Medical Surgical Nursing (31 - 60)

31. An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take
Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s
disease, the best response would be:

A. “The medication will limit thyroid hormone secretion.”
B. “The medication limit synthesis of the thyroid hormones.”
C. “The medication will block the cardiovascular symptoms of Grave’s disease.”
D. “The medication will increase the synthesis of thyroid hormones.”

Answer: (C) “The medication will block the cardiovascular symptoms of Grave’s disease.”
Propranolol (Inderal) is a beta-adrenergic blocker that controls the cardiovascular manifestations brought about by increased secretion of the thyroid hormone in Grave’s disease.

32. During the first 24 hours after thyroid surgery, the nurse should include in her care:
A. Checking the back and sides of the operative dressing
B. Supporting the head during mild range of motion exercise
C. Encouraging the client to ventilate her feelings about the surgery
D. Advising the client that she can resume her normal activities immediately

Answer: (A) Checking the back and sides of the operative dressing
Following surgery of the thyroid gland, bleeding is a potential complication. This can best be assessed by checking the back and the sides of the operative dressing as the blood may flow towards the side and back leaving the front dry and clear of drainage.

33. On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops:

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

Answer: (C) Progressive weight gain
Hypothyroidism, a decrease in thyroid hormone production, is characterized by hypometabolism that manifests itself with weight gain.

34. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin?
A. Lipodystrophy can result and is extremely painful
B. Poor rotation technique can cause superficial hemorrhaging
C. Lipodystrophic areas can result, causing erratic insulin absorption rates from these
D. Injection sites can never be reused

Answer: (C) Lipodystrophic areas can result, causing erratic insulin absorption rates from these
Lipodystrophy is the development of fibrofatty masses at the injection site caused by repeated use of an injection site. Injecting insulin into these scarred areas can cause the insulin to be poorly absorbed and lead to erratic reactions.

35. Which of the following would be inappropriate to include in a diabetic teaching plan?
A. Change position hourly to increase circulation
B. Inspect feet and legs daily for any changes
C. Keep legs elevated on 2 pillows while sleeping
D. Keep the insulin not in use in the refrigerator

Answer: (C) Keep legs elevated on 2 pillows while sleeping
The client with DM has decreased peripheral circulation caused by microangiopathy. Keeping the legs elevated during sleep will further cause circulatory impairment.

36. Included in the plan of care for the immediate post-gastroscopy period will be:
A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours

Answer: (B) Assess gag reflex prior to administration of fluids
The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.

36. Included in the plan of care for the immediate post-gastroscopy period will be:
A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours

Answer: (B) Assess gag reflex prior to administration of fluids
The client, after gastroscopy, has temporary impairment of the gag reflex due to the anesthetic that has been sprayed into his throat prior to the procedure. Giving fluids and food at this time can lead to aspiration.

37. Which description of pain would be most characteristic of a duodenal ulcer?
A. Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
B. RUQ pain that increases after meal
C. Sharp pain in the epigastric area that radiates to the right shoulder
D. A sensation of painful pressure in the midsternal area

Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area that is relieved by food intake
Duodenal ulcer is related to an increase in the secretion of HCl. This can be buffered by food intake thus the relief of the pain that is brought about by food intake.

38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:

A. Reposition the NGT by advancing it gently NSS
B. Notify the MD of your findings
C. Irrigate the NGT with 50 cc of sterile
D. Discontinue the low-intermittent suction

Answer: (B) Notify the MD of your findings
The client’s feeling of vomiting and the reduction in the volume of NGT drainage that is thick are signs of possible abdominal distention caused by obstruction of the NGT. This should be reported immediately to the MD to prevent tension and rupture on the site of anastomosis caused by gastric distention.

39. After Billroth II Surgery, the client developed dumping syndrome. Which of the following should
the nurse exclude in the plan of care?

A. Sit upright for at least 30 minutes after meals
B. Take only sips of H2O between bites of solid food
C. Eat small meals every 2-3 hours
D. Reduce the amount of simple carbohydrate in the diet

Answer: (A) Sit upright for at least 30 minutes after meals
The dumping syndrome occurs within 30 mins after a meal due to rapid gastric emptying, causing distention of the duodenum or jejunum produced by a bolus of food. To delay the emptying, the client has to lie down after meals. Sitting up after meals will promote the dumping syndrome.

40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori.
Which of the following statements indicate an understanding of this data?

