Med Surg Review Exam 1 Answer Key - Practice Keys Level 2 | Questions and
Answers | Latest Update
Detailed Answer Key
Med Surg Review exam
1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse
expect? (Select all that apply.)
A. Dyspnea
B. Barrel chest
C. Clubbing of the fingers
D. Shallow respirations
E. Bradycardia
Rationale: Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate
oxygen exchange in the lungs.Barrel chest is correct. The lungs of clients who have emphysema
lose their elasticity, and the diaphragm becomes permanently flattened by overdistention of the
lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces
the barrel chest typical of emphysema clients.Clubbing of the fingers is correct. Air is trapped in
the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from
these chronic low blood-oxygen levels.Shallow respirations is correct. Clients who have
emphysema lose lung elasticity; consequently, respirations become increasingly shallow and
more rapid.Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate
for less oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the
nurse expect to observe? (Select all that apply.)
A. Buffalo hump
B. Purple striations
C. Moon face
D. Tremors
E. Obese extremities
Rationale: Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of
cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the
shoulders, is a common manifestation of Cushing's syndrome.
Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are
a common manifestation of Cushing's syndrome. This is due to the collection of body fat in these
areas.
Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients who
have this manifestation present with a round, red, full face.
Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome.
Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a
protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism.
reated on:05/13/2020 Page 1
, Detailed Answer Key
Med Surg Review exam
3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following
actions should the nurse take? (Select all that apply.)
A. Encourage fluid intake.
B. Monitor the puncture site for hematoma.
C. Insert a urinary catheter.
D. Elevate the client’s head of bed.
E. Apply a cervical collar to the client.
Rationale: Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to
replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a
headache.Monitor the puncture site for a hematoma is correct. The nurse should monitor and
report a hematoma at the insertion site because this can indicate bleeding.Insert a urinary
catheter is incorrect. There is no indication for a urinary catheter insertion.Elevate the client’s
head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the risk
for a headache.Apply a cervical collar to the client is incorrect. There is no indication for a
cervical collar for this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine
preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all
that apply.)
A. Decreasing anxiety
B. Controlling emesis
C. Relaxing skeletal muscles
D. Preventing surgical site infections
E. Reducing the amount of narcotics needed for pain relief
Rationale: Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective
antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with
moderate anxiety.Controlling emesis is correct. The nurse should include that hydroxyzine is an
effective antiemetic and is used to control nausea and vomiting in pre- and postoperative
clients.Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines,
such as diazepam (Valium), are used to produce skeletal muscle relaxation.Preventing surgical
site infections is incorrect. The nurse should instruct the client that antibiotics administered prior
to surgery are used to diminish the risk of surgical site infections; hydroxyzine, an antiemetic,
does not have any effect on bacteria.Reducing the amount of narcotics needed for pain relief is
correct. Hydroxyzine increases the effects of narcotic pain medications. The nurse should
instruct the client that when it is used for surgical clients, narcotic requirements may be
significantly reduced.
reated on:05/13/2020 Page 2
, Detailed Answer Key
Med Surg Review exam
5. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching
has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that
apply.)
A. Polyuria
B. Blurry vision
C. Tachycardia
D. Polydipsia
F. Sweating
Rationale: Polyuria is incorrect. Hyperglycemia causes polyuria.Blurry vision is correct. Manifestations of
hypoglycemia include blurry vision, tremors, anxiety, irritability, headache, and
hypotension.Tachycardia is correct. Manifestations of hypoglycemia include tachycardia,
tremors, anxiety, irritability, headache, and hypotension.Polydipsia is incorrect. Hyperglycemia
causes polydipsia.Sweating is correct. Manifestations of hypoglycemia include sweating,
tremors, anxiety, irritability, headache, and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the
nurse expect? (Select all that apply.)
A. Edema
B. Erythema
C. Tophi
D. Tight skin
E. Symmetrical joint pain
Rationale: Edema is correct. Swelling over the affected joints is a classic manifestation of gout.Erythema is
correct. Redness over the affected joints is a classic manifestation of gout.Tophi is correct.
Tophi are a classic manifestation of gout. They are nodules that form in subcutaneous tissue
due to the accumulation of urate crystals.Tight skin is correct. Tight skin over the affected joints
is a classic manifestation of gout.Symmetrical joint pain is incorrect. Symmetrical joint pain is a
manifestation of rheumatoid arthritis, not gout.
