IGNATAVICIUS TEST BANK, MEDICAL-
SURGICAL NURSING, QUESTIONS WITH
CORRECT ANSWERS
A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which
w w w w w w w w w w w w w w w w w w
finding would the nurse report to the primary health care provider?
w w w w w w w w w w
A. Creatinine: 2.9 mg/dL
w w w
B. Hematocrit: 30%
w w
C. Sodium: 146 mEq/L
w w w
D. White blood cell count: 12,000 mm^3 - correct answer A. An elevated creatinine indicates kidney damage,
w w w w w w w w w w w w w w w w w
which occurs in SCD. The rest are expected findings in SCD.
w w w w w w w w w w
The nurse is assessing a client in sickle cell disease crisis. What PRIORITY client problem will the nurse expect?
w w w w w w w w w w w w w w w w w w
A. Infection
w
B. Pallor
w
C. Pain
w
D. Fatigue - correct answer C. The priority expected client problem for clients experiencing SCD crisis is pain,
w w w w w w w w w w w w w w w w w w
often concentrated in the legs, arms, and joints.
w w w w w w w
A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV.
w w w w w w w w w w w w w w w w w w w w
Which fluid choice is best?
w w w w
a. 0.45% normal saline
w w w
b. 0.9% normal saline
w w w
,c. Dextrose 50% (D50)
w w w
d. Lactated Ringer's solution - correct answer A. Because clients in sickle cell crisis are often dehydrated, the
w w w w w w w w w w w w w w w w w w
fluid of choice is a hypotonic solution such as 0.45% normal saline.
w w w w w w w w w w w
A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes
w w w w w w w w w w w w w w w w w
PRIORITY?
A. Administer oxygen
w w
B. Initiate pulse oximetry
w w w
C. Give pain medication
w w w
D. Start an IV line - correct answer A. All actions are appropriate, but remembering the ABCs, oxygen would
w w w w w w w w w w w w w w w w w w w
come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt
w w w w w w w w w w w w w w w w w w w w
the process. w
A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly
w w w w w w w w w w w w w w w w
after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests
w w w w w w w w w w w w w w w w w w w w
pain medication, what action by the nurse is best?
w w w w w w w w
A. Give the client pain medication if it is time for another dose.
w w w w w w w w w w w w
B. Instruct the client not to request pain medication too early.
w w w w w w w w w w
C. Request the primary health care provider leave a prescription for a placebo.
w w w w w w w w w w w w
D. Tell the - correct answer A. Clients with sickle cell crisis often have severe pain that is managed with up to 48
w w w w w w w w w w w w w w w w w w w w w w
hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If
w w w w w w w w w w w w w w w w w w w w w w w w
the client can receive another dose of medication, the nurse would provide it.
w w w w w w w w w w w w
The nurse is caring for a client experiencing sickle cell disease crisis. Which PRIORITY action would help
w w w w w w w w w w w w w w w w w
prevent infection. w
A. Administering prophylactic antibiotics.
w w w
B. Monitoring the client's temperature.
w w w w
C. Checking the client's white blood cell count
w w w w w w w
D. Performing frequent handwashing - correct answer D. Frequent and thorough handwashing is the most
w w w w w w w w w w w w w w w
important intervention that helps prevent infection. w w w w w
A nurse in a hematology clinic is working with four different clients who have polycythemia vera. Which client
w w w w w w w w w w w w w w w w w w
would the nurse assess first? w w w w
,A. Client with a blood pressure of 180/98 mm Hg
w w w w w w w w w
B. Client who reports shortness of breath
w w w w w w
C. Client who reports calf tenderness
w w w w w
D. Client with a swollen and painful left great toe - correct answer B. Clients with polycythemia vera often
w w w w w w w w w w w w w w w w w w w
have clotting abnormalities due to hyperviscous blood with sluggish flow. The client reporting shortness of
w w w w w w w w w w w w w w w
breath may have a pulmonary embolism and should be seen first.
