Med Surg 1 Exam 2
Questions and Answers
1. The postanesthesia recovery unit nurse is receiving a hand-off report
fromthe nurse anesthetist and the circulating nurse for an 82-year-old
client who had a 2-hour open reduction of a fractured elbow. For which
reported infor- mation about the client or surgery does the receiving
nurse ask the reportingteam for more details?
A. The client is Jewish.
B. The estimated blood loss is 150 mL.
C. The client reported an allergy to codeine.
D. The total intraoperative urine output is 25 mL Answer : D
Rationale: The total intraoperative urine output is very low. Information
regarding theclient's total intake, kidney function, and fluid status is needed.
2. A postoperative client's arterial blood gas (ABG) values are pH 7.36,
HCO321 mEq/L, Paco2 35 mm Hg, Pao2 98 mm Hg. What is the nurse's
priority action?
A. Compare these values with the client's preoperative ABG values.
B. Assess the airway and notify the physician.
,C. Document the values as the only action.
D. Increase the oxygen flow rate Answer : C
Rationale: All of these ABG results are within the normal range and indicate
ade- quacy of ventilation, gas exchange, and kidney function. Documentation
is the onlyaction that needs to be taken.
3. The client who had neck surgery to remove the entire thyroid gland is
transferred to the medical-surgical unit after 4 hours in the PACU. The
clientreports difficulty swallowing. What is the nurse's priority action?
A. Assess the client's respiratory status.
B. Inspect the client's throat with a penlight.
C. Adjust the position of the drain in the incision.
D. Reassure the client that this is a normal and common problem after
anes-thesia Answer : A
Rationale: Most clients have a sore throat for the first 12 to 24 hours after
intubationduring surgery, and this is made worse when the client tries to
swallow. However,
it is important for the nurse to differentiate soreness from true difficulty
swallowing.Surgery in the neck area can cause swelling that reduces the
lumen of the throat. This can cause respiratory impairment and swallowing
difficulties. The most impor-tant action is to assess the airway and respiratory
response to ensure that breathingimpairment is not accompanying a
swallowing problem.
,4. When changing the client's abdominal dressing on the second
postoper-ative day, the nurse observes crusting on about half of the
suture line and oozing of a small amount of serosanguineous drainage.
What is the nurse's
best action?
A. Loosen the sutures or staples in the area where crusts have formed.
B. Clean the suture line with sterile saline and apply new dressings.
C. Gently remove the crusts and culture the material beneath.
D. Apply pressure over the incision and notify the surgeon Answer : B
Serosanguineous drainage and a small amount of crusting are normal
incision findings on the second postoperative day. The suture line needs to be
cleaned anda new dressing applied. The other actions are inappropriate.
5. Why is it important to wear sterile gloves during a dressing
change?A They protect the client from infection.
B They protect the nurse from infection.
C They protect both the client and the nurse from
infection.D Their use prevents lawsuits Answer : C
Standard Precautions and infection control protect both the nurse and the
clientfrom infection.
6. The client has just undergone a surgical procedure with general
, anesthe-sia. Which finding indicates that the client needs further
assessment in thepostanesthesia care unit?
A Pain at the surgical site
B Requirement for verbal stimuli to
awakenC Snoring sounds when inhaling
D Sore throat on swallowing: C
Snoring sounds when inhaling may indicate respiratory depression.
(A sore throat on swallowing is normal post intubation., Requiring verbal
stimuli toawaken is normal post sedation.
Postsurgical pain at the surgical site is normal.)
7. Which client is at greatest risk for slow wound
healing?A 12-year-old healthy girl
B 47-year-old obese man with
diabetesC 48-year-old woman who
smokes
D 98-year-old healthy man: B
Diabetes and obesity significantly contribute to slow wound healing
8. The nurse reviews with the client a routine discharge teaching plan
concern- ing postoperative care. Which statement by the client indicates
that teachingwas effective?
