ASN 231 Med-Surg FINAL EXAM WITH OVER
200 QUESTIONS AND VERIFIED
ANSWERS/LATEST UPDATED STUDY GUIDE
WITH QUESTIONS AND ANSWERS WITH
RATIONALES ALREADY GRADED A
1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies
that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take
when interviewing this client?
a. Tell the client that he or she needs to quit smoking to stop further cancer development.
b. Encourage the client to be completely honest about both tobacco and marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis - ANSWER>>ANS: C
Smoking assessments and cessation information can be an uncomfortable and sensitive topic among
both clients and health care providers. The nurse would maintain a nonjudgmental attitude in order to
foster trust with the client. Telling the client he or she needs to quit smoking is paternalistic and
threatening. Assessing exposure to smoke includes more than tobacco and marijuana. The nurse would
avoid giving the client false hope but when taking a history, it is most important to get accurate
information.
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the
correct intervention?
a. Client reports being dizzy—nurse calls the Rapid Response Team.
b. Client's heart rate is 55 beats/min—nurse withholds pain medication.
c. Client has reduced breath sounds—nurse calls primary health care provider immediately.
d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate. - ANSWER>>ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or
absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness
without other data would not lead the nurse to call the RRT. If the client's heart rate is 55 beats/min, no
reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and
would not warrant changing the oxygen flow rate.
3. A nurse assesses a client's respiratory status. Which information is most important for the nurse to
obtain?
a. Average daily fluid intake.
b. Neck circumference.
c. Height and weight.
d. Occupation and hobbies. - ANSWER>>ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's
occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake,
height, and weight, these will not be as important as determining his occupation and hobbies. This is part
,of the I-PREPARE assessment model for particulate matter exposure. Determining the client's neck
circumference will not be an important part of a respiratory assessment.
4. A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest
diameter. Which question would the nurse ask the client in response to this finding?
a. "Are you taking any medications or herbal supplements?"
b. "Do you have any chronic breathing problems?"
c. "How often do you perform aerobic exercise?"
d. "What is your occupation and what are your hobbies?" - ANSWER>>ANS: B
The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side)
diameter. This ratio normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and
the ratio is 1:1, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of
a long-term chronic airflow limitation problem, such as chronic emphysema. It can also be seen in people
who have lived at a high altitude for many years. Medications, herbal supplements, and aerobic exercise
are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants
that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more
direct and would be asked first
5. A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are
absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most
important?
a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site. - ANSWER>>ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a
needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry reading and perform
other respiratory assessments. Temperature is not a priority. The nurse can ask about other symptoms
while conducting the assessment. The nurse would assess the biopsy site and/or dressings, but this is
not the first action.
6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would
the nurse complete prior to the procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client. - ANSWER>>ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would
ensure signed informed consent has been obtained. Verifying that the client understands complications
and explaining the procedure to be performed will be done by the primary health care provider, not the
nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to
a thoracentesis
7. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 L of oxygen.
d. The trachea is shifted toward the opposite side of the neck. - ANSWER>>ANS: D
, A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a
medical emergency. The other findings are normal or near normal. The nurse would report this finding
immediately or call the Rapid Response Team
8. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water.
What action would the nurse take next?
a. Call the primary health care provider and request food and water for the client.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client's gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow. - ANSWER>>ANS: C
The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing
the client anything to eat or drink, the nurse must check for the return of this reflex
9. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when
climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 L per nasal cannula
d. Complete bedrest with frequent repositioning - ANSWER>>ANS: A
A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without
pausing has class IV dyspnea. The nurse would provide assistance with activities of daily living. These
clients would be encouraged to participate in activities as tolerated. They would not be on complete
bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.
10. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the
nurse include in this client's teaching?
a. "Make a list of reasons why smoking is a bad habit."
b. "Rise slowly when getting out of bed in the morning."
c. "Smoking while taking this medication will increase your risk of a stroke."
d. "Stopping this medication suddenly increases your risk for a heart attack." - ANSWER>>ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and
heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would
encourage the client to make a list of reasons for stopping the habit but would not phrase it so
judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly
does not increase the risk of heart attack.
11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The
client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take
next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client's peripheral pulses.
d. Obtain blood and sputum cultures - ANSWER>>ANS: B
Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of
benzocaine spray. This condition can lead to death. The nurse would notify the Rapid Response Team to
provide advanced care. An albuterol treatment would not address the client's oxygenation problem.
Assessment of pulses and cultures will not provide data necessary to treat the client.
