Medical Surgical Testbank Exam
Questions with 100% Correct Answers
23. A patient who has been hospitalized for 2 days has been receiving normal saline
IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which
assessment finding by the nurse is the priority to report to the health care provider?
a.
Serum sodium level of 138 mEq/L (138 mmol/L)
b.
Gradually decreasing level of consciousness (LOC)
c.
Oral temperature of 100.1 F with bibasilar lung crackles
d.
Weight gain of 2 pounds (1 kg) above the admission weight - Answer-Gradually
decreasing level of consciousness (LOC)
Rationale: The patients history and change in LOC could be indicative of several
fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit,
hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further
diagnostic information will be ordered by the health care provider to determine the
cause of the change in LOC and the appropriate interventions. The weight gain,
elevated temperature, crackles, and serum sodium level also will be reported, but do
not indicate a need for rapid action to avoid complications.
24. When assessing a patient with increased extracellular fluid (ECF) osmolality, the
priority assessment for the nurse to obtain is
a.
skin turgor.
b.
heart sounds.
c.
mental status.
d.
,capillary refill. - Answer-mental status.
Rationale: Changes in ECF osmolality lead to swelling or shrinking of cells in the
central nervous system, initially causing confusion, which may progress to coma or
seizures. Although skin turgor, capillary refill, and heart sounds also may be affected
by ECF osmolality changes and resultant fluid shifts, these are signs that occur later
and do not have as immediate an impact on patient outcomes.
25. A patient with renal failure who has been taking aluminum hydroxide/magnesium
hydroxide suspension (Maalox) at home for indigestion is somnolent and has
decreased deep tendon reflexes. Which action should the nurse take first?
a.
Notify the patients health care provider.
b.
Withhold the next scheduled dose of Maalox.
c.
Review the magnesium level on the patients chart.
d.
Check the chart for the most recent potassium level. - Answer-Review the
magnesium level on the patients chart.
Rationale: The patient has a history and symptoms consistent with
hypermagnesemia; the nurse should check the chart for a recent serum magnesium
level. Notification of the health care provider will be done after the nurse knows the
magnesium level. The Maalox should be held, but more immediate action is needed
to correct the patients decreased deep tendon reflexes (DTRs) and somnolence.
Monitoring of potassium levels also is important for patients with renal failure, but the
patients current symptoms are not consistent with hyperkalemia.
26. A postoperative patient who is receiving nasogastric suction is complaining of
anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and
the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should
the nurse take first?
a.
Discontinue the nasogastric suctions for a few hours.
b.
Notify the health care provider about the ABG results.
,c.
Teach the patient about the need to take slow, deep breaths.
d.
Give the patient the PRN morphine sulfate 4 mg intravenously. - Answer-Give the
patient the PRN morphine sulfate 4 mg intravenously.
Rationale: The patients respiratory alkalosis is caused by the increased respiratory
rate associated with pain and anxiety. The nurses first action should be to medicate
the patient for pain. Although the nasogastric suction may contribute to the alkalosis,
it is not appropriate to discontinue the tube when the patient needs gastric suction.
The health care provider may be notified about the ABGs but is likely to instruct the
nurse to medicate for pain. The patient will not be able to take slow, deep breaths
when experiencing pain.
27. Which of these actions can the nurse who is caring for a critically ill patient with
multiple intravenous (IV) lines delegate to an experienced LPN?
a.
Administer IV antibiotics through the implantable port.
b.
Monitor the IV sites for redness, swelling, or tenderness.
c.
Remove the patients nontunneled subclavian central venous catheter.
d.
Adjust the flow rate of the 0.9% normal saline in the peripheral IV line. - Answer-
Monitor the IV sites for redness, swelling, or tenderness.
Rationale: An experienced LPN has the education, experience, and scope of
practice to monitor IV sites for signs of infection. Administration of medications,
adjustment of infusion rates, and removal of central catheters in critically ill patients
require RN level education and scope of practice.
28. Which assessment finding about a patient who has a serum calcium level of 7.0
mEq/L is most important for the nurse to report to the health care provider?
a.
The patient is experiencing laryngeal stridor.
, b.
The patient complains of generalized fatigue.
c.
The patients bowels have not moved for 4 days.
d.
The patient has numbness and tingling of the lips. - Answer-The patient is
experiencing laryngeal stridor.
Rationale: Laryngeal stridor may lead to respiratory arrest and requires rapid action
to correct the patients calcium level. The other data also are consistent with
hypocalcemia, but do not indicate a need for immediate action.
29. Following a thyroidectomy, a patient complains of a tingling feeling around my
mouth. The nurse will immediately check for
a.
an elevated serum potassium level.
b.
the presence of Chvosteks sign.
c.
a decreased thyroid hormone level.
d.
bleeding on the patients dressing. - Answer-the presence of Chvosteks sign.
Rationale: The patients symptoms indicate possible hypocalcemia, which can occur
secondary to parathyroid injury/removal during thyroidectomy. There is no indication
of a need to check the potassium level, the thyroid hormone level, or for bleeding.
30. A patient with advanced lung cancer is admitted to the emergency department
with urinary retention caused by renal calculi. Which of these laboratory values will
require the most immediate action by the nurse?
a.
Arterial blood pH is 7.32.
b.
