correct Answer: C Rationale: Splinting the affected side, such as by having the client lie on the right side, restricts expansion and reduces friction between pleurae, which helps decrease the pain. Oxygen will not help relieve pain, but it will help to relieve dyspnea and hypoxemia. Coughing and deep-breathing is necessary, but these typically will increase the client’s pain, not relieve it. Opioid analgesics should be administered with caution to prevent depression of the cough reflex and respiratory drive. 6. Which electrocardiogram change would the nurse expect to assess in a client complaining of chest pain and experiencing myocardial ischemia?
A. Inverted T waves B. Prolonged PR intervals C. ST-segment elevation D. Widening QRS complexes Correct Answer: A Rationale: Inverted T waves are a sign of ischemic changes. Prolonged PR intervals signal a delay in atrioventricular junction. ST-segment elevation suggests cardiac muscle injury. Widened QRS complexes suggest bundle-branch blocks and ventricular beats. 7. Which data would the nurse expect to assess in a client admitted with right-sided heart failure? A. Heart sound and tachycardia B. Decreased urinary output and restlessness C. Nausea and anorexia D. Orthopnea and crackles Correct Answer: C Rationale: In right-sided heart failure, the viscera and peripheral tissues become congested. Venous engorgement and venous stasis in the abdominal organs lead to nausea and anorexia in right-sided heart failure. A heart sound, tachycardia, decreased blood flow to the kidneys causing decreased urinary output, and restlessness due to impaired gas exchange and tissue oxygenation occur with leftsided heart failure. Congestion in the lungs in left-sided heart failure produces orthopnea and crackles. 8. Two days following insertion of a temporary demand pacemaker set at 60 beats per minute, the nurse assesses the client’s heart rate at 85 beats per minute. Which intervention should the nurse implement? A. Further monitoring of the client’s vital signs as ordered B. Getting an electrocardiogram (ECG) to verify pacemaker capture C. Increasing the pacemaker setting to 70 beats per minute D. Notifying the health care provider of possible pacer malfunction Correct Answer: A Rationale: The client’s pacemaker is a demand type pacemaker that senses the heart’s intrinsic rhythm; it will only function if the client’s own heart rate falls below the predetermined set rate. There is nothing wrong in this situation. Nothing should be changed and there is no need to contact the health care provider. Because the client’s heart rate is 85, the pacemaker will not fire and there will be no pacemaker spikes to see on an ECG. (However, if a problem occurs, the nurse would not change any settings without the health care provider’s order.) 9. Which instruction would the nurse include when teaching clients diagnosed with irritable bowel syndrome (IBS)? A. Decrease fluid intake during meals. B. Eat a bland diet. C. Eat high-fiber, low gas-forming foods. D. Take antianxiety agents. Correct Answer: C Rationale: Clients with IBS should eat a high-fiber, low gas-producing diet and increase, not decrease, their fluid intake. No supportive evidence exists that a bland diet helps to alleviate the
symptoms of IBS. Stress can cause exacerbations of IBS, but administration of antianxiety agents is usually not necessary. 10. A client has a diagnosis of hypertension based on three systolic blood pressure readings above 90 mm Hg. Which data would the nurse expect to find on assessment? A. Ankle edema B. Bluish-white skin C. Chronic swollen limbs D. No abnormal symptoms Correct Answer: D Rationale: Hypertension usually produces no symptoms until vascular changes occur. Ankle edema is typically seen with varicose veins. Bluish-white skin is typically seen with f rostbite. Chronic swollen limbs are associated with chronic venous insufficiency. Sample Review Questions on Medical and Surgical Nursing Part 4 1. A client who is complaining of right lower quadrant pain, nausea, and vomiting has a low-grade fever, rebound tenderness, and an elevated white blood cell (WBC) count. Which intervention should the nurse perform first? A. Administering antacids for gastroenteritis B. Advising the client to assume a high Fowler’s position for a peptic ulcer C. Calling the surgeon in anticipation of an appendectomy D. Suggesting a course of antibiotics to treat peritonitis Correct Answer: C Rationale: The client is exhibiting classic findings associated with appendicitis, which requires surgery as soon as possible; notifying the surgeon should be the nurse’s first action. Rebound tenderness is not associated with gastroenteritis, which is characterized by generalized abdominal cramping, diarrhea, fever, and malaise. A high Fowler’s position would not alleviate pain produced by a peptic ulcer, which includes burning, aching, and gnawing pain. Nausea and vomiting are not generally associated with peritonitis, which is indicated by diffuse abdominal pain, rebound tenderness, fever, and an elevated WBC count. 2. Which assessment finding would be an appropriate indicator for evaluating a client with heart failure and a nursing diagnosis of decreased cardiac output? A. Decreased intermittent claudication B. Increased ability to walk to the bathroom without fatigue C. Increased heart rate by 10 beats per minute D. Weight gain of 3 pounds in one day Correct Answer: B Rationale: Fatigue may be associated with decreased cardiac output; an increase in the client’s ability to ambulate to the bathroom without fatigue indicates improvement in cardiac output. A decrease in intermittent claudication indicates improved peripheral perfusion, but it does not demonstrate increased cardiac output. The body normally responds to a decrease in cardiac output by increasing the heart rate. Weight gain indicates fluid retention and a worsening of the client’s heart failure.
