Nursing textbooks medical-surgical practice questions, set 18
Nursing textbooks · medical-surgical
Nursing textbooks medical-surgical practice questionsset 18
You practice adult health stems across systems, then name the action that changes the outcome. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the Nursing textbooks exam guide or more Nursing textbooks practice questions.
Five medical-surgical questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
For which patient behavior would limit setting be most essential?
A. Clings to the nurse and asks for advice about inconsequential matters.
B. Is flirtatious and provocative with staff members of the opposite sex.
C. Is hypervigilant and refuses to attend unit activities as prescribed.
D. Urges a suspicious patient to hit anyone who stares at them.
Show answer and rationale
Correct answer: D — Urges a suspicious patient to hit anyone who stares at them.
The correct option is an example of a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of patients is at risk. Limit setting may be occasionally used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.
Question 2
Before administering the first dose to the client, which assessment should the nurse perform as part of the preadministration assessment?
A. Review of renal and hepatic function tests
B. Inspection of patient's stools
C. Evaluation of patient's lifestyle and diet
D. General history of patient's health
Show answer and rationale
Correct answer: D — General history of patient's health
Before administering the first dose of penicillin, the nurse should obtain and review the patient's general health history, including any allergy history, a history of all medical and surgical treatments, a drug history, and the current symptoms of the infection. The patient's stool is examined only after penicillin has been administered if the patient has diarrhea. It is not required to evaluate the patient's lifestyle and diet as part of the preadministration assessment for the first dose. Renal and hepatic function tests may be performed at intervals during penicillin therapy, usually not before it.
Question 3
A client admitted to a local health care facility is to undergo surgery with spinal anesthesia. Which of the following is the nurse most likely to observe when caring for this client?
A. Moderate muscle relaxation
B. Loss of feeling in the lower abdomen
C. Hypotension as anesthesia deepens
D. Increase in the client's heart rate
Show answer and rationale
Correct answer: B — Loss of feeling in the lower abdomen
Spinal anesthesia involves the injection of a local anesthetic drug into the subarachnoid space of the spinal cord. There is a loss of feeling (anesthesia) and movement in the lower extremities, lower abdomen, and perineum. Spinal anesthesia is not known to increase a client's heart rate. Spinal anesthesia also does not cause hypotension or moderate muscle relaxation. Enflurane is a volatile liquid anesthetic that causes hypotension once it deepens. Halothane, which is a volatile liquid anesthetic, produces moderate muscle relaxation. Both halothane and enflurane are drugs used for general anesthesia.
Question 4
A nurse is working for a health care provider who participates in a health maintenance organization (HMO) and will be assisting with the billing. What type of information regarding capitation does the nurse need to understand?
A. Fees are not based on the number of services provided but rather are projected to the number of participants and expected services.
B. Fees are based on the number of services billed for by the primary care provider.
C. The HMO makes money based on the degree of illness and number of diagnostic tests that are performed.
D. The fees that are charged are different even with the same diagnosis.
Show answer and rationale
Correct answer: A — Fees are not based on the number of services provided but rather are projected to the number of participants and expected services.
With an HMO, fees are not based on the number of services provided but rather are projected to the number of participants and expected services. This type of financial management is referred to as capitation, which refers to the actual head or person count. Fees are not based on the number of services a provider bills for rather are based on capitation. The HMO makes money by keeping people healthy and out of the hospital and does not base fees on the client's degree of illness or the number of diagnostic tests done. The fees are the same regardless of the actual service or frequency of care provided.
Question 5
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?
A. Draw blood for albumin, prealbumin, and total protein.
B. Prepare for and assist with obtaining a wound culture.
C. Place the client in bed and instruct the client to elevate the foot.
D. Assess the right leg for pulses, skin color, and temperature.
Show answer and rationale
Correct answer: D — Assess the right leg for pulses, skin color, and temperature.
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot is appropriate after assessment of arterial flow to the area.
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Question 6
A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?
A. Fresh frozen plasma
B. A colloid solution such as hetastarch (Hespan)
C. A crystalloid solution such as lactated Ringer's
D. Albumin
Correct answer:
Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hetastarch, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.
A 37 year old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. The patient says, 'That girl looked like she was 19 years old.' Which defense mechanism is this patient using?
A. Denial
B. Identification
C. Displacement
D. Rationalization
Correct answer:
Rationalization is used to justify upsetting behaviors by creating reasons that would allow the individual to believe that the behaviors were warranted or appropriate. The patient is rationalizing molestation of a minor. Denial is used to avoid dealing with the problems and responsibilities related to one's behaviors. Identification is incorporating the image of an emulated person and then acting, thinking, and feeling like that person. Displacement is the discharge of pent-up feelings onto something or someone else in the environment that is less threatening than the original source of the feelings.
