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Medical-Surgical Exam - Version A
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- The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?
A. Cyanosis of the fingertips. B. Bradycardia and bradypnea. C. Presence of S3 and S4 heart sounds. D. 3+ pitting edema of the lower extremities. Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands (A) which may lead to gangrene. (B, C, and D) are abnormal findings, but do not indicate the development of septic emboli. Points Earned: 0/ Correct Answer: A Your Response: C
- A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client?
A. Xylocaine (Lidocaine). B. Procainamide (Pronestyl). C. Phenytoin (Dilantin). D. Digoxin (Lanoxin). Digoxin (Lanoxin) (D) is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate,
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and effecting cardiac output. (A, B, and C) are not indicated in the initial treatment of uncontrolled atrial fibrillation.
Points Earned: 0/ Correct Answer: D Your Response: A
- How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
A. Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. B. Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. C. Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. D. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.
In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest (D). The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. (A, B, and C) describe incorrect placement of electrodes for telemetry monitoring.
Points Earned: 0/ Correct Answer: D Your Response: A
- The nurse knows that lab values sometimes vary for the older client. Which data should the nurse expect to find when reviewing laboratory values of an 80-year-old male?
A. Increased WBC, decreased RBC. B. Increased serum bilirubin, slightly increased liver enzymes. C. Increased protein in the urine, slightly increased serum glucose levels. D. Decreased serum sodium, an increased urine specific gravity.
In older adults, the protein found in urine slightly rises probably as a result of kidney changes or subclinical urinary tract infections. The serum glucose increases slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024.
Points Earned: 0/ Correct Answer: C Your Response: A
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his speech. Which action should the nurse take?
A. Determine the client is anxious and allow him to sleep. B. Evaluate his blood pressure, pulse, and respiratory status. C. Review the client's pre-operative history for alcohol abuse. D. Continue to monitor the client for reactivity to anesthesia.
Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs (B) will provide information about possible cardiovascular complications, such as stroke. The client's anxiety (A), a history of alcohol abuse (D), or local anesthesia (D) are unrelated to the client's sudden onset of slurred speech.
Points Earned: 1/ Correct Answer: B Your Response: B
- A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit?
A. Lower left quadrant pain and a low-grade fever. B. Severe pain at McBurney's point and nausea. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea.
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever (A). (B) would be indicative of appendicitis. (C and D) are symptoms exhibited with ulcerative colitis.
Points Earned: 1/ Correct Answer: A Your Response: A
- A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because
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A. they occur in the lower lobe alveoli which are more sensitive to infection. B. gram-negative organisms are more resistant to antibiotic therapy. C. they occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. gram-negative pneumonias usually affect infants and small children.
The gram-negative organisms are resistant to drug therapy (B) which makes recovery very difficult. Gram-negative pneumonias affect all lobes of the lung (A). The mean age for contracting this type of pneumonia is 50 years (C and D), and it usually strikes debilitated persons such as alcoholics, diabetics, and those with chronic lung diseases.
Points Earned: 0/ Correct Answer: B Your Response: A
- Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?
A. Place HIV positive clients in strict isolation and limit visitors. B. Wear gloves when coming in contact with the blood or body fluids of any client. C. Conduct mandatory HIV testing of those who work with AIDS clients. D. Freeze HIV blood specimens at -70° F to kill the virus.
The CDC guidelines recommend that healthcare workers use gloves when coming in contact with blood or body fluids from ANY client (B) since HIV is infectious before the client becomes aware of symptoms. (A) is not recommended, nor is it necessary. (C) is very controversial, difficult to enforce, and is not recommended by CDC. (D) does not guarantee to kill the virus. Additionally, the purpose of the blood specimen will determine how it is stored and handled.
Points Earned: 0/ Correct Answer: B Your Response: A
- Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the- knee amputation?
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A. He visits his diabetic brother who just had surgery to amputate an infected foot. B. He is provided with the most current information about the dangers of untreated diabetes. C. He comments on the community service announcements about preventing complications associated with diabetes. D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.
The loss of a limb by a family member (A) will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease. (B, C, and D) may influence his behavior but do not have the personal impact of (A).
Points Earned: 0/ Correct Answer: A Your Response: B
- The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit?
A. Loss of short-term memory, facial tics and grimaces, and constant writhing movements. B. Shuffling gait, masklike facial expression, and tremors of the head. C. Extreme muscular weakness, easy fatigability, and ptosis. D. Numbness of the extremities, loss of balance, and visual disturbances.
(B) are common clinical features of Parkinsonism. (A) are symptoms of chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis.
Points Earned: 1/ Correct Answer: B Your Response: B
- An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client is most likely to reveal which sign/symptom?