3. A client who has frostbite is complaining of pain. In addition to giving medication, which nursing intervention should the nurse implement? A. Administration of sodium bicarbonate B. Elevation of the body part C. Gentle massage of the affected area D. Administration of warmed, humidified oxygen Correct Answer: B Rationale: Elevation of the body part helps to reduce the edema associated with f rostbite. Sodium bicarbonate is indicated for the treatment of hypothermia. Massaging the affected area may result in further tissue damage. Warm, humidified oxygen is used as treatment for hypothermia. 4. A client scheduled for a biopsy of a mass asks the nurse to explain why this surgery is necessary. Which statement would be the nurse’s best response? A. “The physician removes the precancerous mass to prevent cancer from occurring.” B. “This is diagnostic surgery done to confirm or rule out malignancy.” C. “This will provide a more realistic l ook to the body part.” D. “This will relieve your distress and help you to be more comfortable.” Correct Answer: B Rationale: A biopsy is performed to aid in diagnosing whether a mass is benign or malignant. Preventative surgery is done to remove tissue prior to its becoming cancerous; whether or not the mass is precancerous has yet to be determined. Reconstructive surgery provides a more realistic look to a body part. Palliative surgery is used to relieve the client’s distress and help make him more comfortable. 5. A client with deep venous thrombosis develops a sudden onset of severe leg pain. The limb becomes pale, cold, numb, and pulseless. What medical condition would the nurse suspect? A. Acute arterial occlusion B. Dissecting aneurysm C. Postphlebitic syndrome D. Raynaud’s phenomenon Correct Answer: A Rationale: The change in color, temperature, sensation, and pulse accompanied by the sudden onset of pain (the classic “P’s” of assessment) all suggest an acute arterial occlusion. A dissecting aneurysm usually occurs in the chest, not the legs; a tearing or ripping sensation of pain in the anterior chest, back, epigastric region, or abdomen is common. Postphlebitic syndrome is characterized by a brownish discoloration of the skin, the hallmark sign. Raynaud’s phenomenon involves the episodic constriction of the small arteries or arterioles of the extremities, resulting in intermittent pallor and cyanosis of the skin, fingers, toes and, possibly, the ears or nose, followed by hyperemia, which may produce rubor. 6. When obtaining the history of a client admitted with endocarditis, which information from the client interview would the nurse consider as most significant? A. Dental surgery in the recent past B. History of coronary artery disease (CAD)
C. History of marijuana use D. Prolonged use of steroid therapy Correct Answer: A Rationale: Dental surgery is one of the predisposing factors for the development of endocarditis because it may create a portal of entry for microorganisms. A history of valvular heart disease (not CAD), I.V. drug use (not marijuana use), and prolonged I.V. antibiotic therapy (not steroid therapy) are predisposing factors for endocarditis. 7. When assessing a client diagnosed with an abdominal aortic aneurysm, the nurse monitors the client for which signs and symptoms? A. Intermittent episodes of high fever with chills B. Paresthesias and loss of position sense C. Positive Homans’ sign and calf pain D. Pulsatile mass and systolic bruit Correct Answer: D Rationale: A pulsatile mass and systolic bruit are classic signs of an abdominal aortic aneurysm. Intermittent episodes of high fever with chills are associated with secondary lymphedema or other infections. Paresthesias and loss of position sense are associated with peripheral arterial occlusive disease as well as neurovascular and neurologic conditions. A positive Homans’ sign and calf pain are symptoms of deep vein thrombosis. 