Medical Surgical Nursing

MEDICAL SURGICAL NURSING-ANSWERS 1. A 42-year-old client admitted with an acute myocardial infarction asks to see his chart. What should the nurse do first? a. Allow the client to view his chart b. Contact the supervisor and physician for approval c. Ask the client if he has concerns about his care d. Tell the client that he isn't permitted to view his chart. 2. A registered nurse who works in the preoperative area of the operating room notices that a client is scheduled for a partial mastectomy and axillary lymph node removal the following week. The nurse should make sure, that the client is well educated about her surgery by: a. taking with the nursing staff at the physician's office to find out what the client has been taught and her level of understanding b. making sure that the post-anesthesia recovery unit nurses know what to teach the patient before discharge c. providing all of the preoperative teaching before surgery d. having the post-operative nurses teach the patient because she'll be too anxious before surgery 3. A male client brings a list of his prescribed medications to the clinic. During the initial assessment, he tells the nurse that he has been experiencing delayed ejaculation. Which drug class is associated with this problem? a. Anticoagulants b. Antibiotics c. Antihypertensive d. Steroids Situation: Larry was admitted at Manila Doctor's Hospital because of a second-degree burn wound. 4. Before debriding a second-degree burn wound in the left lower leg, the nurse should do which of the following? a. Apply Lindane (Kwell) to the affected area b. Medicate the client with narcotic analgesic c. Administer acylovir (Zovirax) IV d. Apply a topical antimicrobial ointment 5. Larry’s anterior trunk, both front upper extremities, both

lower extremities sustained second and third degree burn. Estimate the total percentage of body surface area burned using the Rule of Nines. a. 60% b. 63% c. 62% d. 61% Situation 4. Hearing, impairment appears to be common among elderly patients. But also occurs among children. 6. To assess the degree of hearing impairment of a 70-year-old client. Which communication approach would you initiate? a. Use verbal communication and observe the response b. Give message to client in writing c. Asks a family member about the client's d. Post a sign "Patient deaf" 7. While you are mating your routine rounds you were told that there is a client in the 1CU who is in respirator and who lipreads. To establish relationship with him, communication is best accomplished by: a. Speaking slowly but aloud b. Writing messages c. Gesturing while speaking d. Using simple "charade" approach or strategy 8. One of your client's has just undergone an ear surgery. Which of the following would be inappropriate in planning for his care? a. Administration of anti-emetics and analgesics as ordered b. Daily irrigation of the ear canal c. Walking with assistance at least 24 hours after operation d. Teaching the patient to avoid sneezing, coughing and nose blowing 9. Which of the following conditions would an irrigation of the ear canal be appropriate intervention? a. Foreign body in the ear canal b. Serious otitis c. Impacted cerumen d. Tympanic membrane perforation

10. Children who have undetected hearing loss are likely to exhibit which of the following: a. Indifference and lack of interest in the environment b. Hyperactivity c. An increased interest in reading d. Hand gestures while speaking Situation 9. One of the main fools of the nursing profession is the use of therapeutic communication. The following situation would require you of your communication skills. 11. A patient who is diagnosed to have terminal illness tells you. "I’m really scared. Am I dying?" What could be your most appropriate response? a. "Tell me about what you think." b. "I'm sure you are scared; other clients in your situation feel the same way." c. "You should be careful not to let your family know you're scared" d. "Why are you scared?" 12. The nurse assessing a male client who has been admitted for treatment of alcoholism. Which question by the nurse is least appropriate? a. "How much do you think?" b. "What other drugs do you use?" . c. "How is your general health?" d. "Why do you drink so much?" 13. A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation? a. "Your wife's need to help you is a reality you should accept" b. "Do you think your wife might benefit from counseling?" c. "You feel you need privacy when changing your colostomy?" d. "Have you discussed the situation with your doctor?" 14. An 87 year old widow was hospitalized for treatment of chronic renal disease. She lives with her daughter and son-inlaw and their family, who are very supportive. She is now ready for discharge. The doctor has ordered high carbohydrates, low-protein, low sodium diet for her and the

