MDC IV EXAM 1 QUESTIONS AND
ANSWERS22
5. A nurse is assessing a client in postoperative recovery. The client complains of the following
symptoms. Which of the following is abnormal and should be reported immediately?
a. Emesis that is red
b. Complaint of feeling cold
c. Nausea
d. Complaint of pain - ANSWERS-a. Emesis that is red
6. A client's neurological status deteriorates over hours, and a craniotomy is performed to
evacuate a hematoma. Which nursing intervention is indicated to help decrease the threat of
increased intracranial pressure?
a. Elevate the head of the bed 30 degrees
b. Cluster nursing interventions to provide uninterrupted periods of rest
c. Teach the client to cough and deep breathe to prevent the necessity for suctioning
d. Teach the client to hold his breath and bear down while repositioning in bed. - ANSWERS-a.
Elevate the head of the bed 30 degrees
7. A client presents to the emergency room with complaints of bilateral lower extremity loss of
sensation that started in the feet but has now progressed to the knees and hips. The nurse
interprets these symptoms to indicate an immediate workup for which of the following
diseases?
a. Myasthenia gravis
b. Simple, partial seizure
c. Guillain-Barre Syndrome
d. Cerebrovascular accident - ANSWERS-c. Guillain-Barre Syndrome
,8. The charge nurse is obtaining the client's signature on a surgical consent form. The client
states, I didn't really understand what my surgeon explained, but I trust him completely, which
response by the charge nurse is correct?
a. I need to contact your surgeon so your questions can be answered
b. I can answer any questions that you might have regarding your surgery.
c. As long as you are comfortable, then you may sign the consent form.
d. Maybe you should call your surgeon to be sure it is okay to sign the consent. - ANSWERS-a. I
need to contact your surgeon so your questions can be answered
9. A client has a head injury and is presenting with signs and symptoms of increased intracranial
pressure. Which nursing intervention would be helpful in reducing this pressure?
a. Place the neck in a neutral position to promote venous drainage
b. Suction hourly to stimulate the cough reflex
c. Add extra blankets to keep the client warm.
d. Turn the client frequently to prevent skin impairment - ANSWERS-a. Place the neck in a
neutral position to promote venous drainage
10. A client has recently suffered a stroke with left-sided weakness. The nurse assesses for
dysphagia, especially with thin liquids. Which nursing intervention is most helpful in assisting
this patient to swallow safely?
a. The client should avoid all liquids.
b. Instructing to tuck the chin when swallowing
c. Give sips of water with each bite
d. Turn head to the left. - ANSWERS-b. Instructing to tuck the chin when swallowing
, 11. A client has a comminuted fracture of T6-T7, resulting in paraplegia. The nurse educates the
client on preventing autonomic dysreflexia. Which of the following is the priority intervention in
this medical emergency?
a. Scheduled bladder and bowel training
b. Choosing foods to prevent nausea
c. Avoiding food allergies
d. Preventing electrolyte imbalances - ANSWERS-a. Scheduled bladder and bowel training
12. The nurse develops a care plan for a client recovering from surgery. What nursing
interventions will the nurse include to minimize the effects of venous stasis?
a. Pillows under the knee in a position of comfort
b. Sitting with feet flat on the floor
c. Early ambulation
d. Gentle leg massage - ANSWERS-c. Early ambulation
13. The client has an order for 0.45% sodium chloride 1 liter to infuse over 15 hours. At what
rate in mL/hr would the nurse set the infusion pump? Round to the nearest whole number, do
not use a trailing zero. - ANSWERS-67 ml/hr
14. A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the
drug is effective when it causes which action?
a. Induces sleep
b. Stimulates the client's appetite
c. Relieves muscular spasticity
d. Reduces the urine bacterial count - ANSWERS-c. Relieves muscular spasticity
15. Sudden chest pain combined with dyspnea, cyanosis, and tachycardia are symptoms
associated with which of the following complications of surgery?