8. Which scientific rationale must the nurse keep in mind when administering oxygen to a client with chronic obstructive pulmonary disease (COPD)? A. A facemask is necessary for delivery of adequate B. Oxygen is reserved for use when the client is short of breath. C. The client is encouraged to remove the oxygen as often as possible. D. The oxygen must be administered at a low rate. Correct Answer: D Rationale: The primary stimulus to breathe for the client with COPD is hypoxia. If oxygen were administered at too high a rate, the client’s respiratory drive would be depressed. The increased effectiveness of using a facemask as opposed to a nasal cannula has not been proven. Due to loss of supporting structures and narrowing of airways, the condition is irreversible; intermittent oxygen is not effective. 9. Which client would require the nurse to be on highest alert for the development of a pulmonary embolism (PE)? A. A woman who has taken hormonal contraceptives for the past 2 years B. A client who has had laparoscopic gallbladder surgery C. A client with arterial vascular disease and difficulty walking D. A client who has experienced multiple trauma and fractures Correct Answer: D Rationale: A client with massive trauma and multiple orthopedic injuries is at increased risk for developing a PE. The injury may predispose the client to fat emboli and bony fragments that can become emboli, and the prolonged period of immobility that results from the injuries and their treatment further compounds the client’s risk. Women on hormonal contraceptives have a slightly
higher risk for PE, but this risk is not as great as that for the client experiencing multiple trauma and fractures. The risk for cardiovascular complications increases after age 35 in women who smoke and after age 40 in women who do not smoke. Laparoscopic cholecystectomy is now considered a relatively minor procedure requiring a short hospitalization, usually in an outclient department. A client with arterial vascular disease may be at increased risk for pulmonary emboli but PE usually develops in the venous system. 10. Which assessment finding would be the most appropriate indicator for evaluating the adequacy of gas exchange for the postoperative client with a thoracotomy? A. Effective coughing and deep-breathing B. Oxygen saturation level of 98% C. Report of breathing without difficulty D. Report of pain relief Correct Answer: B Rationale: Following a thoracotomy, the goal is to promote adequate gas exchange, evidenced by objective parameters including oxygen saturation, normal blood gases, and breath sounds. Effective coughing and deep breathing help to maintain a patent airway and promote lung expansion, but they do not ensure adequate gas exchange. Although client reports of breathing without difficulty are an important assessment, adequacy of gas exchange is best evaluated by objective findings. Assessment and pain relief is important, but pain relief is not a reliable indicator of adequate gas exchange. Sample Review Question for Medical and Surgical Nursing Part 5 1. When auscultating the breath sounds of a client with bacterial pneumonia, the nurse would expect to find which assessment data? A. Adventitious breath sounds with crackles and wheezes B. Bronchial breath sounds over consolidated lung fields C. Decreased breath sounds with crackles and a pleural friction rub D. Wheezing with expiration more prolonged than inspiration Correct Answer: B Rationale: In normal, clear lungs, bronchial breath sounds would be heard over the large airways and vesicular breath sounds would be heard over the clear lungs. With pneumonia, exudate fills the air spaces producing consolidation and bronchial breath sounds over these areas. Adventitious breath sounds, including crackles and wheezes, would be indicative of acute respiratory failure. Decreased breath sounds with crackles and a pleural friction rub would suggest a pulmonary embolism. Wheezing with expiration that is more prolonged than inspiration is indicative of chronic obstructive pulmonary disease. When documenting the assessment finding of a client with emphysema who has an increase in the anteroposterior diameter of the chest, which term would the nurse use? 2.