family has asked for assistance in planning low-sodium diet meals. Which of the following choices best reflects the predischarge information the nurse should provide for the client's family regarding low-sodium diet? a. Avoid canned and processed foods, do not use salt replacements substitute herbs and replaces for salt in cooking and when seasoning foods, call a dietitian for help. b. Use potassium salts in place of table salt when coking and seasoning foods, read the labels on packaged foods to determine sodium content, and avoid snacks food c. Limit milk and dairy products, cook separate meals that are low in sodium and encourage increased fluid intake d. Avoid eating in a restaurant, soak vegetables well before cooking to remove sodium, omit all canned foods, and remove salt shakes from table. 15. You are encouraging your patient for major cancer operation to verbalize her fears. She remarked," I am afraid to do". Your appropriate response is a. "I know how you feel about your condition". b. "Don't worry, you are in good hands." c. "Let me call a chaplain to see you." d. "Let us asks your doctor about your operation." 16. The nurse is caring for a client whose arterial blood gases indicate metabolic acidosis. The nurse knows that of the following, the least likely to cause metabolic acidosis is: a. cardiac arrest b. Diabetic ketoacidosis c. decreased serum potassium level d. renal failure 17. The nurse is caring for a client who is receiving IV fluids, Which observation the nurse makes best indicates that the IV has infiltrated? a. Pain at the site b. A change in flow rate c. Coldness around the insertion site d. Redness around the insertion site 18 A 27 y.o adult is admitted for treatment of Crohn's disease. Which information is most significant when the nurse assesses

nurtritional health? a. Anthropometric measurements b. bleeding gums c. dry skin d. facial rubor 19. ASA (aspirin) is being administered to a client. The nurse understands that the most common mechanism of action for nonnarcotic analgesic is their ability to: a. Inhibit prostaglandin systhesis b. After pain perception in the cerebellum c. Directly affect the central nervous system d. Target the pain-producing effect of kinins 20. The nurse caring for an adult client who is receiving TPN will need to be monitored for which of the following metabolic complications? a. Hypoglycemia and Hypercalcemia b. Hyperglycemia and Hypokalemia c. Hyperglycemia and Kyperkalemia d. Hyperkalemia and Hypercalcemia 21. Total parenteral nutrition is ordered for an adult. Which nutrient is not likely to be in the solution? a. Dextrose 10% b. Trace minerals c. Amino acids d. Non of the above 22. A man has sprained his ankle. The physician would order cold applied to the injured area to. a. Reduce the body's temperature b. Increase circulation to the area c. Aid in absorbing the edema d. Relieve pain and control bleeding. 23. An adult is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water? a. 65 F b. 90 F

c. 110 F d. 105 F 24. An adult has chronic lower back pain and receives hot pack three times a week. The nurse knows that the treatment is given for which of the following reasons? a. To help remove debris from the wound b. To keep the client warm and raise his temperature c. To improve the client's general circulation d. To relieve muscle spasm and promote muscle relaxation 25. A patient classification system where patients minimal theraphy and less frequent observation a. minimal care (category 1) b. moderate care (category 2) c. maximum care (category 3) d. intensive care (category 4) 26. The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressing is best? a. Dry gauze dressing b. wet gauze dressing c. wet to dry dressing d. moisture vapor permeable dressing 27. The client has been placed in the trendelenburg position. The nurse knows the effects of this position to the client include which of the following. a. increase blood flow to the feet b. decrease blood pressure c. increase pressure on the diaphragm d. decrease intracranial pressure 28. A man who has been in an MVA is going into shock. Before placing the client in a modified trendelenburg position, the nurse should assess the client for: a. long bone fracture b. air embolus c. head injury d. thrombophlebitis

29. The nurse enter a room and finds a fire. Which is the best initial action? a. Evacuate any people in the room, beginning with the most ambultory and ending with the least mobile b. activating the fire alarm or call the operator, depending on the institutions system c. get a fire extinguisher and put out the fire d. close all the windows and doors and turn off any oxygen or electricity appliance. 30. The nurse is to open a sterile package from central supply. Which is the correct direction to open the first lap? a. Toward the nurse b. Away from the nurse c. To the nurse's left or right hand d. It does not matter as long as the nurse touches only the outside edge 31. The nurse knows which of the following is the proper technique for medical asepsis? a. gloving for all the client contact b. changing hospital linens weekly c. using your hands to turn off the faucet after handwashing d. gowning to care for a 1 year old child w/ infections diarrhea 32. An adult ha a left, above the knee amputation two weeks ago. The nurse places him in a prone position tree times a day because a. Prevents pressure ulcer on the sacrum b. helps the prosthesis to fit correctly c. prevents flexion constractures d. allow better blood flow to the heart 33. A woman is to have a pelvic exam. Which of the following should the nurse have the client do first? a. Remove all her clothes and her socks and shoes b. go to the bahtroom and void saving a sample c. assume a lithotomy position on the exam table d. assemble all the equipments needed for the examination 34. An adult is supine. Which of the ff. can the nurse to to

