Medical-Surgical Nursing II | Questions
and Verified Answers ,
Exam 2: PNR206 / PNR 206 (Latest 2024 /
2025 Update) Medical-Surgical Nursing II
| Questions and Verified Answers | 100%
Correct | Grade A – Fortis
What instruction should the nurse include in the discharge teaching for a client who needs to
perform self-catheterization technique at home?
A. maintain sterile technique
B. drink 500 mL of fluid within 2 hours of catheterization
C. use the Cred maneuver before catheterization
D. catheterize every 3 to 4 hours –
ANS :D
The average interval between catheterization for adults is every 3 to 4 hours. Although sterile
technique is indicated in healthcare facilities, clean technique is often followed by the client when
performing self-catheterization at home.
A client's prostate-specific antigen (PSA) exam result showed a PSA density o 0.13 ng/ml. Which
conclusion regarding this lab data is accurate?
A. biopsy of the prostate is indicated
B. probably prostatitis
C. low risk for prostate cancer
D. the presence of cancer cells
- ANS :C
Clients with a PSA density of less than 0.15 ng/ml are considered at low risk for prostate cancer.
The nurse is caring for a client after a transurethral resection of the prostate and determines the
client's urinary catheter is not draining. What should the nurse implement?
A. encourage the client to drink oral fluids
B. change drainage unit tubing
C. irrigate the catheter
D. reposition the catheter drainage tubing
- ANS :C
A BOMB 1
, Medical-Surgical Nursing II | Questions
and Verified Answers ,
Obstruction urinary flow after a TURP is most often due to blood clot, and sterile irrigation should be
implemented to remove the clots that are blocking the catheter.
A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the
client understands?
A. increased frequency of assessment for prostatic cancer is needed
B. ongoing antibiotic therapy is needed for one year
C. the client should not undergo magnetic resonance imaging
D. the client should not be catheterized though the stent for at least three months –
ANS :D
To prevent complications, the client should be cautioned against catheterization through the stent
for three months after stent placement. Long term antibiotic use for one year is not a part of illness
management. There is no contraindication for magnetic resonance imaging. Frequent assessment of
prostate health is part of client teaching for health promotion, but is not increased because of the
stent placement
A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side
effect should the nurse provide to the client about this medication?
A. sensitivity to sunlight
B. muscle fascicultations
C. increased urinary frequency
D. gastrointestinal disturbance –
ANS :D
Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as
nausea and gastric burning. It is recommended that this drug be taken with food to avoid
gastrointestinal upset. Naproxen does not cause sensitivity to sunlight, muscle fasicultations, or
urinary frequency.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment,
what information is important to include?
A. permanent pigment changes to the breast may result
B. there is a possibility of long bone pain
C. dry, itchy, skin changes may occur
D. a low-residue diet may be ordered to reduce the likelihood of diarrhea –
ANS :C.
Side effects from radiation to the breast most often include temporary skin changes such as:
dryness, tenderness, redness, swelling, and pruritis
A BOMB 2
, Medical-Surgical Nursing II | Questions
and Verified Answers ,
The nurse is caring for a client receiving tamoxifen (Nolvadex) for treatment of breast cancer. Which
action should the nurse include in the client's plan of care?
A. encourage milk products to increase calcium intake
B. monitor sodium chloride intake
C. increase fluid intake
D. assist the client in coping with hot flashes –
ANS :D
Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so it should be included in
the plan of care. Increasing fluid intake, monitoring sodium intake, and encouraging milk products to
increase calcium intake re not related to the care of a client receiving tamoxifen
The nurse assessing a middle-aged male client for risk factors related to chronic illness. Which finding
should the nurse assess further?
A. increase in muscle tone but decreased muscle strength
B. increase in abdominal fat deposits
C. thinning hair and dry scalp
D. increase in appetite and taste-bud acuity –
ANS :B
An increase in the abdominal girth may be indicative of the onset of metabolic syndrome, which
places the client at risk for cardiac disease and requires further assessment. During middle
adulthood, common finding include thinning hair, dry skin and scalp, changes in taste bud acuity, and
muscle size and strength, which are consistent with normal system functioning during aging.
What is the priority nursing action while caring for a client on a ventilator when an electrical fire
occurs in the intensive care unit?