w w w w w w w w w w
The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement
w w w w w w w w w w w w w w w w
by the client indicates UNDERSTANDING about those changes?
w w w w w w w
A. "I'll increase animal proteins like fish and meat."
w w w w w w w w
B. "I'll work on increasing my fats and carbohydrates."
w w w w w w w w
C. "I'll avoid eating green leafy vegetables."
w w w w w w
D. "I'll limit my intake of citrus fruits." - correct answer A. Clients who have pernicious anemia have a vitamin
w w w w w w w w w w w w w w w w w w w w
B12 deficiency and need to consume foods high in vitamin B12, such as animal and plant proteins, citrus
w w w w w w w w w w w w w w w w w w
fruits, green leafy vegetables, and dairy products.
w w w w w w
An assistive personnel (AP) is caring for a client with leukemia and asks why the client is still at risk for
w w w w w w w w w w w w w w w w w w w w w
infection when the white blood cell count (WBC) is high. What response by the nurse is correct?
w w w w w w w w w w w w w w w w
A. "If the WBCs are high, there already is an infection present."
w w w w w w w w w w w
B. "The client is in a blast crisis and has too many WBCs."
w w w w w w w w w w w w
C. "There must be a mistake; the WBCs should be very low."
w w w w w w w w w w w
D. "Those WBCs are abnormal and don't provide protection." - correct answer D. In leukemia, the WBCs are
w w w w w w w w w w w w w w w w w w
abnormal and do not provide protection to the client against infection. w w w w w w w w w w
The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the
w w w w w w w w w w w w w w w w w w w w w
PRIORITY?
A. Ask the client about pain.
w w w w w
B. Assess the client for infection.
w w w w w
C. Take a set of vital signs.
w w w w w w
D. Review today's lab results. - correct answer B. Neutropenic clients often do not have classic manifestations
w w w w w w w w w w w w w w w w
of infection, but infection is the most common cause of death in neutropenic clients. The nurse would
w w w w w w w w w w w w w w w w w w
definitely assess for infection. w w w
, A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope
w w w w w w w w w w w w w w w w w w w w w w
with the long recovery period, what action by the nurse is best?
w w w w w w w w w w w
A. Arrange a visitation schedule among family and friends.
w w w w w w w w
B. Explain that this process is difficult but must be endured.
w w w w w w w w w w
C. Help the client find things to hope for each day of recovery
w w w w w w w w w w w w
D. Provide plenty of diversionary activities for this time. - correct answer C. Providing hope is an essential
w w w w w w w w w w w w w w w w w w
nursing function during treatment for any disease process, but especially during the recovery period after
w w w w w w w w w w w w w w w
bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the
w w w w w w w w w w w w w w w w w w w w
recovery period and identify things to hope for during this time.
w w w w w w w w w w
A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?
w w w w w w w w w w w w w w w
A. "Because of immunosuppression, the donor cells take over."
w w w w w w w w
B. "It's like a transfusion reaction because no perfect match exists."
w w w w w w w w w w
C. "The patient's cells are fighting the donor cells for dominance."
w w w w w w w w w w
D. "The donor's cells are actually attacking the patient's cells." - correct answer D. Graft-versus-host disease is
w w w w w w w w w w w w w w w w
an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin
w w w w w w w w w w w w w w w w w
attacking them. w
The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best
w w w w w w w w w w w w w w w w w w w
indicates that an important outcome to manage this problem has been met?
w w w w w w w w w w w
A. Doing activities of daily living using rest periods.
w w w w w w w w
B. Helping plan a daily activity schedule
w w w w w w
C. Requesting a sleeping pill at night.
w w w w w w
D. Telling visitors to leave when fatigued. - correct answer A. Fatigue is a common problem for clients with
w w w w w w w w w w w w w w w w w w w
leukemia. This client is managing her own ADLs using rest periods, which indicates an understanding of
w w w w w w w w w w w w w w w w
fatigue and how to control it. w w w w w
A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a
w w w w w w w w w w w w w w w w w w w w w
PRIORITY?