prevent external rotation of the legs? a. put a pillow under the clients lower legs b. place a pillow directly under the client knee c. use a trochanter rool alongside the client's upper thighs d. lower the client's legs so that they ae below hips. 35. The nurse prepares to palpate a clients maxillary sinues. For this procedure, where should the nurse place the hands? a. On the bridge of the nose b. below the eyebrows c. below the cheekbones d. over the temporal area 36. A client who receives general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? a. Pain related to the surgery b. Fluid volume deficit related to fluid and blood loss from surgery c. Impared physical mobility related to surgery d. Risk for aspiration related to anesthesia 37. After a client receives an IM injection, he complains of a burning pain in the injection site. Which nursing action whould be best to take at this time? a. apply a cold compress to decrease swelling b. apply a warm compress to dilate the blood vessels c. Massage the area to promote absorption of the drug d. Instruct the client to tighten his gluteal muscles to enhance absorption of the drug 38. A patient classification system where patients need close attention and complete care in most activities and requires frequent and complex treatments and medications a. Minimal Care (category 1) b. Moderate Care (category 2) c. Maximum Care (category 3) d. Intensive Care (category 4) 39. An observation consistent with complete-airway obstruction is:

a. Loud crowing when attempting to speak b. Inability to cough c. Wheezes on auscultation d. Gradual 40. The nurse assesses the client's home environment for the safe use crutches. Which one of the following would pose the greatest hazard to the client's safe use of crutches at home? a. A 4-year old cocker spaniel b. Scatter rugs c. Snack tables d. Diet high in fat 41. A patient who has kaposis sarcoma has all of the following nursing diagnoses. To which one should the nurse give priority? a. Altered thought processes related to lesions b. Altered with maintenance related to non compliance c. Defensive coping related to loss of boundaries d. Hopelessness, related to inability to control disease process 42. Which of the following statements, if made by a patient who has had a basal cell carcinoma removed, would indicate to the nurse the need for further instruction? a. "I will use sunscreen with at least a sun protection factor (SPF) of 15.” b. "I will use tanning booths rather than sunbathing from now on." c. "I will stay out of the sun between 10:00 AM and 2:00 PM" d. "I will wear a broad - brimmed heat when I am in the sun" 43. A patient who has a diagnosis is metastatic cancer of the kidney is told by the physician that the kidney needs to be removed. The patient asks the nurse. "What should I do?" Which of the following responses by the nurse would be most therapeutic? a. "Let's talk about your options." b. "You need to follow the doctor's advice." c. "What does your family want you to do." d. "I wouldn't have the surgery done without a second opinion. 44. Which of the following conditions, reported to a nurse by a 20 year old male patient, would indicate a risk for development

of testicular cancer? a. Genital Herpes b. Undescended testicle c. Measles d. Hydrocele 45. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to: a. Limit fluid intake for 24 hours b. Teach muscle tightening exercises c. Teach the procedure for irrigation of the stoma d. Provide cleansing enemas and laxatives as ordered 46. To gain access to a vein and an artery, an external shunt may be used for clients who require hemodialysis. The most serious problem with an external shunt is. a. Septicemia b. Clot-formation c. Exsanguination d. Sclerosis of vessels 47. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to: a. Limit fluid intake for 24 hours b. Teach the procedure for irrigation of the stoma c. Teach muscle-tightening exercises d. Provide cleansing enemas and laxatives as ordered 48. Intramedullary nailing is used in the treatment of: a. Slipped epiphysis of the femur b. Fracture of shaft of the femur c. Fracture of the neck of the femur d. Intertrochanteric fracture of the femur 49. The nurse should know that, following a fracture of the neck of the femur, the desirable position for the a. Internal rotation with extension of the knee b. Internal rotation with flexion of the knee and hip