A. Leukocytosis and febrile. B. Polycythemia and crackles. C. Pharyngitis and sputum production. D. Confusion and tachycardia.
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The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate (D). (A, B, and C) are often absent in the elderly with bacterial pneumonia.
Points Earned: 0/ Correct Answer: D Your Response: B
- During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should the nurse expect this client to have?
A. Racing pulse with exertion. B. Clubbing of the fingers. C. An increased chest diameter. D. Productive cough with grayish-white sputum.
Chronic bronchitis, one of the diseases comprising the diagnosis of COPD, is characterized by a productive cough with grayish-white sputum (D), which usually occurs in the morning and is often ignored by smokers. (A) is not related to chronic bronchitis; however, it is indicative of other problems such as ventricular tachycardia and should be explored. (B and C) are symptoms of emphysema and are not consistent with the other symptoms. (C) is usually referred to as a "barrel chest."
Points Earned: 0/ Correct Answer: D Your Response: A
- Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol?
A. Diuretic therapy. B. Pacemaker implantation. C. Anticoagulation therapy. D. Cardiac catheterization.
The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C) which should be prescribed before rhythm control therapies to prevent cardioembolic
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by clients diagnosed with hypoparathyroidism. (C) lists the signs of an Addisonian (adrenal) crisis. (D) lists the signs of hyperparathyroidism.
Points Earned: 0/ Correct Answer: B Your Response: A
- The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
A. She sustained an insect bite to her left arm yesterday. B. She has lost twenty pounds since the surgery. C. Her healthcare provider now prescribes a calcium channel blocker for hypertension. D. Her hobby is playing classical music on the piano.
A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema (A). (B) is not a factor. Lymphedema is not significantly related to vascular circulation (C). Only overuse of the arm, such as weight-lifting, would cause lymphedema--(D) would not. Points Earned: 1/ Correct Answer: A Your Response: A
- After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?
A. 15 minutes before and 15 minutes after the next dose. B. One hour before and one hour after the next dose. C. 5 minutes before and 30 minutes after the next dose. D. 30 minutes before and 30 minutes after the next dose.
Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV.
Points Earned: 0/ Correct Answer: C
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Your Response: A
- When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching?
A. Recommend that the client carry suction equipment at all times. B. Instruct the client to have writing materials with him at all times. C. Tell the client to carry a medic alert card stating that he is a total neck breather. D. Tell the client not to travel alone.
It is imperative that total neck breathers carry a medic alert notice (C) so that if they have a cardiac arrest, mouth-to-neck breathing can be done. Mouth-to-mouth resuscitation will not help them. They do not need to carry (A) nor refrain from (D). There are many alternative means of communication for clients who have had a laryngectomy; depending on (B) is probably the least effective. How do you know he can read and write?
Points Earned: 0/ Correct Answer: C Your Response: A
- Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?
A. Tinnitus, vertigo, and hearing difficulties. B. Sudden, stabbing, severe pain over the lip and chin. C. Facial weakness and paralysis. D. Difficulty in chewing, talking, and swallowing.
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial) (B). (A) would be characteristic of Méniére's disease (8th cranial nerve). (C) would be characteristic of Bell's palsy (7th cranial nerve). (D) would be characteristic of disorders of the hypoglossal cranial nerve (12th).
Points Earned: 0/ Correct Answer: B Your Response: D
- An adult client is admitted to the hospital burn unit with second and third degree burns over 40% of the body surface
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vitamins. C. Decrease caloric intake. D. Restrict salt and fluid intake.
Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not impact fluid retention.
Points Earned: 0/ Correct Answer: D Your Response: A
- The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include?
A. Safety precautions during activity. B. Assess for changes in size of lymph nodes. C. Maintain a fluid intake of 3 to 4 L per day. D. Administer narcotic analgesic around the clock.
Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to promote excretion of serum calcium. Although the client is at risk for pathologic fractures due to diffuse osteoporosis, mobilization and weight bearing (A) should be encouraged to promote bone reabsorption of circulating calcium, which can cause renal complications. (B) is a component of ongoing assessment. Chronic pain management (D) should be included in the plan of care, but prevention of complications related to hypercalcemia is most important.
Points Earned: 0/ Correct Answer: C Your Response: B
- What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode?
A. Vasodilators and hormones. B. Analgesics and sedatives. C. Anticoagulants and expectorants. D. Bronchodilators and steroids.
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Besides supplemental oxygen, the ARDS client needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, i.e., bronchodilators and steroids (D). (A) would not help the condition. (B) would further depress the client and compromise the ability to breathe. Anticoagulants would be contraindicated since clotting of the blood is not yet a problem, and expectorants are not appropriate for this critically ill client (C).
Points Earned: 1/ Correct Answer: D Your Response: D
- When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?