A. Barrel chest B. Flail chest C. Funnel chest D. Pigeon chest Correct Answer: A Rationale: Barrel chest is a term that refers to an increase in the anteroposterior diameter of the
chest, resulting from overinflation of the lungs. A flail chest results from fractured ribs when a portion of the chest pulls inward upon inspiration. A funnel chest refers to a depression of the lower part of the sternum. A pigeon chest refers to an anterior displacement of the sternum protruding beyond the abdominal plane. 3. When caring for a client with a chest tube inserted in the right chest wall, which assessment data would lead the nurse to suspect that the client is experiencing a tension pneumothorax? A. A cough with purulent sputum B. Frothy pink-tinged sputum C. Markedly decreased ventilation in the left lung D. Subcutaneous emphysema in the chest wall Correct Answer: C Rationale: Decreased ventilation in the opposite lung is indicative of a mediastinal shift, which leads to a tension pneumothorax. A cough with purulent sputum is usually seen in clients diagnosed with pneumonia. Hemoptysis is indicative of lung disease, such as pulmonary embolism and lung cancer. Subcutaneous emphysema, air accumulation in the tissues giving a crackling sensation when palpitated, is usually associated with chest trauma. 4. When evaluating risk for developing cancer, which client would the nurse identify as having the highest risk? A. An asphalt road construction worker who eats meats and potatoes B. A new breast-feeding mother who works in a bank C. An oncology nurse who takes vitamins C and E daily D. A vegetarian who works at a convenience store Correct Answer: A Rationale: Exposure to certain chemicals such as tar, soot, asphalt, oils, and sunlight put this occupation at the highest risk. Also, meats and potatoes are low in fiber, contributing to the risk of cancer. Plus, some processed meats contain chemicals that have been implicated in the development of cancer. Breast-feeding does not increase the client’s risk of developing cancer. Office work also is not considered a risk factor. Working with cancer clients does not increase a person’s risk for developing cancer. Vitamins C and E have been shown to demonstrate preventative attributes. A vegetarian diet is considered to be a healthier diet for deduction of cancer risk because it provides increased fiber. Cruciferous vegetables have been shown to be preventative. Working in a convenience store does not increase risk. 5. A client with a history of coronary artery disease begins to experience chest pain. After putting the client on bedrest and administering a nitroglycerin tablet sublingually, which intervention should the nurse implement first? A. Calling the health care provider B. Checking the heart’s creatine kinase MB (CK-MB) l evel C. Getting a 12-lead electrocardiogram (ECG) D. Preparing the client for angioplasty Correct Answer: C Rationale: For the client experiencing chest pain, obtaining a 12-lead ECG is a priority to reveal possible changes occurring during an acute anginal attack that will be helpful in treatment. Before calling the health care provider, the nurse should obtain the results of the 12-lead ECG so that these
results can be communicated to him. A CK-MB level may be ordered later and the client may need angioplasty in the near future, but getting the 12-lead ECG during the chest pain is the most important priority. 6. Which signs and symptoms would alert the nurse to the possibility of a major complication in a client with pericarditis? A. Crushing chest pain and diaphoresis B. Dyspnea and copious blood-tinged, frothy sputum C. Hypotension and muffled heart sounds D. Tachycardia and oliguria Correct Answer: C Rationale: A major complication associated with pericarditis is pericardial effusion or cardiac tamponade manifested by hypotension and muffled heart sounds. Crushing chest pain and diaphoresis are signs of myocardial infarction. Dyspnea and copious blood-tinged, frothy sputum are signs of acute pulmonary edema, a complication of left-sided heart failure. Tachycardia and oliguria are signs of hemorrhagic shock. 7. Which assessment finding would the nurse identify as indicative of a client’s altered peripheral vascular function? A. Ankle arm index pressure of 0.4 B. Capillary refill time of less than 3 seconds C. Diastolic blood pressure of 84 mm Hg D. Pulses graded as being +4 Correct Answer: A Rationale: The ankle arm index is an objective indicator of arterial disease. Normal value is 1.0. Values less than 0.5 indicate ischemic rest pain. A capillary refill time of less than 3 seconds is considered normal. A diastolic blood pressure of 84 mm Hg is considered within the normal range. Pulses graded as +4 are considered normal. 8. Which valvular disorder would the nurse suspect in a client presenting with fatigue, hemoptysis, and dyspnea on exertion? A. Aortic insufficiency B. Aortic stenosis C. Mitral insufficiency D. Mitral stenosis Correct Answer: D Rationale: Mitral stenosis is an obstruction of blood flowing from the left atrium into the left ventricle, commonly manifested by progressive fatigue due to low cardiac output, hemoptysis, and dyspnea on exertion secondary to pulmonary venous hypertension. Aortic insufficiency refers to the backflow of blood from the aorta i nto the left ventricle during diastole; most clients are asymptomatic, except for a complaint of a forceful heartbeat. Aortic stenosis refers to a narrowing of the orifice between the left ventricle and the aorta; many clients experience no symptoms early on, but eventually develop exertional dyspnea, dizziness, and fainting. Mitral insufficiency refers to the backflow of blood from the left ventricle and aorta; many clients experience no symptoms early on, but eventually develop exertional dyspnea, dizziness, and fainting.