200 QUESTIONS AND VERIFIED
ANSWERS/LATEST UPDATED STUDY GUIDE
WITH QUESTIONS AND ANSWERS WITH
RATIONALES ALREADY GRADED A
1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies
that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take
when interviewing this client?
a. Tell the client that he or she needs to quit smoking to stop further cancer development.
b. Encourage the client to be completely honest about both tobacco and marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis - ANSWER>>ANS: C
Smoking assessments and cessation information can be an uncomfortable and sensitive topic among
both clients and health care providers. The nurse would maintain a nonjudgmental attitude in order to
foster trust with the client. Telling the client he or she needs to quit smoking is paternalistic and
threatening. Assessing exposure to smoke includes more than tobacco and marijuana. The nurse would
avoid giving the client false hope but when taking a history, it is most important to get accurate
information.
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the
correct intervention?
a. Client reports being dizzy—nurse calls the Rapid Response Team.
b. Client's heart rate is 55 beats/min—nurse withholds pain medication.
c. Client has reduced breath sounds—nurse calls primary health care provider immediately.
d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate. - ANSWER>>ANS: C
A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or
absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness
without other data would not lead the nurse to call the RRT. If the client's heart rate is 55 beats/min, no
reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and
would not warrant changing the oxygen flow rate.
3. A nurse assesses a client's respiratory status. Which information is most important for the nurse to
obtain?
a. Average daily fluid intake.
b. Neck circumference.
c. Height and weight.
d. Occupation and hobbies. - ANSWER>>ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's
occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake,
height, and weight, these will not be as important as determining his occupation and hobbies. This is part
,of the I-PREPARE assessment model for particulate matter exposure. Determining the client's neck
circumference will not be an important part of a respiratory assessment.
4. A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest
diameter. Which question would the nurse ask the client in response to this finding?
a. "Are you taking any medications or herbal supplements?"
b. "Do you have any chronic breathing problems?"
c. "How often do you perform aerobic exercise?"
d. "What is your occupation and what are your hobbies?" - ANSWER>>ANS: B
The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side)
diameter. This ratio normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and
the ratio is 1:1, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of
a long-term chronic airflow limitation problem, such as chronic emphysema. It can also be seen in people
who have lived at a high altitude for many years. Medications, herbal supplements, and aerobic exercise
are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants
that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more
direct and would be asked first
5. A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are
absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most
important?
a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site. - ANSWER>>ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a
needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry reading and perform
other respiratory assessments. Temperature is not a priority. The nurse can ask about other symptoms
while conducting the assessment. The nurse would assess the biopsy site and/or dressings, but this is
not the first action.
6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would
the nurse complete prior to the procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client. - ANSWER>>ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would
ensure signed informed consent has been obtained. Verifying that the client understands complications
and explaining the procedure to be performed will be done by the primary health care provider, not the
nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to
a thoracentesis
7. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 L of oxygen.
d. The trachea is shifted toward the opposite side of the neck. - ANSWER>>ANS: D
, A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a
medical emergency. The other findings are normal or near normal. The nurse would report this finding
immediately or call the Rapid Response Team
8. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water.
What action would the nurse take next?
a. Call the primary health care provider and request food and water for the client.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client's gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow. - ANSWER>>ANS: C
The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing
the client anything to eat or drink, the nurse must check for the return of this reflex
9. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when
climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 L per nasal cannula
d. Complete bedrest with frequent repositioning - ANSWER>>ANS: A
A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without
pausing has class IV dyspnea. The nurse would provide assistance with activities of daily living. These
clients would be encouraged to participate in activities as tolerated. They would not be on complete
bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.
10. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the
nurse include in this client's teaching?
a. "Make a list of reasons why smoking is a bad habit."
b. "Rise slowly when getting out of bed in the morning."
c. "Smoking while taking this medication will increase your risk of a stroke."
d. "Stopping this medication suddenly increases your risk for a heart attack." - ANSWER>>ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and
heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would
encourage the client to make a list of reasons for stopping the habit but would not phrase it so
judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly
does not increase the risk of heart attack.
11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The
client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take
next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client's peripheral pulses.
d. Obtain blood and sputum cultures - ANSWER>>ANS: B
Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of
benzocaine spray. This condition can lead to death. The nurse would notify the Rapid Response Team to
provide advanced care. An albuterol treatment would not address the client's oxygenation problem.
Assessment of pulses and cultures will not provide data necessary to treat the client.
