BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL NURSING PRACTICE EXAM QUESTIONS WITH CORRECT DETAILED ANSWERS | ALREADY GRADED A+<RECENT VERSION>

BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL NURSING PRACTICE EXAM QUESTIONS WITH CORRECT DETAILED ANSWERS | ALREADY GRADED A+&lt;RECENT VERSION&gt; 1. Wound dehiscence with evisceration - ANSWER A serious complication where internal tissues/organs protrude through a separated wound. 2. Femoral pulse location - ANSWER The nurse must place her fingertips in the left or right groin to feel for the femoral pulse. 3. Visual acuity 20/60 - ANSWER He can see at 20 feet from the chart what a healthy eye can see at 60 feet. 4. Signs of hemolytic reaction - ANSWER Coughing, crackles, distended neck veins; high fever, chills, vomiting and diarrhea; backache, dyspnea, chest pain, tachycardia; itchiness, urticaria, bronchial asthma, flushing. 5. Purpose of towel under shoulder - ANSWER To balance the breast tissue more evenly on the chest wall. 6. Ileocecal valve activity - ANSWER Most active during auscultation of the abdomen. 7. Abdominal assessment - ANSWER The nurse is performing an abdominal assessment and auscultating for bowel sounds. 8. Snellen chart interpretation - ANSWER The client can only read as far as the 20/60 level on each eye. 9. Granulation tissue overproduction - ANSWER An overproduction of granulation tissue does not indicate a wound opening or protrusion. 10. Normal healing response - ANSWER A normal response to a large wound does not indicate a typical healing process. 11. Popliteal pulse location - ANSWER The popliteal pulse is located behind the knee. 12. Dorsalis pedis pulse location - ANSWER The dorsalis pedis pulse is located at the top of the foot. 13. Reference for physical examination - ANSWER Jarvis's Physical Examination & Health Assessment (8th Ed.) 14. Reference for medical-surgical nursing - ANSWER Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th Ed.) 15. Reference for history taking - ANSWER Bates' Guide to Physical Examination and History Taking (13th Ed.) 16. Reference for pathophysiology - ANSWER Essentials of Pathophysiology (4th Ed.) by Carol Porth. 17. Fluid overload symptoms - ANSWER Coughing, crackles, distended neck veins. 18. Febrile reaction symptoms - ANSWER High fever, chills, vomiting and diarrhea. 19. Allergic reaction symptoms - ANSWER Itching, urticaria. 20. Tachycardia causes - ANSWER Backache, dyspnea, chest pain, tachycardia. 21. Assessment rationale - ANSWER Allows better distribution for palpation. 22. Incorrect assessment locations - ANSWER Lateral femur, behind knee, top of foot are incorrect locations for assessing femoral pulse. 23. Assessment of abdominal wound - ANSWER Inspection reveals a gaping open wound with tissue bulging outward. 24. Assessment of peripheral pulses - ANSWER The nurse is assessing the peripheral pulses of a patient. 25. Colostomy - ANSWER A surgical procedure where a portion of the colon (large intestine) is brought through the abdominal wall to create an artificial opening (called a stoma) for the elimination of stool. 26. Pressure Ulcers - ANSWER Skin breakdown that occurs due to pressure and shear on bony prominences, often exacerbated by improper positioning and movement. 27. Shear - ANSWER Occurs when the skin stays in place but the underlying tissues move, potentially damaging deep tissues and increasing the risk of skin breakdown. 28. Endotracheal Tube Suctioning - ANSWER A procedure that can stimulate the vagus nerve, potentially leading to bradycardia or other cardiac irregularities. 29. Bony Prominences - ANSWER Areas of the body that are prone to pressure ulcers due to their prominence, such as the sacrum and coccyx. 30. Repositioning - ANSWER The act of moving a patient every 2 hours to relieve pressure and promote circulation, helping to prevent pressure ulcers. 31. Lifting Devices - ANSWER Tools used to move patients without dragging them across the bed, preventing friction and shear that can damage skin and underlying tissues. 32. Baby Powder or Cornstarch - ANSWER Substances that should not be used on bony prominences as they can cause skin irritation and do not prevent pressure injuries. 33. Elevating the Head of the Bed - ANSWER Raising the head of the bed to 45-90 degrees increases pressure and shear on the sacrum and coccyx, which are common areas for pressure ulcers. 34. Colon Resection with Anastomosis - ANSWER A surgical procedure that involves excising a section of the colon and restoring bowel continuity without creating a stoma. 35. Coloanal Anastomosis - ANSWER A surgical procedure that involves removing the rectum and suturing the colon to the anus, typically performed after rectal cancer surgery. 36. Ileostomy - ANSWER A surgical procedure that creates a stoma from the ileum (small intestine), not the colon. 37. Vagus Nerve Stimulation - ANSWER A potential effect of endotracheal suctioning that can lead to bradycardia or other cardiac irregularities. 38. Oxygen Saturation Level - ANSWER A measurement of the amount of oxygen in the blood, with a level of 95% considered normal. 39. Hypertension - ANSWER A condition characterized by elevated blood pressure. 40. Cardiac Irregularities - ANSWER Abnormal heart rhythms that can occur as a result of various medical conditions or procedures. 41. Reddish Coloration in the Face - ANSWER A potential sign of various medical conditions, including hypertension or other cardiovascular issues. 42. Increased intrathoracic pressure - ANSWER Can affect heart rate and rhythm during suctioning. 43. Reddish coloration in the client's face - ANSWER Not a specific adverse effect of suctioning; may occur due to increased pressure or anxiety but is not consistently documented. 