Medical Surgical Nursing (61 - 90)

61. An adult is receiving Total Parenteral Nutrition (TPN). Which of the following assessment is essential?
A. evaluation of the peripheral IV site
B. confirmation that the tube is in the stomach
C. assess the bowel sound
D. fluid and electrolyte monitoring

Answer: (D) fluid and electrolyte monitoring
Total parenteral nutrition is a method of providing nutrients to the body by an IV route. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. It is intended to improve the clients nutritional status. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight.
62. Which drug would be least effective in lowering a client's serum potassium level?
A. Glucose and insulin
B. Polystyrene sulfonate (Kayexalate)
C. Calcium glucomite
D. Aluminum hydroxide

Answer: (D) Aluminum hydroxide
Aluminum hydroxide binds dietary phosphorus in the GI tract and helps treat hyperphosphatemia. All the other medications mentioned help treat hyperkalemia and its effects.
63. A nurse is directed to administer a hypotonic intravenous solution. Looking at the following labeled solutions, she should choose
A. 0.45% NaCl
B. 0.9% NaCl
C. D5W
D. D5NSS

Answer: (A) 0.45% NaCl
Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood; 0.9% NaCl and D5W are isotonic solutions with same tonicity as the blood; and D5NSS is hypertonic with a higher tonicity thab the blood.
64. A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT
A. hypertension
B. oliguria
C. tachycardia
D. tachypnea

Answer: (A) hypertension
In hypovolemia, one of the compenasatory mechanisms is activation of the sympathetic nervous system that increases the RR & PR and helps restore the BP to maintain tissue perfusion but not cause a hypertension. The SNS stimulation constricts renal arterioles that increases release of aldosterone, decreases glomerular filtration and increases sodium & water reabsorption that leads to oliguria.
65. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of

A. assuring Maria that she will be cured of cancer
B. assessing Maria's expectations and doubts
C. maintaining a cheerful and optimistic environment
D. keeping Maria's visitors to a minimum so she can have time for herself

Answer: (B) assessing Maria's expectations and doubts
Assessing the client’s expectations and doubts will help lessen her fears and anxieties. The nurse needs to encourage the client to verbalize and to listen and correctly provide explanations when needed.
66. Maria refuses to acknowledge that her breast was removed. She believes that her breast is intact under the dressing. The nurse should

A. call the MD to change the dressing so Kathy can see the incision
B. recognize that Kathy is experiencing denial, a normal stage of the grieving process
C. reinforce Kathy’s belief for several days until her body can adjust to stress of surgery.
D. remind Kathy that she needs to accept her diagnosis so that she can begin rehabilitation exercises.

Answer: (B) recognize that Kathy is experiencing denial, a normal stage of the grieving process
A person grieves to a loss of a significant object. The initial stage in the grieving process is denial, then anger, followed by bargaining, depression and last acceptance. The nurse should show acceptance of the patient’s feelings and encourage verbalization.
67. A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery. Which of the ff. statements about chemotherapy is true?
A. it is a local treatment affecting only tumor cells
B. it affects both normal and tumor cells
C. it has been proven as a complete cure for cancer
D. it is often used as a palliative measure.

Answer: (B) it affects both normal and tumor cells
Chemotherapeutic agents are given to destroy the actively proliferating cancer cells. But these agents cannot differentiate the abnormal actively proliferating cancer cells from those that are actively proliferating normal cells like the cells of the bone marrow, thus the effect of bone marrow depression.
68. Which is an incorrect statement pertaining to the following procedures for cancer diagnostics?
A. Biopsy is the removal of suspicious tissue and the only definitive method to diagnose cancer
B. Ultrasonography detects tissue density changes difficult to observe by X-ray via sound waves.
C. CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor
D. Endoscopy provides direct view of a body cavity to detect abnormality.

Answer: (C) CT scanning uses magnetic fields and radio frequencies to provide cross-sectional view of tumor
CT scan uses narrow beam x-ray to provide cross-sectional view. MRI uses magnetic fields and radio frequencies to detect tumors.
69. A post-operative complication of mastectomy is lymphedema. This can be prevented by

A. ensuring patency of wound drainage tube
B. placing the arm on the affected side in a dependent position
C. restricting movement of the affected arm
D. frequently elevating the arm of the affected side above the level of the heart.

Answer: (D) frequently elevating the arm of the affected side above the level of the heart.
Elevating the arm above the level of the heart promotes good venous return to the heart and good lymphatic drainage thus preventing swelling.
70. Which statement by the client indicates to the nurse that the patient understands precautions necessary during internal radiation therapy for cancer of the cervix?

A. “I should get out of bed and walk around in my room.”
B. “My 7 year old twins should not come to visit me while I’m receiving treatment.”
C. “I will try not to cough, because the force might make me expel the application.”
D. “I know that my primary nurse has to wear one of those badges like the people in the x-ray department, but they are not necessary for anyone else who comes in here.”