c. External rotation with flexion of the knee and hip d. External rotation with extension of the knee and hip 50. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by: a. Stimulating the cerebral cortex b. Blocking the action of cholinesterase c. Replacing deficient neurotransmitters d. Accelerating transmission along neural swaths 51. A client with myasthenia gravis ask the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is: a. A genetic in the production acetylcholine b. A reduced amount of neurotransmitter acetylcholine c. A decreased number of functioning acetylcholine receptor sites d. An inhibition of the enzyme ACHE leaving the end plates folded 52. A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit the nurse should a. Maintain the same dial setting everyday b. Turn the machine several times a day for 10 to 20 minutes c. Adjust the TENS dial until the client perceives pain relief and comfort d. Apply the color-coded electrodes anywhere it is comfortable for the client 53. Although no cause has been determined for scleroderma, it is thought to be caused by: a. Autoimmunity b. Ocular motility c. Increased amino acid metabolism d. Defective sebaceous gland formation 54. The nurse must help the client with pemphigus vulgaris deal with the resulting: a. Infertility b. Paralysis c. Skin lesions d. Impaired digestion

55. The nurse should explain to the client with psoriasis that treatment usually involves: a. Avoiding exposure to the sum b. Topical application of steroids c. Potassium permanganate baths d. Debridement of necrotic plaques 56. The nurses should assess a client with psoriasis a. Pruritic lesions b. Multiple petechiae c. Shiny, scaly lesions d. Erythematous macules 57. A urine specimen for ketones should be removed from a client's retention catheter by: a. Disconnecting the catheter and draining it into a clean container b. Cleansing the drainage valve and removing it from the catheter bag c. Wiping the catheter with alcohol and draining it into a sterile test tube d. Using a sterile syringe to remove it from clamped, cleansed catheter 58. Following an abdominal cholecystectomy, the nurse should assess for signs of respiratory complications because the: a. Incision is in close proximity to the diaphragm b. Length of time required for surgery is prolonged c. Client's resistance is lowered because of bile in the blood d. Bloodstream is invaded by microorganisms from the biliary tract 59. The nurse assess the client with cholecystitis for the development of obstructive jaundice, which would be evidenced by: a. Inadequate absorption of fat-soluble K b. Light amber urine, dark brown stools, yellow skin c. Dark-colored urine, clay colored stools, itchy skin d. Straw-colored urine, putty-colored stools, yellow sclerae 60. A client with cholelithiasis experience discomfort after ingesting fatty foods because. a. Fatty foods are hard to digest

b. Bile flow into the intestine is obstructed c. The liver is manufacturing inadequate bile d. There is inadequate closure of the Ampulla of Vater 61. The chief complaint in a client with Vincent's Angina is: a. Chest pain b. Shortness of breath c. Shoulder discomfort d. Bleeding oral ulcerations

62. Clients with fractured mandibles usually have them immobilized with wires. The life-threatening problem that can develop postoperatively is: a. Infection b. Vomiting c. Osteomyelitis d. Bronchospasm 63. As a result of fractured ribs, the client may develop: a. Scoliosis b. Paradoxical respiration c. Obstructive lung-disease d. Hernation of the diaphragm 64. A client has a bone marrow aspiration performed, immediately after the procedure, the nurse should: a. Position the client on the affected side b. Begin frequent monitoring of vital signs c. Cleanse the site with an antiseptic solution d. Briefly apply pressure over the aspiration site 65. Following a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure but no. evidence of bleeding. The nurse recognizes that this is most likely caused by: a. An inadequate fluid intake b. The after effects of anesthesia c. A reallocation of the blo6d supply d. An increased level of epinephrine

