Test Bank RN Adult Medical Surgical Exam 1
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A nurse is assessing the chest tube drainage system of a postoperative client who has
undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody
drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour
after the initial assessment, the nurse notes that the bubbling in the water seal chamber is
now constant, and the client appears dyspneic. On the basis of these findings, the nurse
should first assess:
A. The client's vital signs
B. The amount of drainage
C. The client's lung sounds
D. The chest tube connections
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, RN Adult Medical Surgical Exam
D. The chest tube connections
Rationale: The client's dyspnea is most likely related to an air leak caused by a loose
connection in the chest tube system. Checking the chest tube connections should be the
initial action because correcting an air leak can quickly resolve the client's symptoms. If a leak
is found and corrected, the dyspnea should improve.
Upon arrival of a client transferred to the surgical unit, what should the nurse plan to do first?
A. Assess the patency of the airway
B. Check tubes and drains for patency
C. Check the dressing for bleeding
D. Assess the vital signs to compare them with preoperative measurements
A. Assess the patency of the airway
Rationale: The initial action for the nurse upon the arrival of a client to the surgical unit is to
assess the patency of the airway. This step takes priority to ensure that the client has a clear
airway for adequate breathing.
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client
indicates a need for additional preparation for the test?
A. I didn't shampoo my hair.
B. I ate breakfast this morning.
C. I didn't take my anticonvulsant today.
D. It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't.
A. I didn't shampoo my hair.
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, RN Adult Medical Surgical Exam
Rationale: For an EEG, it is essential that the client's hair is clean, without any products like
hairspray or gel, to ensure good electrode contact with the scalp.
A healthcare professional has a prescription to collect a 24-hour urine specimen from a client.
Which of the following measures should the healthcare professional take during this
procedure?
A. Keeping the specimen chilled
B. Saving the first urine specimen collected at the start time
C. Discarding the last voided specimen at the end of the collection time
D. Asking the client to void, discarding the specimen, and noting the start time
D. Asking the client to void, discarding the specimen, and noting the start time
Rationale: The correct answer is asking the client to void, discarding the specimen, and noting
the start time. During a 24-hour urine collection, the first voided urine is discarded to ensure
the test starts with an empty bladder.
What should the nurse do before an echocardiogram for a client who has had a myocardial
infarction?
A. Ensuring no food or drink for 4 hours before the procedure
B. Obtaining informed consent from the client
C. Assessing for any history of iodine or shellfish allergies
D. Informing the client about the painless nature and duration of the procedure
D. Informing the client about the painless nature and duration of the procedure
Rationale: The correct answer is to inform the client that the echocardiogram is a painless
procedure that usually takes 30 to 60 minutes to complete. Echocardiography is a
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noninvasive, risk-free, and pain-free test that uses ultrasound to evaluate the heart's structure
and motion.
After an endotracheal tube is placed in a client who experienced sudden onset of respiratory
distress, what should the nurse do?
A. Secure the tube in place with tape
B. Order a chest x-ray for the client
C. Document the depth of tube insertion
D. Auscultate both lungs for breath sounds
D. Auscultate both lungs for breath sounds
Rationale: After endotracheal tube insertion, the nurse should auscultate both lungs for the
presence of breath sounds. This step helps confirm proper tube placement and adequate
ventilation. Auscultation of breath sounds is crucial to ensure that the tube is correctly
positioned in the trachea and not in the esophagus.
A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago.
With which assessment finding is the nurse most concerned?
A. Oxygen saturation of 97%
B. Equal breath sounds in both lungs
C. Absence of cough and gag reflexes
D. Respiratory rate of 20 breaths/min
C. Absence of cough and gag reflexes
Rationale: The absence of cough and gag reflexes is the most concerning finding for the
nurse because it indicates a lack of protective airway reflexes, putting the client at risk of
aspiration.
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