Answer: (B) “My 7 year old twins should not come to visit me while I’m receiving treatment.”
Children have cells that are normally actively dividing in the process of growth. Radiation acts not only against the abnormally actively dividing cells of cancer but also on the normally dividing cells thus affecting the growth and development of the child and even causing cancer itself.
71. High uric acid levels may develop in clients who are receiving chemotherapy. This is caused by:

A. The inability of the kidneys to excrete the drug metabolites
B. Rapid cell catabolism
C. Toxic effect of the antibiotic that are given concurrently
D. The altered blood ph from the acid medium of the drugs

Answer: (B) Rapid cell catabolism
One of the oncologic emergencies, the tumor lysis syndrome, is caused by the rapid destruction of large number of tumor cells. . Intracellular contents are released, including potassium and purines, into the bloodstream faster than the body can eliminate them. The purines are converted in the liver to uric acid and released into the blood causing hyperuricemia. They can precipitate in the kidneys and block the tubules causing acute renal failure.
72. Which of the following interventions would be included in the care of plan in a client with cervical
implant?

A. Frequent ambulation
B. Unlimited visitors
C. Low residue diet
D. Vaginal irrigation every shift

Answer: (C) Low residue diet
It is important for the nurse to remember that the implant be kept intact in the cervix during therapy. Mobility and vaginal irrigations are not done. A low residue diet will prevent bowel movement that could lead to dislodgement of the implant. Patient is also strictly isolated to protect other people from the radiation emissions

73. Which nursing measure would avoid constriction on the affected arm immediately after mastectomy?

A. Avoid BP measurement and constricting clothing on the affected arm
B. Active range of motion exercises of the arms once a day.
C. Discourage feeding, washing or combing with the affected arm
D. Place the affected arm in a dependent position, below the level of the heart

Answer: (A) Avoid BP measurement and constricting clothing on the affected arm
A BP cuff constricts the blood vessels where it is applied. BP measurements should be done on the unaffected arm to ensure adequate circulation and venous and lymph drainage in the affected arm
74. A client suffering from acute renal failure has an unexpected increase in urinary output to 150ml/hr. The nurse assesses that the client has entered the second phase of acute renal failure. Nursing actions throughout this phase include observation for signs and symptoms of

A. Hypervolemia, hypokalemia, and hypernatremia.
B. Hypervolemia, hyperkalemia, and hypernatremia.
C. Hypovolemia, wide fluctuations in serum sodium and potassium levels.
D. Hypovolemia, no fluctuation in serum sodium and potassium levels.

Answer: (C) Hypovolemia, wide fluctuations in serum sodium and potassium levels.
The second phase of ARF is the diuretic phase or high output phase. The diuresis can result in an output of up to 10L/day of dilute urine. Loss of fluids and electrolytes occur.
75. An adult has just been brought in by ambulance after a motor vehicle accident. When assessing the client, the nurse would expect which of the following manifestations could have resulted from sympathetic nervous system stimulation?

A. A rapid pulse and increased RR
B. Decreased physiologic functioning
C. Rigid posture and altered perceptual focus
D. Increased awareness and attention

Answer: (A) A rapid pulse and increased RR
The fight or flight reaction of the sympathetic nervous system occurs during stress like in a motor vehicular accident. This is manifested by increased in cardiovascular function and RR to provide the immediate needs of the body for survival.
76. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse's priority should be

A. placing her in a trendeleburg position
B. putting several warm blankets on her
C. monitoring her hourly urine output
D. assessing her VS especially her RR

Answer: (D) assessing her VS especially her RR
Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications.
77. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is

A. Elevated hematocrit levels.
B. Urine output of 30 to 50 ml/hr.
C. Change in level of consciousness.
D. Estimate of fluid loss through the burn eschar.

Answer: (B) Urine output of 30 to 50 ml/hr.
Hypovolemia is a decreased in circulatory volume. This causes a decrease in tissue perfusion to the different organs of the body. Measuring the hourly urine output is the most quantifiable way of measuring tissue perfusion to the organs. Normal renal perfusion should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is considered adequate and indicates good fluid balance.
78. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the following?