A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. B. Purse the lips while inhaling as deeply as possible and then exhale through the nose. C. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. D. Place one hand on the chest, one hand the abdomen and make both hands move outward.
Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so (A) helps the client visualize the rise and fall of the abdomen. The client should purse the lips while exhaling, not (B). (C and D) are ineffective.
Points Earned: 1/ Correct Answer: A Your Response: A
- A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?
A. Frequent urinary tract infections. B. Inability to get pregnant. C. Premenstrual syndrome. D. Chronic use of laxatives.
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D. apical pulse is 68/min.
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).
Points Earned: 0/ Correct Answer: C Your Response: A
- During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
A. Use a laryngoscope to check for a foreign body lodged in the esophagus. B. Reposition the head to validate that the head is in the proper position to open the airway. C. Turn the client to the side and administer three back blows. D. Perform a finger sweep of the mouth to remove any vomitus.
The most frequent cause of inadequate aeration of the client's lungs during CPR is improper positioning of the head resulting in occlusion of the airway (B). A foreign body can occlude the airway, but this is not common unless choking preceded the cardiac emergency, and (A, C and D) should not be the nurse's first action.
Points Earned: 0/ Correct Answer: B Your Response: C
- A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse’s best response?
A. Explain the effect of the follicle-stimulating and luteinizing hormones. B. Discuss perimenopause and related comfort measures. C. Assess lung fields and for a cough productive of blood- tinged mucous. D. Ask if a fever above 101º F has occurred in the last 24
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hours.
The perimenopausal period begins about 10 years before menopause with the cessation of menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot flashes, so discussions about the perimenopausal body's changes, comfort measures (B), and treatment options should be provided. In-depth pathophysiology of the symptoms (A) may only confuse the client. There is no indication that the client has tuberculosis and an infection, so (C and D) are not indicated.
Points Earned: 0/ Correct Answer: B Your Response: A
- An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion?
A. Pain in the calf awakening him from a sound sleep. B. Calf pain on exertion which stops when standing in one place. C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. D. Pain upon arising in the morning which is relieved after some stretching and exercise.
Thrombophlebitis pain is relieved by rest and elevation of the extremity (C). It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place (B). (A and D) describe pain that is not common with thrombophlebitis.
Points Earned: 0/ Correct Answer: C Your Response: A
- A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information?
A. The vaccine is given annually before the flu season to those over 50 years of age. B. The immunization is administered once to older adults or
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C. Use the diaphragm to prevent conception during the menstrual cycle. D. Do not leave the diaphragm in place longer than 8 hours after intercourse. E. Contact a healthcare provider a sudden onset of fever grater than 101º F appears. F. Replace the old diaphragm every 3 months.
Correct selections are (D and E). The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours (D) to avoid the risk of TSS. If a sudden fever occurs, the client should notify the healthcare provider (E). (A) increases the risk of pregnancy, and (B) can reduce the integrity of the barrier contraceptive but neither prevents the risk of TSS. The diaphragm should not be used during menses (C) because it obstructs the menstrual flow and is not indicated because conception does not occur during this time. (F) is not necessary.
Points Earned: 0/ Correct Answer: D, E Your Response: C, D
- The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide?
A. Two weeks before menstruation. B. Vaginal mucous discharge is thick. C. Low basal temperature. D. First thing in the morning.
Ovulation typically occurs 14 days before menstruation begins (A), and sexual intercourse should occur within 24 hours of ovulation for conception to occur. High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics, which become more "slippery" and stretchy, not (B). A rise in basal temperature, not (C), signals ovulation. The timing during the day is not as significant in determining conception as the day before and after ovulation (D).
Points Earned: 0/ Correct Answer: A Your Response: B
- The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The
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client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement?
A. Ask the client what he means by "heart trouble." B. Call for an ECG to be performed immediately. C. Notify surgery that the ECG is over two years old. D. Notify the client's surgeon immediately.
Clients over the age of 40 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. (B) should be implemented to ensure that the client's current cardiovascular status is stable. Additional data might be valuable (A), but since time is limited, the priority is to obtain the needed ECG. Documentation of vital signs is important, but does not replace the need for the ECG (C). The surgeon only needs to be notified if the ECG cannot be completed, or if there is a significant problem (D).
Points Earned: 0/ Correct Answer: B Your Response: A
- The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?
A. If suctioning will be needed for drainage of the wound. B. If the family would prefer a private or semi-private room. C. If the client also has a Hemovac® in place. D. If the client's wound is infected.
Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most important to place an infected client in a private room (D). A penrose drain does not require (A). Although (B) is information that should be considered, it does not have the priority of (D). (C) is used to drain fluid from a dead space and is not important in choosing a room.