66. The occurrence of chronic illness is greatest in: a. Older adult b. Adolescents c. Young children d. Middle-aged adults 67. A client with full-thickness burns on the chest has a skin graft. During the 1s124 hours after a skin graft, care of the donor site includes immediately reporting. a. Small amount of yellowish green oozing b. A moderate area of serosanguinous oozing c. Epithelialization under the non-adherent dressing d. Separation of the edges of the non-adherent dressing 68. During peritoneal dialysis the nurse observes that drainage of dialysate from the peritoneal cavity has ceased before the required amount has drained out The nurse should assist the client to: a. Turn from side to side b. Drink 8 ounces of water c. Deep breathe and cough d. Periodically rotate the catheter 69. A client has ear surgery. An early response that may be associated with possible damage to the motor branch of the facial nerve is: a. A bitter metallic state b. Dryness of the lips and mouth c. A sensation of pain behind the ear d. An inability to wrinkle the forehead 70. After a prostatectomy, a client complains of painful bladder spasms. To limit these spasms the nurse should: a. Administer a narcotic every 4 hours b. irrigate the Foley catheter with 60 ml of normal saline c. Encourage the client not to contract his muscles as if he were voiding d. Advance the catheter to relieve the pressure against the prostatic fossa 71. After 1 week a client with acute renal failure moves, into

the diuretic phase. During this phase the client must be carefully assessed for signs of: a. Hypovolemia b. Hyperkalemia c. Metabolic acidosis d. Chronic renal failure 72. The nurse checks for hypocalcemia by placing a blood pressure cuff on a client's arm and inflating it. After about 3 minutes the client develops carpopedial spasm. The nurse records this finding as a positive: a. Homan's sign b. Romberg sign c. Chvostek's skin d. Trosseau's sign 73. A client is scheduled for a below-the-knee amputation of the right leg. Legally, the client may not sign the operative consent if: a. Ambivalent feelings regarding operation are present b. Any sedative type of medication has recently been administration c. A discussion of alternative with 2 physicians have not been performed and recorded d. A complete history and physical have not been performed 74. The nurse is assigned to check a client's continuous bladder irrigation. Which one of the following solution is normally used for continuous or intermittent bladder and catheter irrigations? a. Hydrogen peroxide b. Bacteriostatic water c. Sterile normal saline d. Plain water 75. When continuous bladder irrigation is used following prostate surgery, the rate of flow is adjusted: a. To run at 60 drops per minutes b. According to the client's oral intake c. To maintain an output of 500 ml every 8 hours d. To keep the drainage to light pink

76. The nurse is assigned to teach a class in health behaviors to young man. Which of the following can be stated as a probably cause of cancer of the penis? a. A diet high in acidic foods b. Poor personal hygiene c. Exercise d. Circumcision 77. The nurse is assigned to give perineal care to an uncircumcised male client. Which of the following is correct? a. The anal area is washed at a separate time b. The foreskin is retracted and the area beneath the foreskin is cleansed c. The foreskin should not be retracted except by a physician d. The scrotum is carefully washed with sterile normal saline 78. A female nurse is assigned to obtain a history from & client with a urinary tract problem an sexual dysfunction. Which of the following statements might place the client more at ease and willing to give a. history of his problem? a. "When dud you first notice this problem? b. "Why do you think you have a problem?" c. "Do you think you sexual dysfunction is psychological?" d. "Does your sexual dysfunction seem to be related to your urinary tract problem?" 79. A client is scheduled for an ultrasound examination of the prostate. To describe the procedure to the client, the nurse should plan to relate that: a. The procedure is performed using a cystoscope b. A probe will be inserted into the rectum c. A flat disk is placed on the abdomen d. This procedure uses x-rays to produce a visual image 80. To effectively teach men the importance of testicular selfexamination, the nurse should know that testicular carcinoma: a. Rarely metastasizes b. Has a high incidence of early metastasis c. Cannot be detected by laboratory tests d. Must first be biopsied to confirm the diagnosis

81. A nurse is assigned to instruct a client in the method of testicular self-examination. The instruction should include mention that the best time to perform this task is: a. Immediately after getting out of bed in the morning b. Immediately before going to bed c. In the morning after breakfast d. After a warm bath or shower 82. Mr. Dorn has vasectomy. He asks the nurse why he just use a method of birth control because today he, had a sterilization procedure. The most correct answer is: a. The sperm count will not be negative until his testosterone level decrease b. Some minor surgery usually is necessary to ensure sterilization c. Some live sperm will be present in the ejaculatory fluid for a period of time d. Even though a vasectomy is performed, a condom is still recommended for 1 to 2 years 83. A client is scheduled for a cystectomy and asks the nurse what the physician will be able to see during the procedure. The most correct reply is the: a. Kidney and ureters b. Bladder and rectum c. Prostate and ureters d. Urethra and bladder 84. A client is scheduled for a cystectomy and asks the nurse what the physician will be able to see during the procedure. The most correct reply is the: a. Kidney and ureters b. Bladder and rectum c. Prostate and ureters d. Urethra and bladder 85. Nurse assistant attending a nursing conference hears that one of her clients has hydrocele. She asks the nurse how this condition is treated. The most common response is: a. Usually the problem requires more medical or surgical intervention b. Surgery may be necessary to correct the problem c. Wearing a scrotal support usually corrects She problem

