MEDICAL-SURGICAL NURSING EXAM WITH RATIONALE

1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be:

a. Stridor

b. Crackles

c. Wheezes

d. Friction rubs

2. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:

a. Decrease anxiety and restlessness

b. Prevents shock and relieves pain

c. Dilates coronary blood vessels

d. Helps prevent fibrillation of the heart

3. Which of the following should the nurse teach the client about the signs of digitalis toxicity?

a. Increased appetite

b. Elevated blood pressure

c. Skin rash over the chest and back

d. Visual disturbances such as seeing yellow spots

4. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…

a. Retard rapid drug absorption

b. Excrete excessive fluids accumulated at night

c. Prevents sleep disturbances during night

d. Prevention of electrolyte imbalance

5. What would be the primary goal of therapy for a client with pulmonary edema and heart failure?

a. Enhance comfort

b. Increase cardiac output

c. Improve respiratory status

d. Peripheral edema decreased

6. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?

a. Upper extremity flexion with lower extremity flexion

b. Upper extremity flexion with lower extremity extension

c. Extension of the extremities after a stimulus

d. Flexion of the extremities after stimulus

7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:

a. GI bleeding

b. Peptic ulcer disease

c. Abdominal cramps

d. Partial bowel obstruction

8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?

a. Monitoring urine output frequently

b. Monitoring blood pressure every 4 hours

c. Obtaining serum potassium levels daily

d. Obtaining infusion pump for the medication

9. During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?

a. Able to perform self-care activities without pain

b. Severe chest pain

c. Can recognize the risk factors of Myocardial Infarction

d. Can Participate in cardiac rehabilitation walking program

10. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:

a. Application of elastic stockings to prevent flaccid by muscle

b. Use hand roll and extend the left upper extremity on a pillow to prevent contractions

c. Use a bed cradle to prevent dorsiflexion of feet

d. Do passive range of motion exercise

11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be…

a. Hourly urine output

b. Temperature

c. Able to turn side to side

d. Able to sips clear liquid

12. A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is…..

a. To determine the existence of CHD

b. To visualize the disease process in the coronary arteries

c. To obtain the heart chambers pressure

d. To measure oxygen content of different heart chambers

13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to…

a. Elevate clients bed at 45°

b. Instruct the client to cough and deep breathe every 2 hours

c. Frequently monitor client’s apical pulse and blood pressure

d. Monitor clients temperature every hour

14. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?

a. Protamine Sulfate

b. Quinidine Sulfate

c. Vitamin C

d. Coumadin

15. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of…

a. Dental floss

b. Electric toothbrush

c. Manual toothbrush

d. Irrigation device

16. Among the following signs and symptoms, which would most likely be present in a client with mitral gurgitation?

a. Altered level of consciousness

b. Exceptional Dyspnea

c. Increase creatine phospholinase concentration

d. Chest pain

17. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the…

a. Urinary meatus

b. Pain in the Labium

c. Suprapubic area

d. Right or left costovertebral angle

18. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function.

a. Blood pressure

b. Consciousness

c. Distension of the bladder

d. Pulse rate

19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?

a. Tonic seizure

b. Absence seizure

c. Myoclonic seizure

d. Clonic seizure

20. Smoking cessation is critical strategy for the client with Burgher’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?

a. Paracetamol

b. Ibuprofen

c. Nitroglycerin

d. Nicotine (Nicotrol)

21. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by:

a. Episodic vasospastic disorder of capillaries

b. Episodic vasospastic disorder of small veins

c. Episodic vasospastic disorder of the aorta

d. Episodic vasospastic disorder of the small arteries

22. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because…

a. More accurate

b. Can be done by the client

c. It is easy to perform

d. It is not influenced by drugs

23. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost…

a. 0.3 L

b. 1.5 L

c. 2.0 L

d. 3.5 L

24. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:

a. Osmosis

b. Diffusion

c. Active transport

d. Filtration

25. Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking?