A "I may need to restrict my activities for several
Questions and Answers
1. The postanesthesia recovery unit nurse is receiving a hand-off report
fromthe nurse anesthetist and the circulating nurse for an 82-year-old
client who had a 2-hour open reduction of a fractured elbow. For which
reported infor- mation about the client or surgery does the receiving
nurse ask the reportingteam for more details?
A. The client is Jewish.
B. The estimated blood loss is 150 mL.
C. The client reported an allergy to codeine.
D. The total intraoperative urine output is 25 mL Answer : D
Rationale: The total intraoperative urine output is very low. Information
regarding theclient's total intake, kidney function, and fluid status is needed.
2. A postoperative client's arterial blood gas (ABG) values are pH 7.36,
HCO321 mEq/L, Paco2 35 mm Hg, Pao2 98 mm Hg. What is the nurse's
priority action?
A. Compare these values with the client's preoperative ABG values.
B. Assess the airway and notify the physician.
,C. Document the values as the only action.
D. Increase the oxygen flow rate Answer : C
Rationale: All of these ABG results are within the normal range and indicate
ade- quacy of ventilation, gas exchange, and kidney function. Documentation
is the onlyaction that needs to be taken.
3. The client who had neck surgery to remove the entire thyroid gland is
transferred to the medical-surgical unit after 4 hours in the PACU. The
clientreports difficulty swallowing. What is the nurse's priority action?
A. Assess the client's respiratory status.
B. Inspect the client's throat with a penlight.
C. Adjust the position of the drain in the incision.
D. Reassure the client that this is a normal and common problem after
anes-thesia Answer : A
Rationale: Most clients have a sore throat for the first 12 to 24 hours after
intubationduring surgery, and this is made worse when the client tries to
swallow. However,
it is important for the nurse to differentiate soreness from true difficulty
swallowing.Surgery in the neck area can cause swelling that reduces the
lumen of the throat. This can cause respiratory impairment and swallowing
difficulties. The most impor-tant action is to assess the airway and respiratory
response to ensure that breathingimpairment is not accompanying a
swallowing problem.
,4. When changing the client's abdominal dressing on the second
postoper-ative day, the nurse observes crusting on about half of the
suture line and oozing of a small amount of serosanguineous drainage.
What is the nurse's
best action?
A. Loosen the sutures or staples in the area where crusts have formed.
B. Clean the suture line with sterile saline and apply new dressings.
C. Gently remove the crusts and culture the material beneath.
D. Apply pressure over the incision and notify the surgeon Answer : B
Serosanguineous drainage and a small amount of crusting are normal
incision findings on the second postoperative day. The suture line needs to be
cleaned anda new dressing applied. The other actions are inappropriate.
5. Why is it important to wear sterile gloves during a dressing
change?A They protect the client from infection.
B They protect the nurse from infection.
C They protect both the client and the nurse from
infection.D Their use prevents lawsuits Answer : C
Standard Precautions and infection control protect both the nurse and the
clientfrom infection.
6. The client has just undergone a surgical procedure with general
, anesthe-sia. Which finding indicates that the client needs further
assessment in thepostanesthesia care unit?
A Pain at the surgical site
B Requirement for verbal stimuli to
awakenC Snoring sounds when inhaling
D Sore throat on swallowing: C
Snoring sounds when inhaling may indicate respiratory depression.
(A sore throat on swallowing is normal post intubation., Requiring verbal
stimuli toawaken is normal post sedation.
Postsurgical pain at the surgical site is normal.)
7. Which client is at greatest risk for slow wound
healing?A 12-year-old healthy girl
B 47-year-old obese man with
diabetesC 48-year-old woman who
smokes
D 98-year-old healthy man: B
Diabetes and obesity significantly contribute to slow wound healing
8. The nurse reviews with the client a routine discharge teaching plan
concern- ing postoperative care. Which statement by the client indicates
that teachingwas effective?
A "I may need to restrict my activities for several