9. When developing a teaching plan for clients with chronic obstructive pulmonary disease (COPD) about the prevention of acute exacerbations, which topic should be included? A. Administration of antibiotics B. Administration of oxygen as needed C. Performance of deep-breathing and coughing exercises D. Elimination of exposure to pulmonary irritants Correct Answer: D Rationale: One aspect of exacerbation prevention focuses on eliminating the causes and contributory factors associated with COPD, such as pulmonary irritants (e.g., smoke, air pollution, occupational irritants, and allergies). Prevention would focus on eliminating these irritants. Antibiotics are used to treat bronchial infection during exacerbations, but they are not used prophylactically. Although oxygen is used in managing acute exacerbations, it is not a preventative measure. Coughing and deep breathing may help clients clear their airways and prevent further atelectasis, but they will not prevent exacerbation. 10. Which medication would the nurse expect the health care provider to order immediately for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD)? A. A bronchodilator B. A corticosteroid C. An anticoagulant D. An antitussive agent Correct Answer: A Rationale: Initially, for the client newly diagnosed with COPD, the health care provider would order a bronchodilator to open the airways and ease dyspnea. Corticosteroids may be ordered for the client with COPD, but they are usually used for acute exacerbations, not as an initial drug. Anticoagulants interfere with the clotting cascade and would be ordered for a client with an embolic disorder such as pulmonary embolism. An antitussive agent would be used for the client with coughing, such as that occurring with pneumonia.
Sample Nursing Board Exam Review Questions 1 1.
Which 1. 2. 3. 4.
element in the circular chain of infection can be eliminated by preserving skin integrity? Host Reservoir Mode of transmission Portal of entry
Correct Answer: D. In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin 2.
Which of the following will probably result in a break in sterile technique for respiratory isolation? 1. Opening the patient’s window to the outside environment 2. Turning on the patient’s room ventilator 3. Opening the door of the patient’s room leading into the hospital corridor
4.
Failing to wear gloves when administering a bed bath
Correct Answer: C. Respiratory isolation, like strict isolation, requires that the door to the door patient’s room remain closed. However, the patient’s room should be well ventilated, so opening the window or turning on the ventricular is desirable. The nurse does not need to wear gloves for respiratory isolation, but good hand washing is important for all types of isolation. 3.
Which 1. 2. 3. 4.
of the following patients is at greater risk for contracting an infection? A patient with leukopenia A patient receiving broad-spectrum antibiotics A postoperative patient who has undergone orthopedic surgery A newly diagnosed diabetic patient
Correct Answer: A. Leukopenia is a decreased number of leukocytes (white blood cells), which are important in resisting infection. None of the other situations would put the patient at risk for contracting an infection; taking broad-spectrum antibiotics might actually reduce the infection risk. 4.