A. Treatment will include Ranitidine and Antibiotics
B. No treatment is necessary at this time
C. This result indicates gastric cancer caused by the organism
D. Surgical treatment is necessary

Answer: (A) Treatment will include Ranitidine and Antibiotics
One of the causes of peptic ulcer is H. Pylori infection. It releases toxin that destroys the gastric and duodenal mucosa which decreases the gastric epithelium’s resistance to acid digestion. Giving antibiotics will control the infection and Ranitidine, which is a histamine-2 blocker, will reduce acid secretion that can lead to ulcer.

41. What instructions should the client be given before undergoing a paracentesis?
A. NPO 12 hours before procedure
B. Empty bladder before procedure
C. Strict bed rest following procedure
D. Empty bowel before procedure

Answer: (B) Empty bladder before procedure
Paracentesis involves the removal of ascitic fluid from the peritoneal cavity through a puncture made below the umbilicus. The client needs to void before the procedure to prevent accidental puncture of a distended bladder during the procedure.

42. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet?

A. “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
B. “The liver heals better with a high carbohydrates diet rather than protein.”
C. “Most people have too much protein in their diets. The amount of this diet is better for liver healing.”
D. “Because of portal hyperemesis, the blood flows around the liver and ammonia made from protein collects in the brain causing hallucinations.”

Answer: (A) “The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”
The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. A protein-restricted diet will therefore decrease ammonia production.

43. Which of the drug of choice for pain controls the patient with acute pancreatitis?
A. Morphine
B. NSAIDS
C. Meperidine
D. Codeine

Answer: (C) Meperidine
Pain in acute pancreatitis is caused by irritation and edema of the inflamed pancreas as well as spasm due to obstruction of the pancreatic ducts. Demerol is the drug of choice because it is less likely to cause spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.

44. Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
A. encouraging the client to take adequate deep breaths by mouth
B. encouraging the client to cough and deep breathe
C. changing the dressing at least BID
D. irrigate the T-tube frequently

Answer: (B) encouraging the client to cough and deep breathe
Cholecystectomy requires a subcostal incision. To minimize pain, clients have a tendency to take shallow breaths which can lead to respiratory complications like pneumonia and atelectasis. Deep breathing and coughing exercises can help prevent such complications.

45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to:

A. Deflate the esophageal balloon
B. Monitor VS
C. Encourage him to take deep breaths
D. Notify the MD

Answer: (A) Deflate the esophageal balloon
When a client with a Sengstaken-Blakemore tube develops difficulty of breathing, it means the tube is displaced and the inflated balloon is in the oropharynx causing airway obstruction

46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease?

A. Chrons disease
B. Ulcerative colitis
C. Diverticulitis
D. Peritonitis

Answer: (B) Ulcerative colitis
Ulcerative colitis is a chronic inflammatory condition producing edema and ulceration affecting the entire colon. Ulcerations lead to sloughing that causes stools as many as 10-20 times a day that is filled with blood, pus and mucus. The other symptoms mentioned accompany the problem.

47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:

A. Give laxative the night before and a cleansing enema in the morning before the test
B. Render an oil retention enema and give laxative the night before
C. Instruct the client to swallow 6 radiopaque tablets the evening before the study
D. Place the client on CBR a day before the study

Answer: (A) Give laxative the night before and a cleansing enema in the morning before the test
Barium enema is the radiologic visualization of the colon using a die. To obtain accurate results in this procedure, the bowels must be emptied of fecal material thus the need for laxative and enema.

48. The client has a good understanding of the means to reduce the chances of colon cancer when
he states:

A. “I will exercise daily.”
B. “I will include more red meat in my diet.”
C. “I will have an annual chest x-ray.”
D. “I will include more fresh fruits and vegetables in my diet.”

Answer: (D) “I will include more fresh fruits and vegetables in my diet.”
Numerous aspects of diet and nutrition may contribute to the development of cancer. A low-fiber diet, such as when fresh fruits and vegetables are minimal or lacking in the diet, slows transport of materials through the gut which has been linked to colorectal cancer.

49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when
this occurs is to

A. Cover the wound with sterile, moist saline dressing
B. Approximate the wound edges with tapes
C. Irrigate the wound with sterile saline
D. Hold the abdominal contents in place with a sterile gloved hand

Answer: (A) Cover the wound with sterile, moist saline dressing
Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound which can disturb the healing process.