a. Left leg discomfort

b. Weak biceps brachii

c. Triceps muscle spasm

d. Forearm weakness

26. Which of the following statements should the nurse teach the neutropenic client and his family to avoid?

a. Performing oral hygiene after every meal

b. Using suppositories or enemas

c. Performing perineal hygiene after each bowel movement

d. Using a filter mask

27. A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in

a. Sims position

b. Supine position

c. Semi-fowlers position

d. Dorsal recumbent position

28. Which nursing intervention ensures adequate ventilating exchange after surgery?

a. Remove the airway only when client is fully conscious

b. Assess for hypoventilation by auscultating the lungs

c. Position client laterally with the neck extended

d. Maintain humidified oxygen via nasal canula

29. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should…

a. “Strip” the chest tube catheter

b. Check the system for air leaks

c. Recognize the system is functioning correctly

d. Decrease the amount of suction pressure

30. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that…

a. I can eat celery sticks and carrots

b. I can eat broiled scallops

c. I can eat shredded wheat cereal

d. I can eat spaghetti on rye bread

31. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased…

a. Pressure in the portal vein

b. Production of serum albumin

c. Secretion of bile salts

d. Interstitial osmotic pressure

32. A newly admitted client is diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?

a. Vital signs

b. Incision site

c. Airway

d. Level of consciousness

33. A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?

a. Systolic blood pressure less than 90mm Hg

b. Pupils unequally dilated

c. Respiratory rate of 4 breath/min

d. Pulse rate less than 60bpm

34. Nurse Lucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?

a. Results of the surgery will be immediately noticeable postoperatively

b. Normal saline nose drops will need to be administered preoperatively

c. After surgery, nasal packing will be in place 8 to 10 days

d. Aspirin containing medications should not be taken 14 days before surgery

35. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem?

a. Regular insulin

b. Potassium

c. Sodium bicarbonate

d. Calcium gluconate

36. Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:

a. Fish and fruit jam

b. Oranges and grapefruit

c. Carrots and potatoes

d. Spinach and mangoes

37. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should…

a. Rest in sitting position

b. Take a short walk

c. Drink plenty of water

d. Lie down at least 30 minutes

38. After gastroscopy, an adaptation that indicates major complication would be:

a. Nausea and vomiting

b. Abdominal distention

c. Increased GI motility

d. Difficulty in swallowing

39. A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:

a. “Most people need to eat a high protein diet for 12 months after surgery”

b. “I should not eat those foods that upset me before the surgery”

c. “I should avoid fatty foods as long as I live”

d. “Most people can tolerate regular diet after this type of surgery”

40. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is:

a. Restlessness

b. Yellow urine

c. Nausea

d. Clay- colored stools

41. Which of the following antituberculosis drugs can damage the 8th cranial nerve?

a. Isoniazid (INH)

b. Paraoaminosalicylic acid (PAS)

c. Ethambutol hydrochloride (myambutol)

d. Streptomycin

42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following:

a. Genetic defect in gastric mucosa

b. Stress

c. Diet high in fat

d. Helicobacter pylori infection

43. Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?

a. Bile green

b. Bright red

c. Cloudy white

d. Dark brown

44. Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the post operative period. Which of the following is best recommended for the client?

a. Watching circus

b. Bending over

c. Watching TV

d. Lifting objects

45. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:

a. Fracture

b. Strain

c. Sprain

d. Contusion

46. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure

a. Pulling the auricle backward and upward

b. Warming the solution to room temperature

c. Pacing the tip of the dropper on the edge of ear canal

d. Placing client in side lying position

47. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom?

a. Absence of drainage from the ileostomy for 6 or more hours

b. Passage of liquid stool in the stoma

c. Occasional presence of undigested food

d. A temperature of 37.6 °C

48. Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the following complications?

a. Intestinal obstruction

b. Peritonitis

c. Bowel ischemia

d. Deficient fluid volume

49. Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis.

a. Myocardial Infarction

b. Cirrhosis

c. Peptic ulcer

d. Pneumonia

50. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?

a. Watery stool

b. Yellow sclera

c. Tarry stool

d. Shortness of breath

Answers and Rationale Medical Surgical Nursing Practice Test Part 1

1. B. Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.
2. B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.
3. D. Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
4. C. When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.
5. B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention.
6. C. Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury.
7. C. The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea.
8. D. Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.
9. A. By the 2^nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain
10. B. The left side of the body will be affected in a right-sided brain attack.
11. A. After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early.
12. B. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries.
13. C. Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken to detect dysrhythmias related to cardiac irritability.
14. A. Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery.
15. C. The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.
16. B. Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation.
17. D. Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side.
18. A. Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output.
19. C. Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.
20. D. Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome.
21. D. Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.
22. A. Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure.
23. C. One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L.
24. A. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.
25. D. Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.
26. B. Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract.
27. C. Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
28. C. Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur.
29. B. Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.
30. C. Wheat cereal has a low sodium content.
31. A. Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.
32. C. Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange.
33. A. Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
34. D. Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.
35. A. Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem.
36. D. Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and tomatoes.
37. A. Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.
38. B. Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis.
39. D. It may take 4 to 6 months to eat anything, but most people can eat anything they want.
40. D. Clay colored stools are indicative of hepatic obstruction
41. D. Streptomycin is an aminoglycoside and damage on the 8^th cranial nerve (ototoxicity) is a common side effect of aminoglycosides.
42. D. Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium.
43. D. 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.
44. C. Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.
45. A. Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling.
46. C. The dropper should not touch any object or any part of the client’s ear.
47. A. Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed.
48. B. Complications of acute appendicitis are peritonitis, perforation and abscess development.
49. D. A client with acute pancreatitis is prone to complications associated with respiratory system.
50. B. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.