7. A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse
expect to perform? (Select all that apply.)
A. Assess blood glucose level
B. Assess for neck vein distention
C. Monitor for an irregular heart rate
reated on:05/13/2020 Page 3
, Detailed Answer Key
Med Surg Review exam
D. Monitor for postural hypotension
E. Weigh the client daily
Rationale: Cushing's syndrome affects blood glucose levels by causing increased release of glucose from
the liver and decreased sensitivity of insulin receptors. This can result in elevated blood glucose
levels.
8. A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a
nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care?
(Select all that apply.)
A. Perform leg exercises every 2 hr.
B. Encourage hourly use of an incentive spirometer while awake.
C. Document the color, consistency, and amount of nasogastric drainage.
D. Irrigate the nasogastric tube every 4 to 8 hr.
E. Maintain bed rest for 48 hr following surgery.
Rationale: Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg
exercises, independently or with assistance, to prevent skin breakdown.
Encourage hourly use of an incentive spirometer while awake is correct. Postoperative clients
should be encouraged to use the incentive spirometer ten times each hour while awake to
prevent atelectasis.
Document the color, consistency, and amount of nasogastric drainage is correct. Documenting
the color, consistency, and amount of nasogastric drainage is appropriate to include in the
client's plan of care.
Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery, the NG
tube should not be moved or irrigated unless prescribed by the provider.
Maintain bed rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery
should not be included in the plan of care. Early ambulation prevents distention and improves
intestinal mobility.
9. A nurse is assisting with discharge teaching for a client who is postoperative following a laryngectomy. Which of
the following instructions should the nurse include in the teaching? (Select all that apply.)
A. To aid in swallowing food, tip the chin before swallowing.
B. Avoid using liquid supplements.
C. Include warm foods in your diet because they are easier to swallow.
D. Swallow twice after each bite.
reated on:05/13/2020 Page 4
Answers | Latest Update
Detailed Answer Key
Med Surg Review exam
1. A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse
expect? (Select all that apply.)
A. Dyspnea
B. Barrel chest
C. Clubbing of the fingers
D. Shallow respirations
E. Bradycardia
Rationale: Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate
oxygen exchange in the lungs.Barrel chest is correct. The lungs of clients who have emphysema
lose their elasticity, and the diaphragm becomes permanently flattened by overdistention of the
lungs. The muscles of the rib cage also become rigid, and the ribs flare outward. This produces
the barrel chest typical of emphysema clients.Clubbing of the fingers is correct. Air is trapped in
the lungs due to their lack of elasticity, which decreases oxygenation. Clubbing results from
these chronic low blood-oxygen levels.Shallow respirations is correct. Clients who have
emphysema lose lung elasticity; consequently, respirations become increasingly shallow and
more rapid.Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate
for less oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the
nurse expect to observe? (Select all that apply.)
A. Buffalo hump
B. Purple striations
C. Moon face
D. Tremors
E. Obese extremities
Rationale: Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of
cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the
shoulders, is a common manifestation of Cushing's syndrome.
Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are
a common manifestation of Cushing's syndrome. This is due to the collection of body fat in these
areas.
Moon face is correct. Moon face is a common manifestation of Cushing's syndrome. Clients who
have this manifestation present with a round, red, full face.
Tremors is incorrect. Tremors are not a common finding of Cushing's syndrome.
Obese extremities is incorrect. Clients who have Cushing's syndrome have truncal obesity, a
protuberant abdomen, with thin extremities, which is due to an alteration in protein metabolism.
reated on:05/13/2020 Page 1
, Detailed Answer Key
Med Surg Review exam
3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following
actions should the nurse take? (Select all that apply.)
A. Encourage fluid intake.
B. Monitor the puncture site for hematoma.
C. Insert a urinary catheter.
D. Elevate the client’s head of bed.
E. Apply a cervical collar to the client.
Rationale: Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to
replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a
headache.Monitor the puncture site for a hematoma is correct. The nurse should monitor and
report a hematoma at the insertion site because this can indicate bleeding.Insert a urinary
catheter is incorrect. There is no indication for a urinary catheter insertion.Elevate the client’s
head of bed is incorrect. The client should remain flat in bed for 1 hr or more to reduce the risk
for a headache.Apply a cervical collar to the client is incorrect. There is no indication for a
cervical collar for this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine
preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all
that apply.)