d. Drug therapy usually helps control the collection of fluid 86. The nurse is participating in a health class for young women. One subject is cancer of the ovary. Which of the following statements is correct? a. Early symptoms of cancer of the ovary are vague b. This type of cancer has a high cure rate c. Chemotherapy is not used for treating ovarian cancer d. The most prominent early symptoms is an irregular menstrual cycle 87. The nurse is asked to discuss the signs and symptoms of vaginitis caused by the fungus candida albicans with Ms. Barrows. Which one of the following is a usual sign and symptoms of this infection? a. Pain high in the abdomen b. Intensive vaginal and perineal itching c. Decrease in urinary output d. High fever 88. The nurse prepares to give Ms. Edwards a vaginal suppository, which is inserted by means of a special applicator supplied with the drug. Which one of the following is correct? a. Ask the client to void prior to inserting the suppository b. Lubricate the tip of the suppository with petroleum jelly c. Insert the applicator tip gently and with an upward and forward motion d. Insert the applicator approximately ½ inch and depress the plunger 89. The nurse is assigned to give Ms. Milton perineal care. When cleansing the perineum, the cotton ball or wash cloth is gently directed: a. Side to side across the labia majora b. Downward from the pubic area to the anus c. Upward from the anus to the pubic area d. Prom the urinary meatus to the vagina 90. The nurse is assigned to administer a vaginal irrigation (douche). Which of the following is correct? a. The irrigation is best administered with the client standing in a bathtub b. Before inserting, the nozzle is lubricated with petroleum jelly

c. The temperature of the solution should be between 80°F and 84°F d. The nozzle is inserted downward and backward within the vagina 91. The nurse is assigned to teach health-seeking behaviors to young women. One topic the nurse plans to includes is the importance of the Pap test, which is used mainly to detect: a. Ovarian cyst b. Patency of the fallopian tube c. Cervical cancer d. Uterine infections 92. The physician asks the nurse to position a client for a vaginal examination. Which of the following position is normally used for this type of examination? a. Lithotomy position b. Sim's position c. Dorsal recumbent position d. Left lateral position 93. Ms. Hull has had an electrocauterization of her cervix for chronic cervicitis. Following the procedure the nurse should instruct Ms. Hull to: a. Douche the next day to remove debris and blood cloth b. Avoid straining and heavy lifting until the physician permits this activity c. Stay in bed for the next 5 days d. Return in bed for the next 5 days 94. The nursing assistant is assigned to give Ms. Bailey, who has had an abdominal hysterectomy, a sitz bath. She is instructed to use the special sitz bath tub. She asks the nurse why the regular bath tub cannot be used. The most correct reply is based on the fact that a regular bath tab: a. Is more slippery and is dangerous when used for surgical clients b. Cannot supply water that is of the desired temperature for this procedure c. Applies heat to the legs and alters the desired effect of heat directed to the pelvic region d. Cannot be kept as clean as a special sitz bath tub 95. Which of the following solutions would be best for the nurse to use when cleaning the inner cannula of a