Effective hand washing requires the use of: 1. Soap or detergent to promote emulsification 2. Hot water to destroy bacteria 3. A disinfectant to increase surface tension 4. All of the above Correct Answer: A. Soaps and detergents are used to help remove bacteria because of their ability to lower the surface tension of water and act as emulsifying agents. Hot water may lead to skin irritation or burns.
5.
After routine patient contact, hand washing should last at least: 1. 30 seconds 2. 1 minute 3. 2 minute 4. 3 minutes Correct Answer: A. Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of pathogen transmission.
6.
Which 1. 2. 3. 4.
of the following procedures always requires surgical asepsis? Vaginal instillation of conjugated estrogen Urinary Catherization Nasogastric tube insertion Colostomy Irrigation
Correct Answer: B. The urinary system is normally free of microorganisms except at the urinary meatus. Any procedure that involves entering this system must use surgically aseptic measures to maintain a bacteria-free state. 7.
Sterile technique is used whenever: 1. Strict isolation is required 2. Terminal disinfection is performed
3. Invasive procedures are performed 4. Protective isolation is necessary Correct Answer:C. All invasive procedures, including surgery, catheter insertion, and administration of parenteral therapy, require sterile technique to maintain a sterile environment. All equipment must be sterile, and the nurse and the physician must wear sterile gloves and maintain surgical asepsis. In the operating room, the nurse and physician are required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive procedures. Strict isolation requires the use of clean gloves, masks, gowns and equipment to prevent the transmission of highly communicable diseases by contact or by airborne routes. Terminal disinfection is the disinfection of all contaminated supplies and equipment after a patient has been discharged to prepare them for reuse by another patient. The purpose of protective (reverse) isolation is to prevent a person with seriously impaired resistance from coming into contact who potentially pathogenic organisms. 8.
Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? 1. Using sterile forceps, rather than sterile gloves, to handle a sterile item 2. Touching the outside wrapper of sterilized material without sterile gloves 3. Placing a sterile object on the edge of the sterile field 4. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container Correct Answer: C. The edges of a sterile f ield are considered contaminated. When sterile items are allowed to come in contact with the edges of the field, the sterile items also become contaminated.
9.
A natural body defense that plays an active role in preventing infection is: 1. Yawning 2. Body hair 3. Hiccupping 4. Rapid eye movements Correct Answer: B. Hair on or within body areas, such as the nose, traps and holds particles that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from entering or leaving the body. Rapid eye movement marks the stage of sleep during which dreaming occurs.
10. All of the following statement are true about donning sterile gloves except: 1. The first glove should be picked up by grasping the inside of the cuff. 2. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove. 3. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist 4. The inside of the glove is considered sterile Correct Answer: D. The inside of the glove is always considered to be clean, but not sterile. Sample Nursing Board Exam Review Questions 2 1.
When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
1. 2. 3. 4.
Waist tie and neck tie at the back of the gown Waist tie in front of the gown Cuffs of the gown Inside of the gown
Correct Answer: A. The back of the gown is considered clean, the front is contaminated. So, after removing gloves and washing hands, the nurse should untie the back of the gown; slowly move backward away from the gown, holding the inside of the gown and keeping the edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen container; then wash her hands again. 2.
Which of the following nursing interventions is considered the most effective form or universal precautions? 1. Cap all used needles before removing them from their syringes 2. Discard all used uncapped needles and syringes in an impenetrable protective container 3. Wear gloves when administering IM injections 4. Follow enteric precautions Correct Answer: B. According to the Centers for Disease Control (CDC), blood-to-blood contact occurs most commonly when a health care worker attempts to cap a used needle. Therefore, used needles should never be recapped; instead they should be inserted in a specially designed puncture resistant, labeled container. Wearing gloves is not always necessary when administering an I.M. injection. Enteric precautions prevent the transfer of pathogens via feces.
3.
All of the following measures are recommended to prevent pressure ulcers except: 1. Massaging the reddened are with lotion 2. Using a water or air mattress 3. Adhering to a schedule for positioning and turning 4. Providing meticulous skin care Correct Answer: A. Nurses and other health care professionals previously believed that massaging a reddened area with lotion would promote venous return and reduce edema to the area. However, research has shown that massage only increases the likelihood of cellular ischemia and necrosis to the area.
