Medical Surgical Nursing (121 - 150 )

121. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:

A. Stops the flow of fluid when he feels uncomfortable
B. Lubricates the tip of the catheter before inserting it into the stoma
C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion
D. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled

Answer: (C) Hangs the bag on a clothes hook on the bathroom door during fluid insertion
The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.

122. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :

A. Abdominal cramps during fluid inflow
B. Difficulty in inserting the irrigating tube
C. Passage of flatus during expulsion of feces
D. Inability to complete the procedure in half an hour

Answer: (B) Difficulty in inserting the irrigating tube
Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.

123. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:

A. A reaction formation to his recent altered body image.
B. A difficult time accepting reality and is in a state of denial.
C. Impotency due to the surgery and needs sexual counseling
D. Suicide thoughts and should be seen by psychiatrist

Answer: (B) A difficult time accepting reality and is in a state of denial.
As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported

124. The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:

A. Food low in fiber so that there is less stool
B. Everything he ate before the operation but will avoid those foods that cause gas
C. Bland foods so that his intestines do not become irritated
D. Soft foods that are more easily digested and absorbed by the large intestines

Answer: (B) Everything he ate before the operation but will avoid those foods that cause gas
There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.

125. Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated.

When Eddie arrives in the emergency room, the assessment that assume the greatest priority are:

A. Level of consciousness and pupil size
B. Abdominal contusions and other wounds
C. Pain, Respiratory rate and blood pressure
D. Quality of respirations and presence of pulsesQuality of respirations and presence of pulses

Answer: (D) Quality of respirations and presence of pulsesQuality of respirations and presence of pulses
Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished

126. Eddie, a plane crash victim, undergoes endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for him at this time would be to:

A. Facilitate his verbal communication
B. Maintain sterility of the ventilation system
C. Assess his response to the equipment
D. Prepare him for emergency surgery

Answer: (C) Assess his response to the equipment
It is a primary nursing responsibility to evaluate effect of interventions done to the client. Nothing is achieved if the equipment is working and the client is not responding

127. A chest tube with water seal drainage is inserted to a client following a multiple chest injury. A few hours later, the client’s chest tube seems to be obstructed. The most appropriate nursing action would be to

A. Prepare for chest tube removal
B. Milk the tube toward the collection container as ordered
C. Arrange for a stat Chest x-ray film.
D. Clam the tube immediately

Answer: (B) Milk the tube toward the collection container as ordered
This assists in moving blood, fluid or air, which may be obstructing drainage, toward the collection chamber

128. The observation that indicates a desired response to thoracostomy drainage of a client with chest injury is:

A. Increased breath sounds
B. Constant bubbling in the drainage chamber
C. Crepitus detected on palpation of chest
D. Increased respiratory rate

Answer: (A) Increased breath sounds
The chest tube normalizes intrathoracic pressure and restores negative intra-pleural pressure, drains fluid and air from the pleural space, and improves pulmonary function

129. In the evaluation of a client’s response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organs is:

A. Urinary output is 30 ml in an hour
B. Central venous pressure reading of 2 cm H2O
C. Pulse rates of 120 and 110 in a 15 minute period
D. Blood pressure readings of 50/30 and 70/40 within 30 minutes

Answer: (A) Urinary output is 30 ml in an hour
A rate of 30 ml/hr is considered adequate for perfusion of kidney, heart and brain.

130. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:

A. Complete safety of the procedure
B. Expectation of postoperative bleeding
C. Risk of the procedure with his other injuries
D. Presence of abdominal drains for several days after surgery

Answer: (D) Presence of abdominal drains for several days after surgery
Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area that could lead to abscess formation.

131. To promote continued improvement in the respiratory status of a client following chest tube removal after a chest surgery for multiple rib fracture, the nurse should:

A. Encourage bed rest with active and passive range of motion exercises
B. Encourage frequent coughing and deep breathing
C. Turn him from side to side at least every 2 hours
D. Continue observing for dyspnea and crepitus

Answer: (B) Encourage frequent coughing and deep breathing
This nursing action prevents atelectasis and collection of respiratory secretions and promotes adequate ventilation and gas exchange.

132. A client undergoes below the knee amputation following a vehicular accident. Three days postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial nursing approach would be to:

A. Give him explanations of why there is a need to quickly increase his activity
B. Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle
C. Appear cheerful and non-critical regardless of his response to attempts at intervention
D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving

Answer: (D) Accept and acknowledge that his withdrawal is an initially normal and necessary part of grieving
The withdrawal provides time for the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the client’s behavior is an important factor in the nurse’s intervention.

133. The key factor in accurately assessing how body image changes will be dealt with by the client is the:

A. Extent of body change present
B. Suddenness of the change
C. Obviousness of the change
D. Client’s perception of the change

Answer: (D) Client’s perception of the change
It is not reality, but the client’s feeling about the change that is the most important determinant of the ability to cope. The client should be encouraged to his feelings.

134. Larry is diagnosed as having myelocytic leukemia and is admitted to the hospital for chemotherapy. Larry discusses his recent diagnosis of leukemia by referring to statistical facts and figures. The nurse recognizes that Larry is using the defense mechanism known as:

A. Reaction formation
B. Sublimation
C. Intellectualization
D. Projection

Answer: (C) Intellectualization
People use defense mechanisms to cope with stressful events. Intellectualization is the use of reasoning and thought processes to avoid the emotional upsets.

135. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should encourage the client to:

A. Increase his activity level and ambulate frequently
B. Sleep with the head of his bed slightly elevated
C. Drink citrus juices frequently for nourishment
D. Use a soft toothbrush and electric razor

Answer: (D) Use a soft toothbrush and electric razor
Suppression of red bone marrow increases bleeding susceptibility associated with thrombocytopenia, decreased platelets. Anemia and leucopenia are the two other problems noted with bone marrow depression.

136. Dennis receives a blood transfusion and develops flank pain, chills, fever and hematuria. The nurse recognizes that Dennis is probably experiencing:

A. An anaphylactic transfusion reaction
B. An allergic transfusion reaction
C. A hemolytic transfusion reaction
D. A pyrogenic transfusion reaction

Answer: (C) A hemolytic transfusion reaction
This results from a recipient’s antibodies that are incompatible with transfused RBC’s; also called type II hypersensitivity; these signs result from RBC hemolysis, agglutination, and capillary plugging that can damage renal function, thus the flank pain and hematuria and the other manifestations.

137. A client jokes about his leukemia even though he is becoming sicker and weaker. The nurse’s most therapeutic response would be:

A. “Your laugher is a cover for your fear.”
B. “He who laughs on the outside, cries on the inside.”
C. “Why are you always laughing?”
D. “Does it help you to joke about your illness?”

Answer: (D) “Does it help you to joke about your illness?”
This non-judgmentally on the part of the nurse points out the client’s behavior.

138. In dealing with a dying client who is in the denial stage of grief, the best nursing approach is to:

A. Agree with and encourage the client’s denial
B. Reassure the client that everything will be okay
C. Allow the denial but be available to discuss death
D. Leave the client alone to discuss the loss

Answer: (C) Allow the denial but be available to discuss death
This does not take away the client’s only way of coping, and it permits future movement through the grieving process when the client is ready. Dying clients move through the different stages of grieving and the nurse must be ready to intervene in all these stages.

139. During and 8 hour shift, Mario drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this 8 hour period, his fluid balance would be:

A. +55 ml
B. +137 ml
C. +235 ml
D. +485 ml

Answer: (C) +235 ml
The client’s intake was 360 ml (6oz x 30 ml) and loss was 125 ml of fluid; loss is subtracted from intake

140. Mr. Ong is admitted to the hospital with a diagnosis of Left-sided CHF. In the assessment, the nurse should expect to find:

A. Crushing chest pain
B. Dyspnea on exertion
C. Extensive peripheral edema
D. Jugular vein distention

Answer: (B) Dyspnea on exertion
Pulmonary congestion and edema occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary congestion.

141. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide (Lasix). The nurse understands Lasix exerts is effects in the:

A. Distal tubule
B. Collecting duct
C. Glomerulus of the nephron
D. Ascending limb of the loop of Henle

Answer: (D) Ascending limb of the loop of Henle
This is the site of action of Lasix being a potent loop diuretic.

142. Mr. Ong weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs 205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:

A. 0.5 L
B. 1.0 L
C. 2.0 L
D. 3.5 L

Answer: (C) 2.0 L
One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals approximately 2 Liters.

143. Mr. Ong, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical pulse rate is 44 and he is on bed rest. The nurse concludes that his pulse rate is most likely the result of the:

A. Diuretic
B. Vasodilator
C. Bed-rest regimen
D. Cardiac glycoside

Answer: (D) Cardiac glycoside
A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases the conduction speed of impulses within the myocardium and slows the heart rate.

144. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The nurse understands that this diet contains approximately:

A. 2200 calories
B. 2000 calories
C. 2800 calories
D. 1600 calories

Answer: (B) 2000 calories
There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein

145. After the acute phase of congestive heart failure, the nurse should expect the dietary management of the client to include the restriction of:

A. Magnesium
B. Sodium
C. Potassium
D. Calcium

Answer: (B) Sodium
Restriction of sodium reduces the amount of water retention that reduces the cardiac workload

146. Jude develops GI bleeding and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his history would be:

A. The medications he has been taking
B. Any recent foreign travel
C. His usual dietary pattern
D. His working patterns

Answer: (A) The medications he has been taking
Some medications, such as aspirin and prednisone, irritate the stomach lining and may cause bleeding with prolonged use

147. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding is:

A. Three large meals large enough to supply adequate energy.
B. Regular meals and snacks to limit gastric discomfort
C. Limited food and fluid intake when he has pain
D. A flexible plan according to his appetite

Answer: (B) Regular meals and snacks to limit gastric discomfort
Presence of food in the stomach at regular intervals interacts with HCl limiting acid mucosal irritation. Mucosal irritation can lead to bleeding.

148. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy. Following surgery, the client has a nasogastric tube to low continuous suction. He begins to hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:

A. Increasing HCO3
B. Decreasing PCO2
C. Decreasing pH
D. Decreasing PO2

Answer: (B) Decreasing PCO2
Hyperventilation results in the increased elimination of carbon dioxide from the blood that can lead to respiratory alkalosis.

149. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply approximately:

A. 400 Kilocalories
B. 600 Kilocalories
C. 800 Kilocalories
D. 1000 Kilocalories

Answer: (B) 600 Kilocalories
Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only about a third of the basal energy need.

150. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by:

A. Encouraging adequate fluids
B. Applying elastic stockings
C. Massaging gently the legs with lotion
D. Performing active-assistive leg exercises

Answer: (D) Performing active-assistive leg exercises
Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon