Medical Surgical by Nursing Crib

1. A patient is admitted to the medical surgical unit following surgery. Four days after
surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet,
productive cough. The nurse assesses the patient with understanding that an infection that
is acquired during hospitalization is known as:

a. a community acquired infection

b. an iatrogenic infection
c. a nosocomial infection
d. an opportunistic infection

Nosocomial, or hospital-acquired are infections acquired during hospitalization for which

the patient isn’t being primarily treated. Community acquired or opportunistic infections
may not be acquired during hospitalization. An iatrogenic infection is caused by the
doctor or by medical therapy. And an opportunistic infection affects a compromised host.

2. A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing
symptoms of cerebral tissue hypoxia. Which of the following nursing interventions would
be most important in providing care?

a. Providing rest periods throughout the day

b. Instituting energy conservation techniques
c. Assisting in ambulation to the bathroom
d. Checking temperature of water prior to bathing

Cerebral tissue hypoxia is commonly associated with dizziness. The greatest potential
risk to the client with dizziness is injury, especially with changes in position. Planning for
periods of rest and conserving energy are important with someone with anemia because
of his or her fatigue level but most important is safety.

3. A client was involved in a motor vehicular accident in which the seat belt was not
worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains of
shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of the
following assessment findings would concern the nurse most?

a. Temperature of 102 degrees F and productive cough

b. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
c. Trachea deviating to the right
d. Barrel-chested appearance

A mediastinal shift is indicative of a tension pneumothorax along with the other

symptoms in the question. Since the individual was involved in a MVA, assessment
would be targeted at acute traumatic injuries to the lungs, heart or chest wall rather than
other conditions indicated in the other answers. Option A is common with pneumonia;
values in option B are not alarming; and option D is typical of someone with COPD.
4. The proper way to open an envelop-wrapped sterile package after removing the outer
package or tape is to open the first position of the wrapper:

a. away from the body

b. to the left of the body
c. to the right of the body
d. toward the body

when opening an envelop-wrapped sterile package, reaching across the package and
using the first motion to open the top cover away from the body eliminates the need to
later reach across the steri9le field while opening the package. To remove equipment
from the package, opening the first portion of the package toward, to the left, or to the
right of the body would require reaching across a sterile field.

5. Assessment of a client with possible thrombophlebitis to the left leg and a deep vein
thrombosis is done by pulling up on the toes while gently holding down on the knee. The
client complains of extreme pain in the calf. This should be documented as:

a. positive tourniquet test

b. positive homan’s sign
c. negative homan’s sign
d. negative tourniquet test

Pain in the calf while pulling up on the toes is abnormal and indicates a positive test. If
the client feels nothing or just feels like the calf muscle is stretching, it is considered
negative. A tourniquet test is used to measure for varicose veins.

6. Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia. The
doctor orders a series of laboratory tests to determine whether Mr. Elison’s dementia is
treatable. The nurse understands that the most common cause of dementia in this
population is:

a. AIDS
b. Alzheimer’s disease
c. Brain tumors
d. Vascular disease

Alzheimer’s disease is the most common cause of dementia in the elderly population.
AIDS, brain tumors and vascular disease are all less common causes of progressive loss
of mental function in elderly patients.

7. Which of the following nursing interventions is contraindicated in the care of a client

with acute osteomyelitis?
a. Apply heat compress to the affected area
b. Immobilize the affected area
c. Administer narcotic analgesics for pain
d. Administer OTC analgesics for pain

Options B, C and D are appropriate nursing interventions when caring for a client
diagnosed with osteomyelitis. The application of heat can increase edema and pain in the
affected area and spread bacteria through vasodilation.