A. tell another staff member to bring extinguishing equipment to the bedside
B. implement an emergency protocol to remove the client from the ventilator
C. use a bag-valve-mask resuscitator while removing the client from the area
D. close the doors to the client's area when attempting to extinguish the fire –
ANS :C
A client on a ventilator should have respirations maintained with a manual bag-valve-mask
resuscitator while being moved away from the oxygen wall outlet and fire source. the other are not
the priority in maintaining safety during a fire int he client care area.
The nurse is planning pre-operative teaching for a client who will undergo a radical neck dissection
and total laryngectomy. Which information has the greatest priority for this client?
A. prognosis after treatment is excellent
A BOMB 3
, Medical-Surgical Nursing II | Questions
and Verified Answers ,
B. the stoma should never be covered after this type of surgery
C. there is a radical change in appearance as a result of this surgery
D. techniques for esophageal speech are relatively easy to learn with practice
- ANS :C
Radical neck dissection is the removal of lymphatic drainage channel and nodes, sternocleidomastoid
muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this
type of surgery causes the neck to be disfigured.
In planning care for a client with an acute stroke resulting in right-side hemiplegia, which positioning
should the nurse use to maintain optimal functioning?
A. supine with trochanter rolls to the hips
B. left lateral, supine, brief periods on the right side, and prone
C. sim's position alternated with right lateral position q2 hours
D. mid-fowler's with knees supported
- ANS :B
After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side,
which can impair circulation and cause pain, and include the prone position to help prevent flexion
contractures of the hips, prepares the client for optimal functioning and ambulating.
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action
should be included in the plan of care?
A. perform active range of motion three times daily
B. monitor for Battle's sign every four hours
C. teach measures to avoid the Valsalva maneuver
D. maintain the head of bed in a flat position –
ANS :C
The Valsalva maneuver, straining with bowel movements while holding one's breath, increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels. Passive,
not active ROM is performed to avoid ICP, bleeding and rupture. Battle's sign, bruising noted behind
the ear, is a manifestation that may be seen with a basilar skull fracture, not hemorrhagic stroke. The
flat position for the head of the bed is avoided because it increase venous congestion and ICP
A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse
should implement which protocols to prepare the client for this procedure?
A. provide a clear-liquid diet 48 hours before the procedure
B. initiate pre-operative sedation
C. begins fast the morning of the procedure
D. administer an enema before the procedure
A BOMB 4
and Verified Answers ,
Exam 2: PNR206 / PNR 206 (Latest 2024 /
2025 Update) Medical-Surgical Nursing II
| Questions and Verified Answers | 100%
Correct | Grade A – Fortis
What instruction should the nurse include in the discharge teaching for a client who needs to
perform self-catheterization technique at home?
A. maintain sterile technique
B. drink 500 mL of fluid within 2 hours of catheterization
C. use the Cred maneuver before catheterization
D. catheterize every 3 to 4 hours –
ANS :D
The average interval between catheterization for adults is every 3 to 4 hours. Although sterile
technique is indicated in healthcare facilities, clean technique is often followed by the client when
performing self-catheterization at home.
A client's prostate-specific antigen (PSA) exam result showed a PSA density o 0.13 ng/ml. Which
conclusion regarding this lab data is accurate?
A. biopsy of the prostate is indicated
B. probably prostatitis
C. low risk for prostate cancer
D. the presence of cancer cells
- ANS :C
Clients with a PSA density of less than 0.15 ng/ml are considered at low risk for prostate cancer.
The nurse is caring for a client after a transurethral resection of the prostate and determines the
client's urinary catheter is not draining. What should the nurse implement?
A. encourage the client to drink oral fluids
B. change drainage unit tubing
C. irrigate the catheter
D. reposition the catheter drainage tubing
- ANS :C
A BOMB 1
, Medical-Surgical Nursing II | Questions
and Verified Answers ,
Obstruction urinary flow after a TURP is most often due to blood clot, and sterile irrigation should be
implemented to remove the clots that are blocking the catheter.
A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the
client understands?
A. increased frequency of assessment for prostatic cancer is needed
B. ongoing antibiotic therapy is needed for one year
C. the client should not undergo magnetic resonance imaging
D. the client should not be catheterized though the stent for at least three months –
ANS :D
To prevent complications, the client should be cautioned against catheterization through the stent
for three months after stent placement. Long term antibiotic use for one year is not a part of illness
management. There is no contraindication for magnetic resonance imaging. Frequent assessment of
prostate health is part of client teaching for health promotion, but is not increased because of the
stent placement
A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side
effect should the nurse provide to the client about this medication?
