Medical Surgical Assessment A UPDATED
ACTUAL Questions and CORRECT
Answers
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV
contrast agent. Which of the following laboratory findings should the nurse report to the provider
prior to the procedure?
A) Sodium 136 mEq/L
B) Potassium 4.8 mEq/L
C) Creatinine 1.9 mg/dL
D) Calcium 10 mg/dL - CORRECT ANSWER C) Creatinine 1.9 mg/dL
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should
report the finding to the provider before the client has a CT scan with an IV contrast agent. This
finding places the client at risk for developing contrast-induced nephropathy.
A nurse is monitoring a client who is taking acarbose. Which of the following findings should
the nurse identify as an adverse effect of the medication?
A) Polyuria
B) Abdominal cramps
C) Renal insufficiency
D) Insomnia - CORRECT ANSWER B) Abdominal cramps
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for
abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication.
A nurse is assisting with the care of a client who had a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent postprocedure
complications? (Select all)
,A) Monitor the insertion site for bleeding
B) Position the affected extremity at a 45 degree angle
C) Restrict the client's fluid intake
D) Maintain the pressure dressing
E) Check the client's peripheral pulses - CORRECT ANSWER A) Monitor the insertion
site for bleeding
The nurse should monitor the client's insertion site for manifestations of hemorrhaging.
D) Maintain the pressure dressing.
The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for
the cannulation site to heal.
E) Check the client's peripheral pulses.
The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion.
A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary
disease (COPD) and is dyspneic. Which of the following interventions should the nurse include
in the plan?
A) Encourage abdominal breathing
B) Direct the client to inhale with pursed lips
C) Set the oxygen therapy at 5L/min
D) Instruct the client to lean back while coughing - CORRECT ANSWER A) Encourage
abdominal breathing
,The nurse should encourage abdominal breathing, which reduces the workload on the accessory
muscles of respiration during dyspneic episodes.
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR
of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round
the answer to the nearest tenth. Use a leading zero is it applies. Do not use a trailing zero. -
CORRECT ANSWER 7mg/10 mg *1mL= 0.7 mL
A nurse is examining a client's IV site and notes a red line up his arm. The client reports a
throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations
indicate which of the following complications of IV therapy?
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms - CORRECT ANSWER A) Thrombophlebitis
The nurse should identify pain, warmth, and a red streak up the arm as indications of
thrombophlebitis.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following should the nurse include in the teaching?
A) Increase intake of fiber-rich foods
B) Take a laxative every morning
C) Maintain a fluid intake of 1200 mL per day
D) Limit activity to preserve energy - CORRECT ANSWER A) Increase intake of fiber-
rich foods
The nurse should instruct the client to increase the amount of fiber-rich foods in his diet. Dried
beans and brown rice are examples of fiber-rich foods.
, A nurse is caring for a client who has a compound fracture of the femur and was placed in
balanced suspension skeletal traction 4 days ago. Which of the following actions should the
nurse take?
A) Perform pin site care daily
B) Remove the overbed trapeze
C) Remove the boot every 2 hr
D) Keep the weights on a stable, flat surface - CORRECT ANSWER A) Perform pin site
care daily
The nurse should perform pin site care daily with chlorhexidine solution or use a solution
according to facility protocol. The nurse should also monitor the pin sites for manifestations of
infection.
A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
A) Lower the side rails of the client's bed
B) Apply wrist restraints to the client
C) Position the client in the semi-Fowler's position
D) Loosen clothing around the client's neck - CORRECT ANSWER D) Loosen clothing
around the client's neck
The nurse should loosen clothing around the client's neck to maintain an open airway and
prevent aspiration.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should the nurse
include?
ACTUAL Questions and CORRECT
Answers
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV
contrast agent. Which of the following laboratory findings should the nurse report to the provider
prior to the procedure?
A) Sodium 136 mEq/L
B) Potassium 4.8 mEq/L
C) Creatinine 1.9 mg/dL
D) Calcium 10 mg/dL - CORRECT ANSWER C) Creatinine 1.9 mg/dL
Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should
report the finding to the provider before the client has a CT scan with an IV contrast agent. This
finding places the client at risk for developing contrast-induced nephropathy.
A nurse is monitoring a client who is taking acarbose. Which of the following findings should
the nurse identify as an adverse effect of the medication?
A) Polyuria
B) Abdominal cramps
C) Renal insufficiency
D) Insomnia - CORRECT ANSWER B) Abdominal cramps
Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for
abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication.
A nurse is assisting with the care of a client who had a cardiac catheterization via the right
femoral artery. Which of the following actions should the nurse take to prevent postprocedure
complications? (Select all)
,A) Monitor the insertion site for bleeding
B) Position the affected extremity at a 45 degree angle
C) Restrict the client's fluid intake
D) Maintain the pressure dressing
E) Check the client's peripheral pulses - CORRECT ANSWER A) Monitor the insertion
site for bleeding
The nurse should monitor the client's insertion site for manifestations of hemorrhaging.
D) Maintain the pressure dressing.
The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for
the cannulation site to heal.
E) Check the client's peripheral pulses.
The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion.
A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary
disease (COPD) and is dyspneic. Which of the following interventions should the nurse include
in the plan?
A) Encourage abdominal breathing
B) Direct the client to inhale with pursed lips
C) Set the oxygen therapy at 5L/min
D) Instruct the client to lean back while coughing - CORRECT ANSWER A) Encourage
abdominal breathing
,The nurse should encourage abdominal breathing, which reduces the workload on the accessory
muscles of respiration during dyspneic episodes.
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR
of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round
the answer to the nearest tenth. Use a leading zero is it applies. Do not use a trailing zero. -
CORRECT ANSWER 7mg/10 mg *1mL= 0.7 mL
A nurse is examining a client's IV site and notes a red line up his arm. The client reports a
throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations
indicate which of the following complications of IV therapy?
A) Thrombophlebitis
B) Infiltration
C) Hematoma
D) Venous spasms - CORRECT ANSWER A) Thrombophlebitis
The nurse should identify pain, warmth, and a red streak up the arm as indications of
thrombophlebitis.
A nurse is reinforcing teaching about management of constipation with a client who has
hypothyroidism. Which of the following should the nurse include in the teaching?
A) Increase intake of fiber-rich foods
B) Take a laxative every morning
C) Maintain a fluid intake of 1200 mL per day
D) Limit activity to preserve energy - CORRECT ANSWER A) Increase intake of fiber-
rich foods
The nurse should instruct the client to increase the amount of fiber-rich foods in his diet. Dried
beans and brown rice are examples of fiber-rich foods.
, A nurse is caring for a client who has a compound fracture of the femur and was placed in
balanced suspension skeletal traction 4 days ago. Which of the following actions should the
nurse take?
A) Perform pin site care daily
B) Remove the overbed trapeze
C) Remove the boot every 2 hr
D) Keep the weights on a stable, flat surface - CORRECT ANSWER A) Perform pin site
care daily
The nurse should perform pin site care daily with chlorhexidine solution or use a solution
according to facility protocol. The nurse should also monitor the pin sites for manifestations of
infection.
A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the
following actions should the nurse take?
A) Lower the side rails of the client's bed
B) Apply wrist restraints to the client
C) Position the client in the semi-Fowler's position
D) Loosen clothing around the client's neck - CORRECT ANSWER D) Loosen clothing
around the client's neck
The nurse should loosen clothing around the client's neck to maintain an open airway and
prevent aspiration.
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking
dantrolene to manage muscle spasms. Which of the following interventions should the nurse
include?