8. A client with congestive heart failure has digoxin (Lanoxin) ordered everyday. Prior
to giving the medication, the nurse checks the digoxin level which is therapeutic and
ausculates an apical pulse. The apical pulse is 63 bpm for 1 full minute. The nurse
should:

a. Hold the Lanoxin

b. Give the half dose now, wait an hour and give the other half
c. Call the physician
d. Give the Lanoxin as ordered

The Lanoxin should be held for a pulse of 60 bpm. Nurses cannot arbitrarily give half of
a dose without a physician’s order. Unless specific parameters are given concerning pulse
rate, most resources identify 60 as the reference pulse.

9. Nurse Marian is caring for a client with haital hernia, which of the following should
be included in her teaching plan regarding causes:

a. To avoid heavy lifting

b. A dietary plan based on soft foods
c. Its prevalence in young adults
d. Its prevalence in fair-skinned individuals

Heavy lifting is one factor that leads to development of a hiatal hernia. Dietary factors
involve limiting fat intake, not restricting client to soft foods. It is more prevalent in
individuals who are middle-aged or older. Fair-skinned individuals are not prone to this
condition.

10. Joseph has been diagnosed with hepatic encephalopathy. The nurse observes
flapping tremors. The nurse understands that flapping tremors associated with hepatic
encephalopathy are also known as:

a. aphasia
b. ascites
c. astacia
d. asterixis
Flapping tremors associated with hepatic encephalophaty are asterixis. Aphasia is the
inability to speak. Ascites is an accumulation of fluid in the peritoneal cavity. Astacia is
the inability to stand or sit still.
11. Hyperkalemia can be treated with administration of 50% dextrose and insulin. The
50% dextrose:
a. causes potassium to be excreted
b. causes potassium to move into the cell
c. causes potassium to move into the serum
d. counteracts the effects of insulin

The 50% dextrose is given to counteract the effects of insulin. Insulin drives the
potassium into the cell, thereby lowering the serum potassium levels. The dextrose
doesn’t directly cause potassium excretion or any movement of potassium.

12. Which of the following findings would strongly indicate the possibility of cirrhosis?

a. dry skin
b. hepatomegaly
c. peripheral edema
d. pruritus

Although option D is correct, it is not a strong indicator of cirrhosis. Pruritus can occur
for many reasons. Options A and C are incorrect, fluid accumulations is usually in the
form of ascites in the abdomen. Hepatomegaly is an enlarged liver, which is correct. The
spleen may also be enlarged.

13. Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma.
The nurse assesses the client for which of the following common presenting symptoms of
the disorder?
a. halo vision
b. dull eye pain
c. severe eye and face pain
d. impaired night vision

Narrow-angle glaucoma develops abruptly and manifests with acute face and eye pain
and is a medial emergency. Halo vision, dull eye pain and impaired night vision are
symptoms associated with open-angle glaucoma.

14. Chvostek’s sign is associated with which electrolyte impabalnce?

a. hypoclacemia
b. hypokalemia
c. hyponatremia
d. hypophosphatenia

Chvostek’s sign is a spasm of the facial muscles elicited by tapping the facial nerve and is
associated with hypocalcemia. Clinical signs of hypokalemia are muscle weakness, leg
cramps, fatigue, nausea and vomiting. Muscle cramps, anorexia, nausea and vomiting are
clinical signs of hyponatremia. Clinical manifestations associated with
hypophosphatemia include muscle pain, confusion, seizures and coma.

15. What laboratory test is a common measure of the renal function?

a. CBC
b. BUN/Crea
c. Glucose
d. Alanine amino transferase (ALT)

The BUN is primarily used as indicator of kidney function because most renal diseases
interfere with its excretion and cause blood vessels to rise. Creatinine is produced in
relatively constant amounts, according to the amount of muscle mass and is excreted
entirely by the kidneys making it a good indicator of renal function.

16. Nurse Edward is performing discharge teaching for a newly diagnosed diabetic
patient scheduled for a fasting blood glucose test. The nurse explains to the patient that
hyperglycemia is defined as a blood glucose level above:

a. 100 mg/dl
b. 120 mg/dl
c. 130 mg/dl
d. 150 mg/dl

Hyperglycemia is defined as a blood glucose level greater than 120 mg/dl. Blood glucose
levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are considered hyperglycemic. A blood
glucose of 100 mg/dl is normal.