Questions with 100% Correct Answers
23. A patient who has been hospitalized for 2 days has been receiving normal saline
IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which
assessment finding by the nurse is the priority to report to the health care provider?
a.
Serum sodium level of 138 mEq/L (138 mmol/L)
b.
Gradually decreasing level of consciousness (LOC)
c.
Oral temperature of 100.1 F with bibasilar lung crackles
d.
Weight gain of 2 pounds (1 kg) above the admission weight - Answer-Gradually
decreasing level of consciousness (LOC)
Rationale: The patients history and change in LOC could be indicative of several
fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit,
hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further
diagnostic information will be ordered by the health care provider to determine the
cause of the change in LOC and the appropriate interventions. The weight gain,
elevated temperature, crackles, and serum sodium level also will be reported, but do
not indicate a need for rapid action to avoid complications.
24. When assessing a patient with increased extracellular fluid (ECF) osmolality, the
priority assessment for the nurse to obtain is
a.
skin turgor.
b.
heart sounds.
c.
mental status.
d.
,capillary refill. - Answer-mental status.
Rationale: Changes in ECF osmolality lead to swelling or shrinking of cells in the
central nervous system, initially causing confusion, which may progress to coma or
seizures. Although skin turgor, capillary refill, and heart sounds also may be affected
by ECF osmolality changes and resultant fluid shifts, these are signs that occur later
and do not have as immediate an impact on patient outcomes.
25. A patient with renal failure who has been taking aluminum hydroxide/magnesium
hydroxide suspension (Maalox) at home for indigestion is somnolent and has
decreased deep tendon reflexes. Which action should the nurse take first?
a.
Notify the patients health care provider.
b.
Withhold the next scheduled dose of Maalox.
c.
Review the magnesium level on the patients chart.
d.
Check the chart for the most recent potassium level. - Answer-Review the
magnesium level on the patients chart.
Rationale: The patient has a history and symptoms consistent with
hypermagnesemia; the nurse should check the chart for a recent serum magnesium
level. Notification of the health care provider will be done after the nurse knows the
magnesium level. The Maalox should be held, but more immediate action is needed
to correct the patients decreased deep tendon reflexes (DTRs) and somnolence.
Monitoring of potassium levels also is important for patients with renal failure, but the
patients current symptoms are not consistent with hyperkalemia.
26. A postoperative patient who is receiving nasogastric suction is complaining of
anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and
the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should
the nurse take first?
a.
Discontinue the nasogastric suctions for a few hours.
b.
Notify the health care provider about the ABG results.
,c.
Teach the patient about the need to take slow, deep breaths.
d.
Give the patient the PRN morphine sulfate 4 mg intravenously. - Answer-Give the
patient the PRN morphine sulfate 4 mg intravenously.
Rationale: The patients respiratory alkalosis is caused by the increased respiratory
rate associated with pain and anxiety. The nurses first action should be to medicate
the patient for pain. Although the nasogastric suction may contribute to the alkalosis,
it is not appropriate to discontinue the tube when the patient needs gastric suction.
The health care provider may be notified about the ABGs but is likely to instruct the
nurse to medicate for pain. The patient will not be able to take slow, deep breaths
when experiencing pain.
27. Which of these actions can the nurse who is caring for a critically ill patient with
multiple intravenous (IV) lines delegate to an experienced LPN?
a.
Administer IV antibiotics through the implantable port.
b.
Monitor the IV sites for redness, swelling, or tenderness.
c.
Remove the patients nontunneled subclavian central venous catheter.
d.
Adjust the flow rate of the 0.9% normal saline in the peripheral IV line. - Answer-
Monitor the IV sites for redness, swelling, or tenderness.
Rationale: An experienced LPN has the education, experience, and scope of
practice to monitor IV sites for signs of infection. Administration of medications,
adjustment of infusion rates, and removal of central catheters in critically ill patients
require RN level education and scope of practice.
28. Which assessment finding about a patient who has a serum calcium level of 7.0
mEq/L is most important for the nurse to report to the health care provider?
a.
The patient is experiencing laryngeal stridor.
, b.
The patient complains of generalized fatigue.
c.
The patients bowels have not moved for 4 days.
d.
The patient has numbness and tingling of the lips. - Answer-The patient is
experiencing laryngeal stridor.
Rationale: Laryngeal stridor may lead to respiratory arrest and requires rapid action
to correct the patients calcium level. The other data also are consistent with
hypocalcemia, but do not indicate a need for immediate action.
29. Following a thyroidectomy, a patient complains of a tingling feeling around my
mouth. The nurse will immediately check for
a.
an elevated serum potassium level.
b.
the presence of Chvosteks sign.
c.
a decreased thyroid hormone level.
d.
bleeding on the patients dressing. - Answer-the presence of Chvosteks sign.
Rationale: The patients symptoms indicate possible hypocalcemia, which can occur
secondary to parathyroid injury/removal during thyroidectomy. There is no indication
of a need to check the potassium level, the thyroid hormone level, or for bleeding.
30. A patient with advanced lung cancer is admitted to the emergency department
with urinary retention caused by renal calculi. Which of these laboratory values will
require the most immediate action by the nurse?
a.
Arterial blood pH is 7.32.
b.