44. Oxygen saturation level of 95% - ANSWER Not an adverse effect; it is within the acceptable range for many patients. 45. Fecalysis collection amount - ANSWER The nurse should instruct the patient to collect an adequate amount without overflow, which can compromise the sample's integrity. 46. Diagnostic tests for bacterial meningitis - ANSWER A biopsy is not a standard diagnostic test; CSF analysis from a lumbar puncture is used instead. 47. Lumbar tap - ANSWER A standard procedure for diagnosing bacterial meningitis by analyzing cerebrospinal fluid (CSF) for pathogens. 48. Blood culture - ANSWER Crucial in diagnosing bacterial meningitis, as it helps identify the bacteria causing the infection. 49. Computed tomography scan - ANSWER Used to rule out other conditions before a lumbar puncture, but not primarily for diagnosing bacterial meningitis. 50. Specimen cup filled up to the brim - ANSWER Excessive and could lead to spillage or contamination during fecalysis collection. 51. One-third of the cup - ANSWER An appropriate amount for fecalysis collection. 52. One-half of the cup - ANSWER Collecting a larger volume could be unnecessarily difficult and uncomfortable for the patient. 53. Three-fourths of the cup - ANSWER Collecting a larger volume could be unnecessarily difficult and uncomfortable for the patient. 54. Fecal occult blood test - ANSWER A test scheduled for a patient to check for hidden blood in the stool. 55. Double-lumen Foley catheter - ANSWER A type of catheter used for urinary drainage that has two lumens, one for draining urine and the other for inflating a balloon. 56. Urinalysis - ANSWER A laboratory test that analyzes urine to assess health and diagnose conditions. 57. False-positive results - ANSWER A test result that incorrectly indicates the presence of a condition when it is not actually present. 58. Heme content - ANSWER The iron-containing component of hemoglobin in red blood cells, which can cause false-positive results in certain tests if ingested. 59. Naproxen - ANSWER A non-steroidal anti-inflammatory drug (NSAID) used to relieve pain and inflammation. 60. Prednisone - ANSWER A corticosteroid medication used to suppress the immune system and reduce inflammation. 61. Increased oral fluid intake - ANSWER The act of consuming more fluids than usual, often recommended for hydration or to assist with certain medical tests. 62. Compliance with test preparation - ANSWER Following the guidelines and instructions provided for a medical test to ensure accurate results. 63. Discontinuing medication - ANSWER The act of stopping a prescribed medication, which may or may not affect test results depending on the drug. 64. Red meat avoidance - ANSWER The recommendation for patients to refrain from consuming red meat prior to certain medical tests to prevent false-positive results. 65. Increasing fluid intake - ANSWER Generally a positive change and does not affect the results of the fecal occult blood test. 66. Aspirate - ANSWER At least 10ml of urine from the sampling port and withdraw the syringe. 67. Decontaminate hands - ANSWER Apply surgical gloves. 68. Send sample - ANSWER To the laboratory immediately or place in room temperature until it can be transported to ensure accurate results. 69. Clamp tubing - ANSWER If the tubing is still empty, apply a clamp above the level of the sampling port. 70. Why is having someone wait in the car during a nurse's visit not beneficial? - ANSWER A person waiting in the car does not enhance safety during the visit. 71. What time of day is suggested for appointments in high-crime areas? - ANSWER Early morning or late afternoon, but this does not guarantee safety. 72. What should a nurse avoid wearing when making visits in high-crime areas? - ANSWER Expensive jewelry to reduce the chance of being robbed. 73. What is the best action for a nurse who forgets adhesive gauze during a wound care visit? - ANSWER Improvise, if possible, using sterile gauze and adhesive tape. 74. What is the first step in the discharge planning process for a client? - ANSWER Identifying the client's specific needs. 75. What is the rationale for improvising during a home health visit? - ANSWER Improvisation is often necessary in home health situations due to logistical challenges. 76. What should a nurse do if they realize they have forgotten a necessary supply during a home visit? - ANSWER Improvise with available materials instead of leaving the wound open to air. 77. What is one precaution a nurse can take to enhance personal safety during home visits? - ANSWER Avoid driving an expensive car. 78. What is the significance of identifying a client's specific needs during discharge planning? - ANSWER It allows the nurse to develop a tailored care plan and make appropriate referrals. 79. What is the rationale for not leaving valuables in the car during home visits? - ANSWER To prevent theft and ensure personal safety. 80. What does the acronym NAT stand for in the context of nursing notes? - ANSWER Client Needs: Safe, Effective Care Environment: Safety and Infection Control. 81. What is the purpose of the Integrated Process: Nursing Process key in nursing notes? - ANSWER To indicate the application of the nursing process in client care. 82. Why might a nurse schedule a return visit after forgetting supplies? - ANSWER To ensure the client receives proper care, but it does not resolve immediate issues. 83. What is the importance of the rationale provided for each nursing action? - ANSWER It helps to understand the reasoning behind clinical decisions. 84. What is the cognitive level indicated in the nursing notes? - ANSWER Apply, which suggests using knowledge in practical situations.