tracheostomy tube? a. IsopropyI alcohol b. Sodium hydrochloride c. Hydrogen peroxide d. Providone-iodine 96. The nurse observes that the client's knee is swollen and painful. Consequently; which one of the following nursing measures should be carried out? a. Perform passive range of motion during each shift b. Help to change positions to achieve comfort c. Ambulate with him at frequent intervals d. Encourage quadriceps setting exercises 97. If Ms. Drake tells the nurse her feet are cold. Which of the following nursing action would be best a. Apply a hot water bottle b Use an electric heating pad c. Wrap them in a warm blanket d. Elevate her feet on a stool 98. Which of the following would indicate to the nurse that the stationary thrombus in Ms. Fleming suddenly develops? a. Chest pains b. Leg cramps c. Numbness in the foot d. Swelling of the knee 99. Following a total abdominal hysterectomy Ms. Sara Fleming develops a slightly elevated temperature and swelling in the right call of her leg. The physician prescribes warm moist compresses for the client's affected leg. Which of the following nursing actions is correct when applying the warm moist compress? The nurse: a. Heats the water to 120°F b. Uses a sterile technique c. Inspect the skin every 4 hours d. Covers the wet gauze with a towel 100. Ms. Betty Lynch, age 29, holes that she has recently developed a skin problem and makes an appointment to be

seen in a clinic specializing diagnosis of psoriasis is made by the physician. When examining Mr. Lynch's skin for areas of psoriasis, the nurse should look for: a. Weeping lesions on the trunk of the body b. Patches of redness covered with silvery scales c. Areas of redness surrounded by crusts d. A rash characterized by raised, pus-filled lesions 101. Before being discharged, Mr. Heywood must be taught principles f good body mechanics. The nurse would be correct in telling Mr. Heywood that when he picks up something, he should: a. Flex both his knees b. Keep his feet together c. Lift with arms extended d. Bend from the waist 102. The nurse applies a commercially made hot moist pack, called a hydrocollator, to the client's lower back. To reduce the potential for a thermal injury the nurse should plan to: a. Wrap the pack in several thick towels b. Rub skin lotion over the back area c. Place a pillow between hint and the back d. Position the client on rubber ring 103. Which one of the following observations would most indicate to the nurse that the skin over Mr. Heywood's coccyx is becoming impaired? The skin: a. Looks shiny over boy prominences b. Appears red when pressure in relieved c. Feels cool and clammy d. Is moist and warm 104. Before turning Mr. Heywood to wash his back, which instruction should the nurse provide to minimize his discomfort? a. "Hold your breath as you are turning." b. "Move your upper body first then legs." c. "Curl up in a ball before you move." d. "Avoid twisting your body while moving."

105. Which of the following should the nurse use to provide support to Mr. Heywood's spine? a. A sheep skin pad b. An air mattress c. A bed board d. A foam square 106. Mr. Heywood is to remain in bed for the time being. Which position would the nurse find gives Mr. Heywood the most comfort? a. On his back with the head and knees elevated b. On his side with hips and legs straight c. On his abdomen with his head to the side d. On his back with his head and knees straight 107. Mr. Heywood is receiving 10 mg of Diazepam (Vatium) orally t.i.d. Besides diminishing anxiety, the nurse explains that this medication is also used to: a. Reduce emotional depression b. Relax skeletal muscles c. Promote restful sleep d. Relieve inflammation 108. Mr. Barry Heywood, a construction worker, has been experiencing periodic bouts of law back pain. Now, in addition to the pain that radiates into his buttocks, he has some numbness and tingling in his legs. The physician suspects that Mr. Heywood has a herniated intervertebral disk in the lumbar spine. While assessing the disk to indicate that the pain is increased when: a. Eating b. Sneezing c. Resting d. Urinating 109. Mr. Rumsey, who has not regained consciousness, rushed to surgery where his arm is amputated above the elbow. When Mr. Rumsey reacts from the anesthesia, he sees that his forearm is missing. He screams obscenities and sobs uncontrollably. Which of the following is the best action the nurse can take at this time?

a. Leave the room until he has worked through his anger b. Stay with him quietly in the room at his bedside c. Tell him to get control of himself d. Call the hospital chaplain for him 110. In what position should the nurse place Mr. Rumsey while continuing with his assessment and care? a. Prone b. Supine extended c. On his back with his legs elevated d. On his side with his neck 111. During a farming accident Mr. Steve Rumsey's arm gets caught in a corn auger. His lower left arm and band are crushed. Which of the following assessments would the nurse typically find when the paramedics bring Mr. Rumsey to the hospital in shock? The client would have: a. Decreased heart rate b. Decreasing blood pressure c. Increasing bowel sounds d. Increasing urine output 112. Ms. Angela Freeman has acute low back pain. She' has pelvic-belt traction, which she uses intermittently throughout the day. When the nurse helps Ms. Freeman apply the pelvic traction, it would be best to place the top of the belt: a. Just below the ribcage b. Even with her waistline c. Level with the iliac crest d. Where it is most comfortable 113. Ms. Rizal has acute rheumatoid arthritis. Her hands and spine are involved. When the nurse admits Ms. Rizal is most likely to tell the nurse that the first symptoms that caused her to seek health care was: a. Stiff, sore joints b. Generalized fatigue c. Stabbing hand pain d. Disuse of fingers 114. Before Ms. Elkins leaves the emergency department, the nurse demonstrates hew to apply the roller bandage. She is

