UPDATE) MEDICAL SURGICAL NURSING II|
REVIEW WITH QUESTIONS AND VERIFIED
Quiz_________________?
Answer✅
Quiz_________________?
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy.
Which assessment finding requires an immediate intervention by the nurse? -
Answer✅
The client makes noises when he breathes.
-Explanation: Noisy respirations are a sign of a narrowed airway that could be caused by
postoperative bleeding or edema. This finding requires an immediate intervention. Reports
of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are
expected findings. Feeling sleepy from the anesthesia is an expected outcome
Quiz_________________?
A 62-year-old female client being treated for hypertension did not take her daily BP
medication over the weekend because she was out of medication and the pharmacy was
closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82.
Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health
care provider. What is the most appropriate thing for this nurse to advise this client?
1
, Not to worry and to take double the dose of BP medication
To call her health care provider
To take the medication that she missed and retake her BP
To take the recommended daily dose of medication and call the health care provider if the
average of her HBPM readings increase/decrease by 10, or if she has any other concerns. -
Answer✅
To take the recommended daily dose of medication and call the health care provider if the
average of her HBPM readings increase/decrease by 10, or if she has any other concerns.
-Explanation: HBPM readings are the ideal method for monitoring response to treatment for
high BP. This client's average BP after not taking her medication is 138/87 and is not 10
more than what her HBPM reading has been. Clients should be taught when performing
HBPM that they should call the health care provider if the averages of HBPM readings
increase/decrease by 10, or if she has any concerns. The client should not be told to take
double the dose of medication or to take the doses she missed; this is unsafe advice without
consulting a health care provider
Quiz_________________?
A child 4 years of age has a mother who is employed and works from home. To accomplish
her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon
this information, what nursing diagnosis would be applicable to this family? -
Answer✅
Impaired Parenting associated with failure to provide stimuli for growth
-Explanation: Based upon lack of stimuli (sensory deprivation), an appropriate nursing
diagnosis is Impaired Parenting associated with failure to provide stimuli for growth. There
is no information that states the child has impaired senses, sensory overload, or impaired
skin integrity.
Quiz_________________?
A client at a health care facility has been diagnosed with polyuria. Which question should
the nurse ask the client to determine the cause? -
Answer✅
"Have you ever had an elevated blood sugar?"
2
, -Explanation: Polyuria means greater than normal urinary elimination. Untreated diabetes
insipidus and hyperglycemia can greatly increase urine output. Ingestion of diuretics, caffeine,
and alcohol also results in polyuria. Kidney disease is associated with a lack of urine output
Quiz_________________?
A client comes to the emergency department reporting becoming very ill after consuming
shrimp and lobster. How will the nurse document this condition?
contagious disease
infectious disease
communicable disease
noncommunicable disease -
Answer✅
noncommunicable disease
-Explanation: A noncommunicable disease is caused by food or environmental toxin.
Infectious disease, communicable disease, and contagious disease do not describe an illness
that is contracted after eating food
Quiz_________________?
A client has been diagnosed with anorexia nervosa. Which intervention(s) will the nurse
employ during care? Select all that apply. -
Answer✅
-Set a weight goal with the client.
-Assess for depression.
-Supervise client during meals and for 1 hour after.
-Encourage liquid intake over solid foods.
-Monitor for signs of food hoarding or disposing of food.
-Provide small meals and snacks appropriately.
-Explanation: Anorexia nervosa is an emotional disorder characterized by an obsessive
desire to lose weight by refusing to eat. The nurse will assess nutritional status and set a
weight goal with the client to determine if client is under- or overweight and nutritional
needs. Clients with eating disorders often have accompanying depression with suicidal
3
, thoughts and should be monitored for safety. The nurse will supervise the client during
meals and for at least 1 hour after eating to determine client's eating habits and prevent
purging after meals. The nurse will encourage liquid intake over solid foods to eliminate the
need to choose foods and provide hydration. Liquid intake is more easily digested. The
nurse will provide small meals and snacks appropriately to prevent bloating and discomfort
in clients following starvation and will encourage eating more appropriate portions.
Quiz_________________?
A client has undergone foot surgery and will use crutches in the short term. Which teaching
point should the nurse provide to the client? -
Answer✅
"Your elbows will be slightly bent when you are using your crutches."
-Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees
and the hands, not the armpits, should support the client's weight. Supervision of the client
learning to use crutches should not be performed by unlicensed assistive personnel (UAP).
The client should stop ambulating and sit down, if fatigued
Quiz_________________?
A client having a bowel surgery asks why being NPO after surgery is necessary. Which
statement by the nurse best describes the reason? -
Answer✅
To rest the gastrointestinal tract and promote healing
-Explanation: Withholding food may be indicated in the following situations: to rest the
gastrointestinal tract to promote healing, clear the gastrointestinal tract of contents before
surgery or diagnostic procedures, prevent aspiration during surgery or in high-risk clients,
give normal intestinal motility time to return, treat severe vomiting or diarrhea, and to treat
medical problems, such as bowel obstruction or acute inflammation of the gastrointestinal
tract. Withholding food does not cause gas to accumulate or increase the amount of mucus
in the bowel
Quiz_________________?
A client is admitted to the emergency department. He is bleeding from a cut on his head
and his skin color is pale, with diaphoresis. What nursing action should be performed first?