4.
Which 1. 2. 3. 4.
of the following blood tests should be performed before a blood transfusion? Prothrombin and coagulation time Blood typing and cross-matching Bleeding and clotting time Complete blood count (CBC) and electrolyte levels.
Correct Answer: B. Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a person’s blood type) and cross-matching (a procedure that determines the compatibility of the donor’s and recipient’s blood after the blood types has been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur. 5.
The primary purpose of a platelet count is to evaluate the: 1. Potential for clot formation 2. Potential for bleeding
3. Presence of an antigen-antibody response 4. Presence of cardiac enzymes Correct Answer: A. Platelets are disk-shaped cells that are essential for blood coagulation. A platelet count determines the number of thrombocytes in blood available for promoting hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the patient’s potential for bleeding; however, this is not its primary purpose. The normal count ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding. 6.
Which 1. 2. 3. 4.
of the following white blood cell (WBC) counts clearly indicates leukocytosis? 4,500/mm³ 7,000/mm³ 10,000/mm³ 25,000/mm³
Correct Answer: D. Leukocytosis is any transient increase in the number of white blood cells (leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a count of 25,000/mm3 indicates leukocytosis. 7.
After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing: 1. Hypokalemia 2. Hyperkalemia 3. Anorexia 4. Dysphagia Correct Answer: A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means difficulty swallowing.
8.
Which of the following statements about chest X-ray is false? 1. No contradictions exist for this test 2. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons above the waist 3. A signed consent is not required 4. Eating, drinking, and medications are allowed before this test Correct Answer: A. Pregnancy or suspected pregnancy is the only contraindication for a chest X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the Xray and thus should not be worn above the waist. A signed consent is not required because a chest X-ray is not an invasive examination. Eating, drinking and medications are allowed because the X-ray is of the chest, not the abdominal region.
9.
The most appropriate time for the nurse to obtain a sputum specimen for culture is: 1. Early in the morning 2. After the patient eats a light breakfast 3. After aerosol therapy
4. After chest physiotherapy Correct Answer: A. Obtaining a sputum specimen early in this morning ensures an adequate supply of bacteria for culturing and decreases the risk of contamination from food or medication 10. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to: 1. Withhold the moderation and notify the physician 2. Administer the medication and notify the physician 3. Administer the medication with an antihistamine 4. Apply corn starch soaks to the rash Correct Answer: A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, he nurse should withhold the drug and notify the physician, who may choose to substitute another drug. Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order. Although applying corn starch to the rash may relieve discomfort, it is not the nurse’s top priority in such a potentially lifethreatening situation. Sample Nursing Board Exam Review Questions 3 1.
All of the following nursing interventions are correct when using the Z-track method of drug injection except: 1. Prepare the injection site with alcohol 2. Use a needle that’s a least 1” long 3. Aspirate for blood before injection 4. Rub the site vigorously after the injection to promote absorption Correct Answer: D. The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.
2.
The correct method for determining the vastus lateralis site for I.M. injection is to: 1. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest 2. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm 3. Palpate a 1” circular area anterior to the umbilicus 4. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh Correct Answer: D. The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.
3.
The mid-deltoid injection site is seldom used for I.M. injections because it: 1. Can accommodate only 1 ml or less of medication 2. Bruises too easily 3. Can be used only when the patient is lying down 4. Does not readily parenteral medication Correct Answer: A. The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).
4.
The appropriate needle size for insulin injection is: 1. 18G, 1 ½” long 2. 22G, 1” long 3. 22G, 1 ½” long 4. 25G, 5/8” long Correct Answer: D. A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.
5.
The appropriate needle gauge for intradermal injection is: 1. 20G 2. 22G 3. 25G 4. 26G Correct Answer: D. Because an intradermal injection does not penetrate deeply into the skin, a small-bore 25G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
6.
Parenteral penicillin can be administered as an: 1. IM injection or an IV solution 2. IV or an intradermal injection 3. Intradermal or subcutaneous injection 4. IM or a subcutaneous injection Correct Answer: A. Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.
7.