A. Decreasing anxiety
B. Controlling emesis
C. Relaxing skeletal muscles
D. Preventing surgical site infections
E. Reducing the amount of narcotics needed for pain relief
Rationale: Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective
antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with
moderate anxiety.Controlling emesis is correct. The nurse should include that hydroxyzine is an
effective antiemetic and is used to control nausea and vomiting in pre- and postoperative
clients.Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines,
such as diazepam (Valium), are used to produce skeletal muscle relaxation.Preventing surgical
site infections is incorrect. The nurse should instruct the client that antibiotics administered prior
to surgery are used to diminish the risk of surgical site infections; hydroxyzine, an antiemetic,
does not have any effect on bacteria.Reducing the amount of narcotics needed for pain relief is
correct. Hydroxyzine increases the effects of narcotic pain medications. The nurse should
instruct the client that when it is used for surgical clients, narcotic requirements may be
significantly reduced.
reated on:05/13/2020 Page 2
, Detailed Answer Key
Med Surg Review exam
5. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching
has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that
apply.)
A. Polyuria
B. Blurry vision
C. Tachycardia
D. Polydipsia
F. Sweating
Rationale: Polyuria is incorrect. Hyperglycemia causes polyuria.Blurry vision is correct. Manifestations of
hypoglycemia include blurry vision, tremors, anxiety, irritability, headache, and
hypotension.Tachycardia is correct. Manifestations of hypoglycemia include tachycardia,
tremors, anxiety, irritability, headache, and hypotension.Polydipsia is incorrect. Hyperglycemia
causes polydipsia.Sweating is correct. Manifestations of hypoglycemia include sweating,
tremors, anxiety, irritability, headache, and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the
nurse expect? (Select all that apply.)
A. Edema
B. Erythema
C. Tophi
D. Tight skin
E. Symmetrical joint pain
Rationale: Edema is correct. Swelling over the affected joints is a classic manifestation of gout.Erythema is
correct. Redness over the affected joints is a classic manifestation of gout.Tophi is correct.
Tophi are a classic manifestation of gout. They are nodules that form in subcutaneous tissue
due to the accumulation of urate crystals.Tight skin is correct. Tight skin over the affected joints
is a classic manifestation of gout.Symmetrical joint pain is incorrect. Symmetrical joint pain is a
manifestation of rheumatoid arthritis, not gout.
7. A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse
expect to perform? (Select all that apply.)
A. Assess blood glucose level
B. Assess for neck vein distention
C. Monitor for an irregular heart rate
reated on:05/13/2020 Page 3
, Detailed Answer Key
Med Surg Review exam
D. Monitor for postural hypotension
E. Weigh the client daily
Rationale: Cushing's syndrome affects blood glucose levels by causing increased release of glucose from
the liver and decreased sensitivity of insulin receptors. This can result in elevated blood glucose
levels.
8. A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a
nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care?
(Select all that apply.)
A. Perform leg exercises every 2 hr.
B. Encourage hourly use of an incentive spirometer while awake.
C. Document the color, consistency, and amount of nasogastric drainage.
D. Irrigate the nasogastric tube every 4 to 8 hr.
E. Maintain bed rest for 48 hr following surgery.
Rationale: Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg
exercises, independently or with assistance, to prevent skin breakdown.
Encourage hourly use of an incentive spirometer while awake is correct. Postoperative clients
should be encouraged to use the incentive spirometer ten times each hour while awake to
prevent atelectasis.
Document the color, consistency, and amount of nasogastric drainage is correct. Documenting
the color, consistency, and amount of nasogastric drainage is appropriate to include in the
client's plan of care.
Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery, the NG
tube should not be moved or irrigated unless prescribed by the provider.
Maintain bed rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery
should not be included in the plan of care. Early ambulation prevents distention and improves
intestinal mobility.
9. A nurse is assisting with discharge teaching for a client who is postoperative following a laryngectomy. Which of
the following instructions should the nurse include in the teaching? (Select all that apply.)
A. To aid in swallowing food, tip the chin before swallowing.
B. Avoid using liquid supplements.
C. Include warm foods in your diet because they are easier to swallow.
D. Swallow twice after each bite.
reated on:05/13/2020 Page 4