told to remove it for approximately 20 minutes and re-apply it three times a day. It is essential that the nurse tells Ms. Elkins to loosen-the bandage if: a. Her toes feel fairly warm b. Her ankle feels painful c. Her toes appear swollen d. She wears a cotton sock 115. The x-ray reveals that the bones are intact. The physician tells Ms. Elkins that she has severely sprained ankle. The physician directs the nurse to wrap Ms. Elkins foot with an elastic roller bandage referred to by some as an Ace bandage. Where should the nurse begin applying the bandage? a. Below the knee b. Above the knee c. Across the phalanges d. At the metatarsals 116. Following an injury in which Ms. Leona Elkins while climbing stairs, she experiencing immediate swelling of her ankle and pain on movement. Her physician has sent her to the hospital for x-ray. Which on of the following nursing measures would be most helpful for relieving the swelling while preparing to obtain the x-ray of Ms. Elkin's lower leg? a. Dangle the foot b. Elevate the foot c. Exercise the foot d. Immobilize the foot SITUATION: Mr. Ramos was barbecuing outdoors when the gas tank exploded. He sustained second degree and third degree burns of the anterior portion of BOTH arms, the upper half of his anterior trunk and the anterior and posterior portions of his left lower extremity. 117. The BEST initial management of burns that can be employed at the scene is generally which of the following: a. Pour cold water over the burned areas b. Apply clean dressing to the affected area c. Rinse the area with mild soap and water d. Apply tomato juice and ointment over the area 118. At the emergency room, the nurse assessed the extent of

the burn on the patient's body. Based on the rules of nine. Which of the following is the BEST estimate of the burn? a. 36% b. 45% c. 27% d. 54% 119. Which one of the following .blood value determinations is most likely be useful to evaluate the adequacy of the fluid replacement? a. Creatinine levels b. Blood urea nitrogen c. Hematocrit level d. C02 tension 120. The nurse is administering the prescribed IVF. When she evaluated the patient, she suspected fluid overload because of which finding? a. Dark and scant urine output b. Moist rates c. Bradycardia and hypotension d. Facial flushing and twitching

121. The doctor orders MAFENIDE for application over the bum area. The nurse understands that one disadvantage of this drug is that: a. It causes lactic acidosis b. It must be constantly applied c. It has minimal eschar penetration d. It is bacteriostatic SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer. He had undergone lobectomy on the left lower lung. A two-bottle drainage system is inserted. 122. The patient is placed on bed post-operatively in what position? a. Prone b. Trendelenburg

c. Right side d. Left side 123 Water-seal chest drainage involves attaching the chest tube to a: a. Suction machine directly b. Rubber tube/glass tube that is submerged underwater c. Rubber tube that is left open to air d. A closed drainage bottle with sterile water and no external opening 124. If the nurse sees fluid moving up and down during inspiration and expiration on the water seal bottle, she should: a. Do nothing as this is expected b. Immediately check the bottle for leaks c. Call the physician immediately and damp the chest tube d. Cover the wound with wet sterile gauze and send someone to calf the physician 125. If the nurse sees vigorous and continuous bubbling in the second bottle, she should: a. Momentarily clamp the tube to note for air leak b. Administer oxygen to the patient c. Attempt to change a new bottle d. Pull the chest tube out to remove the air leak 126. If the tube accidentally displaces from the chest of the patient, the nurse should do which action first? a. Clamp the tube with the use of forceps b. Obtain a new set of tubing and submerge the tube on the water c. Attempt to reinsert the tube d. Apply vaselinized gauze to the opening