MED-SURG 1 EXAM 2 REVIEW | MEDICAL-SURGICAL NURSING EXAM 2 STUDY
GUIDE | PRACTICE QUESTIONS & ANSWERS
The post anesthesia recovery unit nurse is receiving a hand-off report from the 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 information about the client or surgery does the receiving nurse ask the reporting team
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. - correct answer ✔✔D
Rationale: The total intraoperative urine output is very low. Information regarding the client's total
intake, kidney function, and fluid status is needed.
A postoperative client's arterial blood gas (ABG) values are pH 7.36, HCO3 21 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. - correct answer ✔✔C
Rationale: All of these ABG results are within the normal range and indicate adequacy of ventilation, gas
exchange, and kidney function. Documentation is the only action that needs to be taken.
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 client reports 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 anesthesia. - correct answer ✔✔A
Rationale: Most clients have a sore throat for the first 12 to 24 hours after intubation during 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 important action is to assess the airway and respiratory response to ensure that breathing
impairment is not accompanying a swallowing problem.
When changing the client's abdominal dressing on the second postoperative 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. - correct 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 and a new dressing applied. The other actions are
inappropriate.
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. - correct answer ✔✔C
Standard Precautions and infection control protect both the nurse and the client from infection.
The client has just undergone a surgical procedure with general anesthesia. Which finding indicates that
the client needs further assessment in the postanesthesia care unit?
A Pain at the surgical site
B Requirement for verbal stimuli to awaken
C Snoring sounds when inhaling
D Sore throat on swallowing - correct answer ✔✔C
Snoring sounds when inhaling may indicate respiratory depression.
(A sore throat on swallowing is normal post intubation., Requiring verbal stimuli to awaken is normal
post sedation.
Postsurgical pain at the surgical site is normal.)
Which client is at greatest risk for slow wound healing?
A 12-year-old healthy girl
B 47-year-old obese man with diabetes
C 48-year-old woman who smokes
D 98-year-old healthy man - correct answer ✔✔B
Diabetes and obesity significantly contribute to slow wound heali
The nurse reviews with the client a routine discharge teaching plan concerning postoperative care.
Which statement by the client indicates that teaching was effective?
A "I may need to restrict my activities for several months."
B "The dressing should stay in place unless it gets wet."
C "The incision needs to be cleaned every 4 hours with hydrogen peroxide."
D "The wound will completely heal in about 2 months." - correct answer ✔✔A
To protect the integrity of the wound, activities may need to be restricted.
Which assessment finding in the postoperative client after general anesthesia requires immediate
intervention?
A Heart rate of 58
B Pale, cool extremities
C Respiratory rate of 6
D Suppressed gag reflex - correct answer ✔✔C
The most important postoperative assessment is respiratory assessment, and a rate of 6 is too low.
In conducting a postoperative assessment of the client, what is most important for the nurse to examine
first?
GUIDE | PRACTICE QUESTIONS & ANSWERS
The post anesthesia recovery unit nurse is receiving a hand-off report from the 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 information about the client or surgery does the receiving nurse ask the reporting team
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. - correct answer ✔✔D
Rationale: The total intraoperative urine output is very low. Information regarding the client's total
intake, kidney function, and fluid status is needed.
A postoperative client's arterial blood gas (ABG) values are pH 7.36, HCO3 21 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. - correct answer ✔✔C
Rationale: All of these ABG results are within the normal range and indicate adequacy of ventilation, gas
exchange, and kidney function. Documentation is the only action that needs to be taken.
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 client reports 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 anesthesia. - correct answer ✔✔A
Rationale: Most clients have a sore throat for the first 12 to 24 hours after intubation during 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 important action is to assess the airway and respiratory response to ensure that breathing
impairment is not accompanying a swallowing problem.
When changing the client's abdominal dressing on the second postoperative 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. - correct 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 and a new dressing applied. The other actions are
inappropriate.
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. - correct answer ✔✔C
Standard Precautions and infection control protect both the nurse and the client from infection.
The client has just undergone a surgical procedure with general anesthesia. Which finding indicates that
the client needs further assessment in the postanesthesia care unit?
A Pain at the surgical site
B Requirement for verbal stimuli to awaken
C Snoring sounds when inhaling
D Sore throat on swallowing - correct answer ✔✔C
Snoring sounds when inhaling may indicate respiratory depression.
(A sore throat on swallowing is normal post intubation., Requiring verbal stimuli to awaken is normal
post sedation.
Postsurgical pain at the surgical site is normal.)
Which client is at greatest risk for slow wound healing?
A 12-year-old healthy girl
B 47-year-old obese man with diabetes
C 48-year-old woman who smokes
D 98-year-old healthy man - correct answer ✔✔B
Diabetes and obesity significantly contribute to slow wound heali
The nurse reviews with the client a routine discharge teaching plan concerning postoperative care.
Which statement by the client indicates that teaching was effective?
A "I may need to restrict my activities for several months."
B "The dressing should stay in place unless it gets wet."
C "The incision needs to be cleaned every 4 hours with hydrogen peroxide."
D "The wound will completely heal in about 2 months." - correct answer ✔✔A
To protect the integrity of the wound, activities may need to be restricted.
Which assessment finding in the postoperative client after general anesthesia requires immediate
intervention?
A Heart rate of 58
B Pale, cool extremities
C Respiratory rate of 6
D Suppressed gag reflex - correct answer ✔✔C
The most important postoperative assessment is respiratory assessment, and a rate of 6 is too low.
In conducting a postoperative assessment of the client, what is most important for the nurse to examine
first?