A client who was treated for anemia is being discharged. The client has been instructed to continue with epoetin alfa for a week. Which of the following points should the nurse include in the teaching plan to educate the client about the therapy when caring for the client on an outpatient basis?
A. Avoid use of multivitamin preparations.
B. Report signs of joint pain to the primary health care provider.
C. Follow the recommended diet provided by the primary health care provider.
D. Take the drug on an empty stomach or with water.
Correct answer:
When caring for a client who is to take epoetin alfa for anemia, the nurse should instruct the client to report any signs of joint pain, dizziness, headache, fatigue, nausea, vomiting, or diarrhea to the primary health care provider. The nurse should instruct the client to avoid taking multivitamin preparations and to follow the diet recommended by the primary health care provider when caring for a client who has to take folic acid. The nurse should instruct the client to take the drug on an empty stomach or with water when caring for a client who has to take iron supplements on an outpatient basis.
Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion?
A. Clara Barton
B. Linda Richards
C. Dorothea Dix
D. Florence Nightingale
Correct answer:
The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general improvement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pioneer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses of the Union Army.
The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the patient's left hip. Which of the following is the most appropriate nursing diagnosis for this patient?
A. Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
B. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting tissue integrity
C. Impaired skin integrity related to pressure over bony prominence (impaired circulation)
D. Ineffective peripheral tissue perfusion related to sedentary lifestyle
Correct answer:
The patient's major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. The nurse is able to treat the cause of impaired circulation and pressure over bony prominence by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The 'risk for' diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective peripheral tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of deep breathing, gastrointestinal assessment, and effective regulation of temperature?
A. A client with gastrointestinal surgery and general anesthesia
B. A client having a knee replacement and regional anesthesia
C. A client having lower extremity muscle repair and spinal anesthesia
D. A client with spinal stenosis and a regional nerve blockade
Correct answer:
General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication.
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
A. Place the patient in Fowler position.
B. Encourage diaphragmatic breathing.
C. Ask the patient to cough.
D. Initiate oral suctioning of secretions.
Correct answer:
Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.
A nursing student is learning to perform physical assessments. When will the student use the technique of palpation? Select all that apply.
A. Assessing temperature of a patient's feet
B. Counting the apical pulse
C. Assessing for skin turgor
D. Evaluating lymph nodes
E. Assessing for dullness over a tumor
Correct answer:
During palpation, the nurse uses the sense of touch to compare bilateral pulses for symmetrical temperature, assess skin turgor, and check for enlarged lymph nodes. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds provide information about the location, shape, size, and density of tissues, such as dullness over a mass or fluid accumulation. Auscultation refers to listening with a stethoscope to sounds produced in the body; counting the apical pulse or auscultating heart sounds/murmurs are examples.
A client taking oral contraceptive drugs complains of occasional bloating of the abdomen. Which of the following instructions should the nurse offer the client to help alleviate the condition?
A. Limit fluid intake with meals.
B. Take the drug along with food.
C. Decrease the intake of salt.
D. Elevate the legs when sitting.
Correct answer:
The nurse should instruct the client to limit fluid intake with meals if she experiences bloating of the abdomen after oral contraceptive use. Light to moderate exercise also may be helpful. Taking the drug with food alleviates nausea and GI irritation, and not the bloating of the abdomen. A decrease in salt intake causes a decrease in the intake of sodium, which may be beneficial when there is an excess fluid volume, and not when there is bloating of the abdomen. Elevating the legs when sitting prevents thromboembolism seen with oral contraceptive use. It does not prevent bloating of the abdomen.
A nurse caring for a group of patients uses measures to reduce discomfort for the patients during injections. Which technique is recommended?
A. Selecting a needle of the largest gauge that is appropriate for the site and solution to be injected
B. Injecting the medication into contracted muscles to reduce pressure and discomfort at the site
C. Using the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track
D. Applying vigorous pressure in a circular motion after the injection to distribute the medication to the intended site
Correct answer:
The nurse should use the Z-track technique for intramuscular injections to prevent medication from leaking into the needle track, minimizing discomfort. The nurse should select a needle of the smallest gauge that is appropriate for the site and solution to be injected, and select the correct needle length for the type of injection and patient size. The nurse should inject the medication into relaxed muscles since more pressure (causing discomfort) will be required to injected into contracted muscles. The nurse should apply gentle pressure after injection, unless this technique is contraindicated.
About these Nursing textbooks medical-surgical questions
Nursing textbooks medical-surgical practice questions, set 18 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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