MEDICAL SURGICAL NURSING CONCEPTS

MULTIPLE CHOICE 1. The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment ANS: D A postprocedure complication of a TIPS procedure is right-sided heart failure. Therefore, the nurse would perform a cardiovascular assessment before the p...

MULTIPLE CHOICE 1. The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug? a. “Are you taking Vitamin C or B? b. “Do you have any allergy to sulfa drugs?” c. “Can you swallow pills pretty easily?” d. “Do you have insurance to cover this drug?” ANS: B Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should not be given to those who have an aller...

MULTIPLE CHOICE 1. A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider? a. Client who has poor oral hygiene practices. b. Client who smokes and drinks daily. c. Client who tans for an upcoming vacation. d. Client who occasionally uses illicit drugs. ANS: B Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer bu...

MULTIPLE CHOICE 1. An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. “Changes in your liver cause drugs to be metabolized differently.” b. “Perhaps you don’t need as high a dose of the drug as before.” c. “Stomach muscles atrophy with age and you digest more slowly.” d. “Your body probably can’t tolerate as much medication anymo...

MULTIPLE CHOICE 1. During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? a. Hematemesis b. Pain when eating c. Melena d. Weight loss ANS: C All of the other assessment findings are more commonly seen in clients who have gastric ulcers rather than duodenal ulcers. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Peptic ulcer disease, Assessment MSC: Client Needs Catego...

MULTIPLE CHOICE 1. An older client with diabetes is admitted with a heavily draining leg wound. The client’s white blood cell count is 38,000/mm3 (38  109/L) but the client is afebrile. Which nursing action is most appropriate at this time? a. Administer acetaminophen as needed. b. Educate the client on amputation. c. Place the client on Contact Precautions. d. Refer the client to the wound care nurse. ANS: C In the presence of a heavily draining wound, the nurse would pla...

MULTIPLE CHOICE 1. A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? a. Pain of 4 on a scale of 0-10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed ANS: B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of ...

MULTIPLE CHOICE 1. A client asks the nurse about having a total knee arthroplasty to relieve joint pain. Which factor would place the client at the highest risk for impaired postoperative healing? a. Controlled hypertension b. Obesity c. Osteoarthritis d. Mild osteopenia ANS: B Obesity places a client at high risk for many postoperative complications including slower wound and bone healing. The other factors usually do not affect healing after surgery. DIF: Understanding TOP:...

MULTIPLE CHOICE 1. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness ANS: D The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessmen...

MULTIPLE CHOICE 1. The client’s electronic health record indicates genu varum. What does the nurse understand this term to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature ANS: A Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Musculoskeletal assessment, Musculoskeleta...