Medical Surgical Nursing (151 - 175)

151. An unconscious client is admitted to the ICU, IV fluids are started and a Foley catheter is inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to avoid this problem by:

A. Emptying the drainage bag frequently
B. Collecting a weekly urine specimen
C. Maintaining the ordered hydration
D. Assessing urine specific gravity

Answer: (C) Maintaining the ordered hydration
Promoting hydration, maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection

152. The nurse performs full range of motion on a bedridden client’s extremities. When putting his ankle through range of motion, the nurse must perform:

A. Flexion, extension and left and right rotation
B. Abduction, flexion, adduction and extension
C. Pronation, supination, rotation, and extension
D. Dorsiflexion, plantar flexion, eversion and inversion

Answer: (D) Dorsiflexion, plantar flexion, eversion and inversion
These movements include all possible range of motion for the ankle joint

153. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of shearing force on the skin, the head of the bed should be at an angle of:

A. 30 degrees
B. 45 degrees
C. 60 degrees
D. 90 degrees

Answer: (A) 30 degrees
Shearing force occurs when 2 surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Shearing forces are good contributory factors of pressure sores.

154. Rene, age 62, is scheduled for a TURP after being diagnosed with a Benign Prostatic Hyperplasia (BPH). As part of the preoperative teaching, the nurse should tell the client that after surgery:

A. Urinary control may be permanently lost to some degree
B. Urinary drainage will be dependent on a urethral catheter for 24 hours
C. Frequency and burning on urination will last while the cystotomy tube is in place
D. His ability to perform sexually will be permanently impaired

Answer: (B) Urinary drainage will be dependent on a urethral catheter for 24 hours
An indwelling urethral catheter is used, because surgical trauma can cause urinary retention leading to further complications such as bleeding.

155. The transurethral resection of the prostate is performed on a client with BPH. Following surgery, nursing care should include:

A. Changing the abdominal dressing
B. Maintaining patency of the cystotomy tube
C. Maintaining patency of a three-way Foley catheter for cystoclysis
D. Observing for hemorrhage and wound infection

Answer: (C) Maintaining patency of a three-way Foley catheter for cystoclysis
Patency of the catheter promotes bladder decompression, which prevents distention and bleeding. Continuous flow of fluid through the bladder limits clot formation and promotes hemostasis

156. In the early postoperative period following a transurethral surgery, the most common complication the nurse should observe for is:

A. Sepsis
B. Hemorrhage
C. Leakage around the catheter
D. Urinary retention with overflow

Answer: (B) Hemorrhage
After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the prostatic bed.

157. Following prostate surgery, the retention catheter is secured to the client’s leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:

A. Limit discomfort
B. Provide hemostasis
C. Reduce bladder spasms
D. Promote urinary drainage

Answer: (B) Provide hemostasis
The pressure of the balloon against the small blood vessels of the prostate creates a tampon-like effect that causes them to constrict thereby preventing bleeding.

158. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to:

A. Irrigate the catheter with saline
B. Milk the catheter tubing
C. Remove the catheter
D. Notify the physician

Answer: (B) Milk the catheter tubing
Milking the tubing will usually dislodge the plug and will not harm the client. A physician’s order is not necessary for a nurse to check catheter patency.

159. The nurse would know that a post-TURP client understood his discharge teaching when he says “I should:”

A. Get out of bed into a chair for several hours daily
B. Call the physician if my urinary stream decreases
C. Attempt to void every 3 hours when I’m awake
D. Avoid vigorous exercise for 6 months after surgery

Answer: (B) Call the physician if my urinary stream decreases
Urethral mucosa in the prostatic area is destroyed during surgery and strictures my form with healing that causes partial or even complete ueinary obstruction.

160. Lucy is admitted to the surgical unit for a subtotal thyroidectomy. She is diagnosed with Grave’s Disease. When assessing Lucy, the nurse would expect to find:

A. Lethargy, weight gain, and forgetfulness
B. Weight loss, protruding eyeballs, and lethargy
C. Weight loss, exopthalmos and restlessness
D. Constipation, dry skin, and weight gain

Answer: (C) Weight loss, exopthalmos and restlessness
Classic signs associated with hyperthyroidism are weight loss and restlessness because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.

161. Lucy undergoes Subtotal Thyroidectomy for Grave’s Disease. In planning for the client’s return from the OR, the nurse would consider that in a subtotal thyroidectomy:
A. The entire thyroid gland is removed
B. A small part of the gland is left intact
C. One parathyroid gland is also removed
D. A portion of the thyroid and four parathyroids are removed

Answer: (B) A small part of the gland is left intact
Remaining thyroid tissue may provide enough hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.

162. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up emergency equipment, which should include:

A. A crash cart with bed board
B. A tracheostomy set and oxygen
C. An airway and rebreathing mask
D. Two ampules of sodium bicarbonate

Answer: (B) A tracheostomy set and oxygen
Acute respiratory obstruction in the post-operative period can result from edema, subcutaneous bleeding that presses on the trachea, nerve damage, or tetany.

163. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury of the laryngeal nerve every 30 to 60 minutes by:

A. Observing for signs of tetany
B. Checking her throat for swelling
C. Asking her to state her name out loud
D. Palpating the side of her neck for blood seepage

Answer: (C) Asking her to state her name out loud
If the recurrent laryngeal nerve is damaged during surgery, the client will be hoarse and have difficult speaking.

164. On a post-thyroidectomy client’s discharge, the nurse teaches her to observe for signs of surgically induced hypothyroidism. The nurse would know that the client understands the teaching when she states she should notify the physician if she develops:

A. Intolerance to heat
B. Dry skin and fatigue
C. Progressive weight loss
D. Insomnia and excitability

Answer: (B) Dry skin and fatigue
Dry skin is most likely caused by decreased glandular function and fatigue caused by decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism.

165. A client’s exopthalmos continues inspite of thyroidectomy for Grave’s Disease. The nurse teaches her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client understands the teaching when she says: “I should:

A. Elevate the head of my bed at night
B. Avoid moving my extra-ocular muscles
C. Avoid using a sleeping mask at night
D. Avoid excessive blinking

Answer: (C) Avoid using a sleeping mask at night
The mask may irritate or scratch the eye if the client turns and lies on it during the night.

166. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised, and she is in pain and anxious.

Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Clara’s body surface that is burned is:

A. 4.5%
B. 9%
C. 18 %
D. 22.5%

Answer: (D) 22.5%
The entire right lower extremity is 18% the anterior portion of the right upper extremity is 4.5% giving a total of 22.5%

167. The nurse applies mafenide acetate (Sulfamylon cream) to Clara, who has second and third degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:

A. Inhibit bacterial growth
B. Relieve pain from the burn
C. Prevent scar tissue formation
D. Provide chemical debridement

Answer: (A) Inhibit bacterial growth
Sulfamylon is effective against a wide variety of gram positive and gram negative organisms including anaerobes

168. Forty-eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

A. 18 gtt/min
B. 28 gtt/min
C. 32 gtt/min
D. 36 gtt/min

Answer: (B) 28 gtt/min
This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

169. Clara, a burn client, receives a temporary heterograft (pig skin) on some of her burns. These grafts will:
A. Debride necrotic epithelium
B. Be sutured in place for better adherence
C. Relieve pain and promote rapid epithelialization
D. Frequently be used concurrently with topical antimicrobials.

Answer: (C) Relieve pain and promote rapid epithelialization
The graft covers nerve endings, which reduces pain and provides a framework for granulation that promotes effective healing.

170. A client with burns on the chest has periodic episodes of dyspnea. The position that would provide for the greatest respiratory capacity would be the:

A. Semi-fowler’s position
B. Sims’ position
C. Orthopneic position
D. Supine position

Answer: (C) Orthopneic position
The orthopneic position lowers the diaphragm and provides for maximal thoracic expansion

171. Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

A. Brief exaggeration of symptoms
B. Prolonged symptomatic improvement
C. Rapid but brief symptomatic improvement
D. Symptomatic improvement of just the ptosis

Answer: (C) Rapid but brief symptomatic improvement
Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.

172. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:

A. Develop a teaching plan
B. Facilitate psychologic adjustment
C. Maintain the present muscle strength
D. Prepare for the appearance of myasthenic crisis

Answer: (C) Maintain the present muscle strength
Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

173. The most significant initial nursing observations that need to be made about a client with myasthenia include:
A. Ability to chew and speak distinctly
B. Degree of anxiety about her diagnosis
C. Ability to smile an to close her eyelids
D. Respiratory exchange and ability to swallow

Answer: (D) Respiratory exchange and ability to swallow
Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

174. Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:

A. Administer the medication exactly on time
B. Administer the medication with food or mild
C. Evaluate the client’s muscle strength hourly after medication
D. Evaluate the client’s emotional side effects between doses

Answer: (C) Evaluate the client’s muscle strength hourly after medication
Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

175. Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:

A. Change her diet order from soft foods to clear liquids
B. Place an emergency tracheostomy set in her room
C. Assess her respiratory status before and after meals
D. Coordinate her meal schedule with the peak effect of her medication, Mestinon

Answer: (D) Coordinate her meal schedule with the peak effect of her medication, Mestinon
Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.