17. Mang Edison is on bed rest has developed an ulcer that is full thickness and is
penetrating the subcutaneous tissue. The nurse documents that this ulcer is in which of
the following stages?

a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4

A stage 3 ulcer is full thickness involving the subcutaneous tissue. A stage 1 ulcer has a
defined area of persistent redness in lightly pigmented skin. A stage 2 ulcer involves
partial thickness skin loss. Stage 4 ulcers extend through the skin and exhibit tissue
necrosis and muscle or bone involvement.

18. A 24 year old male patient comes to the clinic after contracting genital herpes.
Which of the following intervention would be most appropriate?
a. Encourage him to maintain bed rest for several days
b. Monitor temperature every 4 hours
c. Instruct him to avoid sexual contact during acute phases of illness
d. Encourage him to use antifungal agents regularly

Herpes is a virus and is spread through direct contact. An antifungal would not be useful;
bed rest and temperature measurement are usually not necessary.

19. An 8 year old boy is brought to the trauma unit with a chemical burn to the face.
Priority assessment would include which of the following?

a. Skin integrity
b. BP and pulse
c. Patency of airway
d. Amount of pain

A burn face, neck or chest may cause airway closure because of the edema that occurs
within hours. Remember the ABC’s: airway, breathing and circulation. Airway always
comes first, even before pain. The nurse will also assess options B and D, but these are
not the highest priority assessments.

20. A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL. Which of
the following complaints would be indicative of tissue hypoxia related to anemia?

a. dizziness
b. fatigue relieved by rest
c. skin that is warm and dry to the touch
d. apathy

Central tissue hypoxia is commonly associated with dizziness. Recognition of cerebral

hypoxia is critical since the body will attempt to shunt oxygenated blood to vital organs.

21. Hazel Murray, 32 years old complains of abrupt onset of chest and back pain and
loss of radial pulses. The nurse suspects that Mrs. Murray may have:

a. Acute MI
b. CVA
c. Dissecting abdominal aorta
d. Dissecting thoracic aneurysm

A dissecting thoracic aneurysm may cause loss of radical pulses and severe chest and
back pain. An MI typically doesn’t cause loss of radial pulses or severe back pain. CVA
and dissecting abdominal aneurysm are incorrect responses.

22. Nurse Alexandra is establishing a plan of care for a client newly admitted with
SIADH. The priority diagnosis for this client would be which of the following?
a. Fluid volume deficit
b. Anxiety related to disease process
c. Fluid volume excess
d. Risk for injury

SIADH results in fluid retention and hyponatremia. Correction is aimed at restoring fluid
and electrolyte balance. Anxiety and risk for injury should be addressed following fluid
volume excess.

23. Nursing management of the client with a UTI should include:

a. Taking medication until feeling better

b. Restricting fluids
c. Decreasing caffeine drinks and alcohol
d. Douching daily

Caffeine and alcohol can increase bladder spasms and mucosal irritation, thus increase
the signs and symptoms of UTI. All antibiotics should be taken completely to prevent
resistant strains of organisms.

24. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The
nurse understands that a postoperative patient who’s maintained on bed rest is at high risk
for developing:

a. angina
b. arterial bleeding
c. deep vein thrombosis (DVT)
d. dehiscence of the wound

DVT, is the most probable complication for postoperative patients on bed rest. Options
A, B and D aren’t likely complications of the post operative period.

25. Which of the following statement is true regarding the visual changes associated
with cataracts?

a. Both eyes typically cataracts at the same time

b. The loss of vision is experienced as a painless, gradual blurring
c. The patient is suddenly blind
d. The patient is typically experiences a painful, sudden blurring of vision.

Typically, a patient with cataracts experiences painless, gradual loss of vision. Although
both eyes may develop at different rates.