A. Genetic testing
w w
B. Infection prevention
w w
SURGICAL NURSING, QUESTIONS WITH
CORRECT ANSWERS
A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which
w w w w w w w w w w w w w w w w w w
finding would the nurse report to the primary health care provider?
w w w w w w w w w w
A. Creatinine: 2.9 mg/dL
w w w
B. Hematocrit: 30%
w w
C. Sodium: 146 mEq/L
w w w
D. White blood cell count: 12,000 mm^3 - correct answer A. An elevated creatinine indicates kidney damage,
w w w w w w w w w w w w w w w w w
which occurs in SCD. The rest are expected findings in SCD.
w w w w w w w w w w
The nurse is assessing a client in sickle cell disease crisis. What PRIORITY client problem will the nurse expect?
w w w w w w w w w w w w w w w w w w
A. Infection
w
B. Pallor
w
C. Pain
w
D. Fatigue - correct answer C. The priority expected client problem for clients experiencing SCD crisis is pain,
w w w w w w w w w w w w w w w w w w
often concentrated in the legs, arms, and joints.
w w w w w w w
A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV.
w w w w w w w w w w w w w w w w w w w w
Which fluid choice is best?
w w w w
a. 0.45% normal saline
w w w
b. 0.9% normal saline
w w w
,c. Dextrose 50% (D50)
w w w
d. Lactated Ringer's solution - correct answer A. Because clients in sickle cell crisis are often dehydrated, the
w w w w w w w w w w w w w w w w w w
fluid of choice is a hypotonic solution such as 0.45% normal saline.
w w w w w w w w w w w
A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes
w w w w w w w w w w w w w w w w w
PRIORITY?
A. Administer oxygen
w w
B. Initiate pulse oximetry
w w w
C. Give pain medication
w w w
D. Start an IV line - correct answer A. All actions are appropriate, but remembering the ABCs, oxygen would
w w w w w w w w w w w w w w w w w w w
come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt
w w w w w w w w w w w w w w w w w w w w
the process. w
A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly
w w w w w w w w w w w w w w w w
after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests
w w w w w w w w w w w w w w w w w w w w
pain medication, what action by the nurse is best?
w w w w w w w w
A. Give the client pain medication if it is time for another dose.
w w w w w w w w w w w w
B. Instruct the client not to request pain medication too early.
w w w w w w w w w w
C. Request the primary health care provider leave a prescription for a placebo.
w w w w w w w w w w w w
D. Tell the - correct answer A. Clients with sickle cell crisis often have severe pain that is managed with up to 48
w w w w w w w w w w w w w w w w w w w w w w
hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If
w w w w w w w w w w w w w w w w w w w w w w w w
the client can receive another dose of medication, the nurse would provide it.
w w w w w w w w w w w w
The nurse is caring for a client experiencing sickle cell disease crisis. Which PRIORITY action would help
w w w w w w w w w w w w w w w w w
prevent infection. w
A. Administering prophylactic antibiotics.
w w w
B. Monitoring the client's temperature.
w w w w
C. Checking the client's white blood cell count
w w w w w w w
D. Performing frequent handwashing - correct answer D. Frequent and thorough handwashing is the most
w w w w w w w w w w w w w w w
important intervention that helps prevent infection. w w w w w
A nurse in a hematology clinic is working with four different clients who have polycythemia vera. Which client
w w w w w w w w w w w w w w w w w w
would the nurse assess first? w w w w
,A. Client with a blood pressure of 180/98 mm Hg
w w w w w w w w w
B. Client who reports shortness of breath
w w w w w w
C. Client who reports calf tenderness
w w w w w
D. Client with a swollen and painful left great toe - correct answer B. Clients with polycythemia vera often
w w w w w w w w w w w w w w w w w w w
have clotting abnormalities due to hyperviscous blood with sluggish flow. The client reporting shortness of
w w w w w w w w w w w w w w w
breath may have a pulmonary embolism and should be seen first.
w w w w w w w w w w
The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement
w w w w w w w w w w w w w w w w
by the client indicates UNDERSTANDING about those changes?