A. sensitivity to sunlight
B. muscle fascicultations
C. increased urinary frequency
D. gastrointestinal disturbance –
ANS :D
Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as
nausea and gastric burning. It is recommended that this drug be taken with food to avoid
gastrointestinal upset. Naproxen does not cause sensitivity to sunlight, muscle fasicultations, or
urinary frequency.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment,
what information is important to include?
A. permanent pigment changes to the breast may result
B. there is a possibility of long bone pain
C. dry, itchy, skin changes may occur
D. a low-residue diet may be ordered to reduce the likelihood of diarrhea –
ANS :C.
Side effects from radiation to the breast most often include temporary skin changes such as:
dryness, tenderness, redness, swelling, and pruritis
A BOMB 2
, Medical-Surgical Nursing II | Questions
and Verified Answers ,
The nurse is caring for a client receiving tamoxifen (Nolvadex) for treatment of breast cancer. Which
action should the nurse include in the client's plan of care?
A. encourage milk products to increase calcium intake
B. monitor sodium chloride intake
C. increase fluid intake
D. assist the client in coping with hot flashes –
ANS :D
Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so it should be included in
the plan of care. Increasing fluid intake, monitoring sodium intake, and encouraging milk products to
increase calcium intake re not related to the care of a client receiving tamoxifen
The nurse assessing a middle-aged male client for risk factors related to chronic illness. Which finding
should the nurse assess further?
A. increase in muscle tone but decreased muscle strength
B. increase in abdominal fat deposits
C. thinning hair and dry scalp
D. increase in appetite and taste-bud acuity –
ANS :B
An increase in the abdominal girth may be indicative of the onset of metabolic syndrome, which
places the client at risk for cardiac disease and requires further assessment. During middle
adulthood, common finding include thinning hair, dry skin and scalp, changes in taste bud acuity, and
muscle size and strength, which are consistent with normal system functioning during aging.
What is the priority nursing action while caring for a client on a ventilator when an electrical fire
occurs in the intensive care unit?
A. tell another staff member to bring extinguishing equipment to the bedside
B. implement an emergency protocol to remove the client from the ventilator
C. use a bag-valve-mask resuscitator while removing the client from the area
D. close the doors to the client's area when attempting to extinguish the fire –
ANS :C
A client on a ventilator should have respirations maintained with a manual bag-valve-mask
resuscitator while being moved away from the oxygen wall outlet and fire source. the other are not
the priority in maintaining safety during a fire int he client care area.
The nurse is planning pre-operative teaching for a client who will undergo a radical neck dissection
and total laryngectomy. Which information has the greatest priority for this client?
A. prognosis after treatment is excellent
A BOMB 3
, Medical-Surgical Nursing II | Questions
and Verified Answers ,
B. the stoma should never be covered after this type of surgery
C. there is a radical change in appearance as a result of this surgery
D. techniques for esophageal speech are relatively easy to learn with practice
- ANS :C
Radical neck dissection is the removal of lymphatic drainage channel and nodes, sternocleidomastoid
muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this
type of surgery causes the neck to be disfigured.
In planning care for a client with an acute stroke resulting in right-side hemiplegia, which positioning
should the nurse use to maintain optimal functioning?
A. supine with trochanter rolls to the hips
B. left lateral, supine, brief periods on the right side, and prone
C. sim's position alternated with right lateral position q2 hours
D. mid-fowler's with knees supported
- ANS :B
After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side,
which can impair circulation and cause pain, and include the prone position to help prevent flexion
contractures of the hips, prepares the client for optimal functioning and ambulating.
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action
should be included in the plan of care?
A. perform active range of motion three times daily
B. monitor for Battle's sign every four hours
C. teach measures to avoid the Valsalva maneuver
D. maintain the head of bed in a flat position –
ANS :C
The Valsalva maneuver, straining with bowel movements while holding one's breath, increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels. Passive,
not active ROM is performed to avoid ICP, bleeding and rupture. Battle's sign, bruising noted behind
the ear, is a manifestation that may be seen with a basilar skull fracture, not hemorrhagic stroke. The
flat position for the head of the bed is avoided because it increase venous congestion and ICP
A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse
should implement which protocols to prepare the client for this procedure?
A. provide a clear-liquid diet 48 hours before the procedure
B. initiate pre-operative sedation
C. begins fast the morning of the procedure
D. administer an enema before the procedure
A BOMB 4
