Medical-Surgical Nursing, 7th Edition by Linda S. Williams 42 questions with answers

1. A 30-year-old patient with ulcerative colitis is scheduled for a proctosigmoidoscopy. Which finding should cause the nurse to clarify routine preparation orders with the physician? a. The patients age b. Presence of severe diarrhea c. Complaints of abdominal cramping d. Patients weight is 10% below ideal body weight - 1. ANS: B Routine preparation with severe diarrhea can result in electrolyte imbalance. Bowel preparation may not be ordered for patients with bleeding or severe diarrhea. A. C. D. The patients age, complaints of abdominal cramping, or current weight are not contraindications for the routine preparation for this diagnostic test. 2. The nurse is caring for a patient who is placed on a modified bland diet. Which should be removed before serving the patients dinner tray? a. Salt b. Sugar c. Pepper d. Mayonnaise - 2. ANS: CPepper, which is spicy, would not be included in a bland diet. A. B. D. These food items are bland. 3. The nurse is preparing to initiate a tube feeding through a patients nasogastric (NG) tube. Prior to initiating this feeding what should the nurse use to irrigate the tube? a. Sterile water b. Normal saline c. Cranberry juice d. Carbonated water - 3. ANS: B Normal saline is used for NG tube irrigation to prevent loss of electrolytes. A. Sterile water could cause an electrolyte imbalance in the patient. C. D. Cranberry juice and carbonated water are not appropriate fluids to flush a nasogastric tube. 4. The nurse is inspecting a patients oral cavity. What is the most important safety reason for the nurse to inspect for loose teeth when collecting data on the oral cavity of a patient? a. Loose teeth are unsightly to the patient. b. Loose teeth can cause dental abscesses. c. Loose teeth can be aspirated into the airway. d. Loose teeth can prevent the patient from eating. - 4. ANS: C Loose teeth can be aspirated into the airway and become a choking risk. A. The nurse is not inspecting for loose teeth because it is unsightly to the patient. B. The nurse is not inspecting for loose teeth because of the risk for dental abscesses. D. Missing teeth is more likely to prevent a patient from eating. 5. The nurse is collecting data from a patient who is scheduled for an ileostomy. Which technique should the nurse use to help identify optimal stoma placement? a. Palpation b. Inspection c. Percussion d. Auscultation - 5. ANS: B Inspection is observation. The abdomen is visually inspected to note the condition of the skin, the contour, belt line, and other factors that would affect optimal stoma placement. A. C. D. These techniques of data collection would not be appropriate when determining optimal placement for a stoma. 6. A licensed practical nurse (LPN) who typically works on a medical unit has been assigned to cover staffing deficits on a surgical unit. After obtaining report, the nurse realizes that one of the assigned patients is currently receiving parenteral nutrition (PN). Which action should the nurse take? a. Provide patient care as assigned. b. Ask another nurse to trade patients for the shift. c. Notify the supervisor that another nurse will need to be pulled. d. Notify the charge nurse that an adjustment in the patient assignment is necessary. - 6. ANS: D Usually, registered nurses (RNs) are responsible for administering PN. Therefore, the LPN should discuss the assignment with the charge nurse and seek a possible adjustment. A. Providing patient care as assigned would be beyond the LPNs scope of practice. B. The LPN cannot make a patient care assignment change. C. The LPN needs to work through the charge nurse. 7. The nurse is collecting data from a patient who reports right upper abdominal quadrant warmth and tenderness. When the nurse touches the area lightly to assess for warmth and tenderness, what data collection technique is being used? a. Palpation b. Inspection c. Percussion d. Auscultation - 7. ANS: A Light palpation uses touch and depresses the abdomen 0.5 to 1 inch. B. Inspection is looking at or observing an area. C. Percussion is using the hands and fingers to produce a sound that identifies the density of the organs beneath the area being percussed. D. Auscultation is the use of a stethoscope to listen for sounds. 8. The nurse is caring for a patient whose NG tube, attached to low intermittent suction to decompress a bowel obstruction, is not draining. After checking placement, which action should the nurse take? a. Advance the NG tube 2 inches. b. Change the suction setting to high. c. Reinsert the NG tube in the other nare. d. Irrigate the NG tube with 30 milliliters of normal saline. - 8. ANS: D The nurse should irrigate the NG tube with 30 mL of normal saline to see if it is obstructed or on the stomach wall. B. Suction should remain on a low setting to prevent damage to the lining of the stomach. A. The tube should not be advanced without an HCPs order. C. The NG tube should not be pulled and reinserted without an HCPs order.