The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is: 1. 0.6 mg 2. 10 mg 3. 60 mg 4. 600 mg Correct Answer: D. gr 10 x 60mg/gr 1 = 600 mg
8.
The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml? 1. 5 gtt/minute 2. 13 gtt/minute 3. 25 gtt/minute 4. 50 gtt/minute Correct Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
9.
Which 1. 2. 3. 4.
of the following is a sign or symptom of a hemolytic reaction to blood transfusion? Hemoglobinuria Chest pain Urticaria Distended neck veins
Correct Answer: A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms of impending anaphylaxis. Distended neck veins are an indication of hypervolemia 10. Which 1. 2. 3. 4.
of the following conditions may require fluid restriction? Fever Chronic Obstructive Pulmonary Disease Renal Failure Dehydration
Correct Answer: C. In renal failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged. Sample Nursing Board Exam Review Questions 4 1.
All of the following are common signs and symptoms of phlebitis except: 1. Pain or discomfort at the IV insertion site 2. Edema and warmth at the IV insertion site 3. A red streak exiting the IV insertion site 4. Frank bleeding at the insertion site Correct Answer: D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a l ocalized allergic reaction to the needle or catheter. Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.
2.
The best way of determining whether a patient has learned to instill ear medication properly is for the nurse to: 1. Ask the patient if he/she has used ear drops before 2. Have the patient repeat the nurse’s instructions using her own words 3. Demonstrate the procedure to the patient and encourage to ask questions
4.
Ask the patient to demonstrate the procedure
Correct Answer: D. Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching. 3.
Which 1. 2. 3. 4.
of the following types of medications can be administered via gastrostomy tube? Any oral medications Capsules whole contents are dissolve in water Enteric-coated tablets that are thoroughly dissolved in water Most tablets designed for oral use, except for extended-duration compounds
Correct Answer: D. Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube. 4.
A patient who develops hives after receiving an antibiotic is exhibiting drug: 1. Tolerance 2. Idiosyncrasy 3. Synergism 4. Allergy Correct Answer: D. A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined. Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater than that of their separate effects.
5.
A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except: 1. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours 2. Check the pressure dressing for sanguineous drainage 3. Assess a vital signs every 15 minutes for 2 hours 4. Order a hemoglobin and hematocrit count 1 hour after the arteriography Correct Answer: D. A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected. The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.
6.
The nurse explains to a patient that a cough: 1. Is a protective response to clear the respiratory tract of irritants 2. Is primarily a voluntary action 3. Is induced by the administration of an antitussive drug 4. Can be inhibited by “splinting” the abdomen Correct Answer: A. Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen supports the abdominal muscles when a patient coughs.
7.
An infected patient has chills and begins shivering. The best nursing intervention is to: 1. Apply iced alcohol sponges 2. Provide increased cool liquids 3. Provide additional bedclothes 4. Provide increased ventilation Correct Answer: C. In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytotic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabloism, and thus increased heat production.
8.
A clinical nurse specialist is a nurse who has: 1. Been certified by the National League for Nursing 2. Received credentials from the Philippine Nurses’ Association 3. Graduated from an associate degree program and is a registered professional nurse 4. Completed a master’s degree in the prescribed clinical area and is a registered professional nurse. Correct Answer: D. A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse. The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses. The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing., such as medical surgical nursing. These certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high quality nursing care in the area of her certification. A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bed side nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.
9.
The purpose of increasing urine acidity through dietary means is to: 1. Decrease burning sensations 2. Change the urine’s color 3. Change the urine’s concentration 4. Inhibit the growth of microorganisms Correct Answer: D. Microorganisms usually do not grow in an acidic environment.
10. Clay colored stools indicate: 1. Upper GI bleeding 2. Impending constipation 3. An effect of medication 4. Bile obstruction Correct Answer: D. Bile colors the stool brown. Any infl ammation or obstruction that impairs bile flow will affect the stool pigment, yielding l ight, clay-colored stool. Upper GI bleeding results in black or tarry stool. Constipation is characterized by small, hard masses. Many medications and foods will discolor stool – f or example, drugs containing iron turn stool black.; beets turn stool red.