4
REVIEW WITH QUESTIONS AND VERIFIED
Quiz_________________?
Answer✅
Quiz_________________?
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy.
Which assessment finding requires an immediate intervention by the nurse? -
Answer✅
The client makes noises when he breathes.
-Explanation: Noisy respirations are a sign of a narrowed airway that could be caused by
postoperative bleeding or edema. This finding requires an immediate intervention. Reports
of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are
expected findings. Feeling sleepy from the anesthesia is an expected outcome
Quiz_________________?
A 62-year-old female client being treated for hypertension did not take her daily BP
medication over the weekend because she was out of medication and the pharmacy was
closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82.
Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health
care provider. What is the most appropriate thing for this nurse to advise this client?
1
, Not to worry and to take double the dose of BP medication
To call her health care provider
To take the medication that she missed and retake her BP
To take the recommended daily dose of medication and call the health care provider if the
average of her HBPM readings increase/decrease by 10, or if she has any other concerns. -
Answer✅
To take the recommended daily dose of medication and call the health care provider if the
average of her HBPM readings increase/decrease by 10, or if she has any other concerns.
-Explanation: HBPM readings are the ideal method for monitoring response to treatment for
high BP. This client's average BP after not taking her medication is 138/87 and is not 10
more than what her HBPM reading has been. Clients should be taught when performing
HBPM that they should call the health care provider if the averages of HBPM readings
increase/decrease by 10, or if she has any concerns. The client should not be told to take
double the dose of medication or to take the doses she missed; this is unsafe advice without
consulting a health care provider
Quiz_________________?
A child 4 years of age has a mother who is employed and works from home. To accomplish
her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon
this information, what nursing diagnosis would be applicable to this family? -
Answer✅
Impaired Parenting associated with failure to provide stimuli for growth
-Explanation: Based upon lack of stimuli (sensory deprivation), an appropriate nursing
diagnosis is Impaired Parenting associated with failure to provide stimuli for growth. There
is no information that states the child has impaired senses, sensory overload, or impaired
skin integrity.
Quiz_________________?
A client at a health care facility has been diagnosed with polyuria. Which question should
the nurse ask the client to determine the cause? -
Answer✅
"Have you ever had an elevated blood sugar?"
2
, -Explanation: Polyuria means greater than normal urinary elimination. Untreated diabetes
insipidus and hyperglycemia can greatly increase urine output. Ingestion of diuretics, caffeine,
and alcohol also results in polyuria. Kidney disease is associated with a lack of urine output
Quiz_________________?
A client comes to the emergency department reporting becoming very ill after consuming
shrimp and lobster. How will the nurse document this condition?
contagious disease
infectious disease
communicable disease
noncommunicable disease -
Answer✅
noncommunicable disease
-Explanation: A noncommunicable disease is caused by food or environmental toxin.
Infectious disease, communicable disease, and contagious disease do not describe an illness
that is contracted after eating food
Quiz_________________?
A client has been diagnosed with anorexia nervosa. Which intervention(s) will the nurse
employ during care? Select all that apply. -
Answer✅
-Set a weight goal with the client.
-Assess for depression.
-Supervise client during meals and for 1 hour after.
-Encourage liquid intake over solid foods.
-Monitor for signs of food hoarding or disposing of food.
-Provide small meals and snacks appropriately.
-Explanation: Anorexia nervosa is an emotional disorder characterized by an obsessive
desire to lose weight by refusing to eat. The nurse will assess nutritional status and set a
weight goal with the client to determine if client is under- or overweight and nutritional
needs. Clients with eating disorders often have accompanying depression with suicidal
3
, thoughts and should be monitored for safety. The nurse will supervise the client during
meals and for at least 1 hour after eating to determine client's eating habits and prevent
purging after meals. The nurse will encourage liquid intake over solid foods to eliminate the
need to choose foods and provide hydration. Liquid intake is more easily digested. The
nurse will provide small meals and snacks appropriately to prevent bloating and discomfort
in clients following starvation and will encourage eating more appropriate portions.
Quiz_________________?
A client has undergone foot surgery and will use crutches in the short term. Which teaching
point should the nurse provide to the client? -
Answer✅
"Your elbows will be slightly bent when you are using your crutches."
-Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees
and the hands, not the armpits, should support the client's weight. Supervision of the client
learning to use crutches should not be performed by unlicensed assistive personnel (UAP).
The client should stop ambulating and sit down, if fatigued
Quiz_________________?
A client having a bowel surgery asks why being NPO after surgery is necessary. Which
statement by the nurse best describes the reason? -
Answer✅
To rest the gastrointestinal tract and promote healing
-Explanation: Withholding food may be indicated in the following situations: to rest the
gastrointestinal tract to promote healing, clear the gastrointestinal tract of contents before
surgery or diagnostic procedures, prevent aspiration during surgery or in high-risk clients,
give normal intestinal motility time to return, treat severe vomiting or diarrhea, and to treat
medical problems, such as bowel obstruction or acute inflammation of the gastrointestinal
tract. Withholding food does not cause gas to accumulate or increase the amount of mucus
in the bowel
Quiz_________________?
A client is admitted to the emergency department. He is bleeding from a cut on his head
and his skin color is pale, with diaphoresis. What nursing action should be performed first?
4