A. Spontaneous pneumothorax
B. Ruptured diaphragm
C. Hemothorax
D. Pericardial tamponade

Answer: (D) Pericardial tamponade
Pericardial tamponade occurs when there is presence of fluid accumulation in the pericardial space that compresses on the ventricles causing a decrease in ventricular filling and stretching during diastole with a decrease in cardiac output. . This leads to right atrial and venous congestion manifested by a CVP reading above normal.
79. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except
A. administering an irritant that will stimulate vomiting
B. aspirating secretions from the pharynx if respirations are affected
C. neutralizing the chemical
D. washing the esophagus with large volumes of water via gastric lavage

Answer: (A) administering an irritant that will stimulate vomiting
Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed.
80. Which initial nursing assessment finding would best indicate that a client has been successfully resuscitated after a cardio-respiratory arrest?
A. Skin warm and dry
B. Pupils equal and react to light
C. Palpable carotid pulse
D. Positive Babinski's reflex

Answer: (C) Palpable carotid pulse
Presence of a palpable carotid pulse indicates the return of cardiac function which, together with the return of breathing, is the primary goal of CPR. Pulsations in arteries indicates blood flowing in the blood vessels with each cardiac contraction. Signs of effective tissue perfusion will be noted after.
81. Chemical burn of the eye are treated with
A. local anesthetics and antibacterial drops for 24 – 36 hrs.
B. hot compresses applied at 15-minute intervals
C. Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water
D. cleansing the conjunctiva with a small cotton-tipped applicator

Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or preferably sterile water
Prompt treatment of ocular chemical burns is important to prevent further damage. Immediate tap-water eye irrigation should be started on site even before transporting the patient to the nearest hospital facility. In the hospital, copious irrigation with normal saline, instillation of local anesthetic and antibiotic is done.
82. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to:
A. Force air out of the lungs
B. Increase systemic circulation
C. Induce emptying of the stomach
D. Put pressure on the apex of the heart

Answer: (A) Force air out of the lungs
The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.
83. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should:
A. ask them to stay in the waiting area until she can spend time alone with them
B. speak to both parents together and encourage them to support each other and express their emotions freely
C. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other
D. ask the MD to medicate the parents so they can stay calm to deal with their son’s death.

Answer: (B) speak to both parents together and encourage them to support each other and express their emotions freely
Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.
84. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to:

A. increase BP
B. decrease mucosal swelling
C. relax the bronchial smooth muscle
D. decrease bronchial secretions

Answer: (C) relax the bronchial smooth muscle
Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.

85. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the
A. upper half of the sternum
B. upper third of the sternum
C. lower half of the sternum
D. lower third of the sternum

Answer: (C) lower half of the sternum
The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration.
86. The nurse is performing an eye examination on an elderly client. The client states ‘My vision is blurred, and I don’t easily see clearly when I get into a dark room.” The nurse best response is:

A. “You should be grateful you are not blind.”
B. “As one ages, visual changes are noted as part of degenerative changes. This is normal.”
C. “You should rest your eyes frequently.”
D. “You maybe able to improve you vision if you move slowly.”

Answer: (B) “As one ages, visual changes are noted as part of degenerative changes. This is normal.”
Aging causes less elasticity of the lens affecting accommodation leading to blurred vision. The muscles of the iris increase in stiffness and the pupils dilate slowly and less completely so that it takes the older person to adjust when going to and from light and dark environment and needs brighter light for close vision.
87. Which of the following activities is not encouraged in a patient after an eye surgery?
A. sneezing, coughing and blowing the nose
B. straining to have a bowel movement
C. wearing tight shirt collars
D. sexual intercourse

Answer: (D) sexual intercourse
To reduce increases in IOP, teach the client and family about activity restrictions. Sexual intercourse can cause a sudden rise in IOP.

88. Which of the following indicates poor practice in communicating with a hearing-impaired client?
A. Use appropriate hand motions
B. Keep hands and other objects away from your mouth when talking to the client
C. Speak clearly in a loud voice or shout to be heard
D. Converse in a quiet room with minimal distractions

Answer: (C) Speak clearly in a loud voice or shout to be heard
Shouting raises the frequency of the sound and often makes understanding the spoken words difficult. It is enough for the nurse to speak clearly and slowly.
89. A client is to undergo lumbar puncture. Which is least important information about LP?

A. Specimens obtained should be labeled in their proper sequence.
B. It may be used to inject air, dye or drugs into the spinal canal.
C. Assess movements and sensation in the lower extremities after the
D. Force fluids before and after the procedure.

Answer: (D) Force fluids before and after the procedure.
LP involves the removal of some amount of spinal fluid. To facilitate CSF production, the client is instructed to increase fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after the procedure.

90. A client diagnosed with cerebral thrombosis is scheduled for cerebral angiography. Nursing care of the client includes the following EXCEPT

A. Inform the client that a warm, flushed feeling and a salty taste may be
B. Maintain pressure dressing over the site of puncture and check for
C. Check pulse, color and temperature of the extremity distal to the site of
D. Kept the extremity used as puncture site flexed to prevent bleeding.

Answer: (D) Kept the extremity used as puncture site flexed to prevent bleeding.
Angiography involves the threading of a catheter through an artery which can cause trauma to the endothelial lining of the blood vessel. The platelets are attracted to the area causing thrombi formation. This is further enhanced by the slowing of blood flow caused by flexion of the affected extremity. The affected extremity must be kept straight and immobilized during the duration of the bedrest after the procedure. Ice bag can be applied intermittently to the puncture site.