Medical Surgical Nursing Test Bank Questions and Answers A+
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which
of the following instructions should the nurse include? - ANSWER-Flex the foot every hour
when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce the risk for
thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion? - ANSWER-Bubbling in
the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial
fibrillation. Which of the following values should the nurse identify as a desired outcome for this
therapy? - ANSWER-INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction
(MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the
medication must be monitored to ensure the anticoagulation is within the therapeutic range and
prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of
anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who
has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the
greater trochanter of his left hip. Which of the following instructions should the nurse include in
the teaching? - ANSWER-Change position every hour
,Rationale: Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse
should also instruct the client to limit the angle of the hips when in a lateral position to no more
than 30°. This positioning prevents direct pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of the following
findings is the nurse's priority to report to the provider? - ANSWER-Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding to report to the provider is restlessness, which can be an indication the
client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid
removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other
manifestations include nausea, vomiting, fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The
client is unable to void on the bedpan. Which of the following actions should the nurse take first?
- ANSWER-Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing process is to assess the client.
Scanning the bladder with a portable ultrasound device will determine the amount of urine in the
bladder
A nurse is planning a health promotional presentation for a group of African American clients at
a community center. Which of the following disorders presents the greatest risk to this group of
clients? - ANSWER-Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse should
determine that the disorder with the greatest risk for this group of clients is hypertension. The
prevalence of hypertension is highest among African American clients, followed by Caucasian
clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to
the nurse that the client's condition is improving? - ANSWER-Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's status.
, A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago. Which of
the following findings should the nurse report to the provider immediately? - ANSWER-Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction
caused by edema or laryngeal spasms. The nurse should report the finding immediately and
implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the
following findings should the nurse report to the provider? - ANSWER-The client reports back
pain
Rationale: The nurse should notify the provider if the client reports back pain, which can indicate
that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of transmission
precautions should the nurse initiate? - ANSWER-Airborne
Rationale: Airborne precautions are required for clients who have infections due to micro-
organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis,
measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care? - ANSWER-
Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the client's room in case
of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the
following findings is the nurse's priority? - ANSWER-Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is an elevated temperature. An elevated temperature is a
manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which
of the following instructions should the nurse include? - ANSWER-Flex the foot every hour
when awake.
Rationale: The nurse should instruct the client to flex the foot every hour to reduce the risk for
thromboembolism and promote venous return.
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system.
Which of the following findings is an indication of lung re-expansion? - ANSWER-Bubbling in
the water seal chamber has ceased.
Rationale: Bubbling in the water seal chamber ceases when the lung re-expands.
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial
fibrillation. Which of the following values should the nurse identify as a desired outcome for this
therapy? - ANSWER-INR 2.5
Rationale: Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction
(MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the
medication must be monitored to ensure the anticoagulation is within the therapeutic range and
prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of
anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who
has atrial fibrillation.
A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the
greater trochanter of his left hip. Which of the following instructions should the nurse include in
the teaching? - ANSWER-Change position every hour
,Rationale: Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse
should also instruct the client to limit the angle of the hips when in a lateral position to no more
than 30°. This positioning prevents direct pressure on the trochanter.
A nurse is assessing a client following the completion of hemodialysis. Which of the following
findings is the nurse's priority to report to the provider? - ANSWER-Restlessness
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding to report to the provider is restlessness, which can be an indication the
client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid
removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other
manifestations include nausea, vomiting, fatigue, and headache.
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The
client is unable to void on the bedpan. Which of the following actions should the nurse take first?
- ANSWER-Scan the bladder with a portable ultrasound.
Rationale: The first action the nurse should take using the nursing process is to assess the client.
Scanning the bladder with a portable ultrasound device will determine the amount of urine in the
bladder
A nurse is planning a health promotional presentation for a group of African American clients at
a community center. Which of the following disorders presents the greatest risk to this group of
clients? - ANSWER-Hypertension
Rationale: When using the safety/risk reduction approach to client care, the nurse should
determine that the disorder with the greatest risk for this group of clients is hypertension. The
prevalence of hypertension is highest among African American clients, followed by Caucasian
clients, and then Hispanic clients.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to
the nurse that the client's condition is improving? - ANSWER-Glucose 272 mg/dL
Rationale: A glucose reading less than 300 mg/dL indicates improvement in the client's status.
, A nurse is caring for a client following extubation of an endotracheal tube 10 min. ago. Which of
the following findings should the nurse report to the provider immediately? - ANSWER-Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction
caused by edema or laryngeal spasms. The nurse should report the finding immediately and
implement an intervention.
A nurse is caring for a client who had a nephrostomy tube inserted 112 hr ago. Which of the
following findings should the nurse report to the provider? - ANSWER-The client reports back
pain
Rationale: The nurse should notify the provider if the client reports back pain, which can indicate
that the nephrostomy tube is dislodged or clogged.
A nurse is admitting a client who has active TB. Which of the following types of transmission
precautions should the nurse initiate? - ANSWER-Airborne
Rationale: Airborne precautions are required for clients who have infections due to micro-
organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis,
measles, varicella, and disseminated varicella zoster.
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer.
Which of the following interventions should the nurse include in the plan of care? - ANSWER-
Keep a lead-lined container in the client's room
Rationale: The nurse should keep a lead-lined container and forceps in the client's room in case
of accidental dislodgement of the implant.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the
following findings is the nurse's priority? - ANSWER-Temperature 38.9° C (102° F)
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is an elevated temperature. An elevated temperature is a
manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in