50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to

A. Strain all urine.
B. Ambulate.
C. Remain on bed rest.
D. Ask for medications to relax him.

Answer: (B) Ambulate.
Free unattached stones in the urinary tract can be passed out with the urine by ambulation which can mobilize the stone and by increased fluid intake which will flush out the stone during urination.

51. A female client is admitted with a diagnosis of acute renal failure. She is awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance?
A. Hyponatremia
B. Hyperkalemia
C. Hyperphosphatemia
D. Hypercalcemia

Answer: (A) Hyponatremia
The normal serum sodium level is 135 – 145 mEq/L. The client’s serum sodium is below normal. Hyponatremia also manifests itself with abdominal cramps and nausea and vomiting
52. Assessing the laboratory findings, which result would the nurse most likely expect to find in a
client with chronic renal failure?

A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl
B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl
D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum calcium

Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
Chronic renal failure is usually the end result of gradual tissue destruction and loss of renal function. With the loss of renal function, the kidneys ability to regulate fluid and electrolyte and acid base balance results. The serum Ca decreases as the kidneys fail to excrete phosphate, potassium and hydrogen ions are retained.
53. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing action would be of highest priority with regard to the external shunt?

A. Heparinize it daily.
B. Avoid taking blood pressure measurements or blood samples from the affected arm.
C. Change the Silastic tube daily.
D. Instruct the client not to use the affected arm.

Answer: (B) Avoid taking blood pressure measurements or blood samples from the affected arm.
In the client with an external shunt, don’t use the arm with the vascular access site to take blood pressure readings, draw blood, insert IV lines, or give injections because these procedures may rupture the shunt or occlude blood flow causing damage and obstructions in the shunt.
54. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching?

A. TURP is the most common operation for BPH.
B. Explain the purpose and function of a two-way irrigation system.
C. Expect bloody urine, which will clear as healing takes place.
D. He will be pain free.

Answer: (D) He will be pain free.
Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.

55. Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On physical examination, the nurse should be looking for tenderness on palpation at McBurney’s point, which is located in the
A. left lower quadrant
B. left upper quadrant
C. right lower quadrant
D. right upper quadrant

Answer: (C) right lower quadrant
To be exact, the appendix is anatomically located at the Mc Burney’s point at the right iliac area of the right lower quadrant.

56. Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge teaching should include
A. telling him to avoid heavy lifting for 4 to 6 weeks
B. instructing him to have a soft bland diet for two weeks
C. telling him to resume his previous daily activities without limitations
D. recommending him to drink eight glasses of water daily

Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks
The client should avoid lifting heavy objects and any strenuous activity for 4-6 weeks after surgery to prevent stress on the inguinal area. There is no special diet required. The fluid intake of eight glasses a day is good advice but is not a priority in this case.

57. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?

A. 18%
B. 22%
C. 31%
D. 40%

Answer: (C) 31%
Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% - head; 9% - each upper extremity; 18%- front chest and abdomen; 18% - entire back; 18% - each lower extremity and 1% - perineum.
58. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by:

A. An increase in the total volume of intracranial plasma
B. Excessive renal perfusion with diuresis
C. Fluid shift from interstitial space
D. Fluid shift from intravascular space to the interstitial space

Answer: (D) Fluid shift from intravascular space to the interstitial space
This period is the burn shock stage or the hypovolemic phase. Tissue injury causes vasodilation that results in increase capillary permeability making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.
59. If a client has severe bums on the upper torso, which item would be a primary concern?
A. Debriding and covering the wounds
B. Administering antibiotics
C. Frequently observing for hoarseness, stridor, and dyspnea
D. Establishing a patent IV line for fluid replacement

Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea
Burns located in the upper torso, especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy and difficult breathing. Maintaining a patent airway is a primary concern.

60. Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?

A. Changing the location of the bed or the TV set, or both, daily
B. Encouraging the client to chew gum and blow up balloons
C. Avoiding the use of a pillow for sleep, or placing the head in a position of hyperextension
D. Helping the client to rest in the position of maximal comfort

Answer: (D) Helping the client to rest in the position of maximal comfort
Mobility and placing the burned areas in their functional position can help prevent contracture deformities related to burns. Pain can immobilize a client as he seeks the position where he finds less pain and provides maximal comfort. But this approach can lead to contracture deformities and other complications.