ANSWERS22
5. A nurse is assessing a client in postoperative recovery. The client complains of the following
symptoms. Which of the following is abnormal and should be reported immediately?
a. Emesis that is red
b. Complaint of feeling cold
c. Nausea
d. Complaint of pain - ANSWERS-a. Emesis that is red
6. A client's neurological status deteriorates over hours, and a craniotomy is performed to
evacuate a hematoma. Which nursing intervention is indicated to help decrease the threat of
increased intracranial pressure?
a. Elevate the head of the bed 30 degrees
b. Cluster nursing interventions to provide uninterrupted periods of rest
c. Teach the client to cough and deep breathe to prevent the necessity for suctioning
d. Teach the client to hold his breath and bear down while repositioning in bed. - ANSWERS-a.
Elevate the head of the bed 30 degrees
7. A client presents to the emergency room with complaints of bilateral lower extremity loss of
sensation that started in the feet but has now progressed to the knees and hips. The nurse
interprets these symptoms to indicate an immediate workup for which of the following
diseases?
a. Myasthenia gravis
b. Simple, partial seizure
c. Guillain-Barre Syndrome
d. Cerebrovascular accident - ANSWERS-c. Guillain-Barre Syndrome
,8. The charge nurse is obtaining the client's signature on a surgical consent form. The client
states, I didn't really understand what my surgeon explained, but I trust him completely, which
response by the charge nurse is correct?
a. I need to contact your surgeon so your questions can be answered
b. I can answer any questions that you might have regarding your surgery.
c. As long as you are comfortable, then you may sign the consent form.
d. Maybe you should call your surgeon to be sure it is okay to sign the consent. - ANSWERS-a. I
need to contact your surgeon so your questions can be answered
9. A client has a head injury and is presenting with signs and symptoms of increased intracranial
pressure. Which nursing intervention would be helpful in reducing this pressure?
a. Place the neck in a neutral position to promote venous drainage
b. Suction hourly to stimulate the cough reflex
c. Add extra blankets to keep the client warm.
d. Turn the client frequently to prevent skin impairment - ANSWERS-a. Place the neck in a
neutral position to promote venous drainage
10. A client has recently suffered a stroke with left-sided weakness. The nurse assesses for
dysphagia, especially with thin liquids. Which nursing intervention is most helpful in assisting
this patient to swallow safely?
a. The client should avoid all liquids.
b. Instructing to tuck the chin when swallowing
c. Give sips of water with each bite
d. Turn head to the left. - ANSWERS-b. Instructing to tuck the chin when swallowing
, 11. A client has a comminuted fracture of T6-T7, resulting in paraplegia. The nurse educates the
client on preventing autonomic dysreflexia. Which of the following is the priority intervention in
this medical emergency?
a. Scheduled bladder and bowel training
b. Choosing foods to prevent nausea
c. Avoiding food allergies
d. Preventing electrolyte imbalances - ANSWERS-a. Scheduled bladder and bowel training
12. The nurse develops a care plan for a client recovering from surgery. What nursing
interventions will the nurse include to minimize the effects of venous stasis?
a. Pillows under the knee in a position of comfort
b. Sitting with feet flat on the floor
c. Early ambulation
d. Gentle leg massage - ANSWERS-c. Early ambulation
13. The client has an order for 0.45% sodium chloride 1 liter to infuse over 15 hours. At what
rate in mL/hr would the nurse set the infusion pump? Round to the nearest whole number, do
not use a trailing zero. - ANSWERS-67 ml/hr
14. A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the
drug is effective when it causes which action?
a. Induces sleep
b. Stimulates the client's appetite
c. Relieves muscular spasticity
d. Reduces the urine bacterial count - ANSWERS-c. Relieves muscular spasticity
15. Sudden chest pain combined with dyspnea, cyanosis, and tachycardia are symptoms
associated with which of the following complications of surgery?