w w w w w w w
A. "I'll increase animal proteins like fish and meat."
w w w w w w w w
B. "I'll work on increasing my fats and carbohydrates."
w w w w w w w w
C. "I'll avoid eating green leafy vegetables."
w w w w w w
D. "I'll limit my intake of citrus fruits." - correct answer A. Clients who have pernicious anemia have a vitamin
w w w w w w w w w w w w w w w w w w w w
B12 deficiency and need to consume foods high in vitamin B12, such as animal and plant proteins, citrus
w w w w w w w w w w w w w w w w w w
fruits, green leafy vegetables, and dairy products.
w w w w w w
An assistive personnel (AP) is caring for a client with leukemia and asks why the client is still at risk for
w w w w w w w w w w w w w w w w w w w w w
infection when the white blood cell count (WBC) is high. What response by the nurse is correct?
w w w w w w w w w w w w w w w w
A. "If the WBCs are high, there already is an infection present."
w w w w w w w w w w w
B. "The client is in a blast crisis and has too many WBCs."
w w w w w w w w w w w w
C. "There must be a mistake; the WBCs should be very low."
w w w w w w w w w w w
D. "Those WBCs are abnormal and don't provide protection." - correct answer D. In leukemia, the WBCs are
w w w w w w w w w w w w w w w w w w
abnormal and do not provide protection to the client against infection. w w w w w w w w w w
The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the
w w w w w w w w w w w w w w w w w w w w w
PRIORITY?
A. Ask the client about pain.
w w w w w
B. Assess the client for infection.
w w w w w
C. Take a set of vital signs.
w w w w w w
D. Review today's lab results. - correct answer B. Neutropenic clients often do not have classic manifestations
w w w w w w w w w w w w w w w w
of infection, but infection is the most common cause of death in neutropenic clients. The nurse would
w w w w w w w w w w w w w w w w w w
definitely assess for infection. w w w
, A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope
w w w w w w w w w w w w w w w w w w w w w w
with the long recovery period, what action by the nurse is best?
w w w w w w w w w w w
A. Arrange a visitation schedule among family and friends.
w w w w w w w w
B. Explain that this process is difficult but must be endured.
w w w w w w w w w w
C. Help the client find things to hope for each day of recovery
w w w w w w w w w w w w
D. Provide plenty of diversionary activities for this time. - correct answer C. Providing hope is an essential
w w w w w w w w w w w w w w w w w w
nursing function during treatment for any disease process, but especially during the recovery period after
w w w w w w w w w w w w w w w
bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the
w w w w w w w w w w w w w w w w w w w w
recovery period and identify things to hope for during this time.
w w w w w w w w w w
A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?
w w w w w w w w w w w w w w w
A. "Because of immunosuppression, the donor cells take over."
w w w w w w w w
B. "It's like a transfusion reaction because no perfect match exists."
w w w w w w w w w w
C. "The patient's cells are fighting the donor cells for dominance."
w w w w w w w w w w
D. "The donor's cells are actually attacking the patient's cells." - correct answer D. Graft-versus-host disease is
w w w w w w w w w w w w w w w w
an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin
w w w w w w w w w w w w w w w w w
attacking them. w
The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best
w w w w w w w w w w w w w w w w w w w
indicates that an important outcome to manage this problem has been met?
w w w w w w w w w w w
A. Doing activities of daily living using rest periods.
w w w w w w w w
B. Helping plan a daily activity schedule
w w w w w w
C. Requesting a sleeping pill at night.
w w w w w w
D. Telling visitors to leave when fatigued. - correct answer A. Fatigue is a common problem for clients with
w w w w w w w w w w w w w w w w w w w
leukemia. This client is managing her own ADLs using rest periods, which indicates an understanding of
w w w w w w w w w w w w w w w w
fatigue and how to control it. w w w w w
A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a
w w w w w w w w w w w w w w w w w w w w w
PRIORITY?
A. Genetic testing
w w
B. Infection prevention
w w
