MEDICAL SURGICAL NURSING CONCEPTS

MULTIPLE CHOICE 1. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client’s temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client’s daily white blood cell count ANS: A Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes would be done with st...

MULTIPLE CHOICE 1. A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism. Standard Precautions would be used. Bleeding Precautions, reverse isolation, or Contact Precautions are not necessary. DIF: Applying TOP: Integ...

MULTIPLE CHOICE 1. The emergency department (ED) manager is reviewing client charts to determine how well the staff perform when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a. Antibiotics started before admission. b. Blood cultures obtained within 20 minutes. c. Chest x-ray obtained within 30 minutes. d. Pulse oximetry obtained on all clients. ANS: A Goals for treatment of community-acquired pneumon...

MULTIPLE CHOICE 1. A nurse assesses a client who is recovering from a myocardial infarction. The client’s blood pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client’s chart as the only action. ANS: A The mos...

MULTIPLE CHOICE 1. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client’s hands. d. Sedate the client immediately. ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, c...

MULTIPLE CHOICE 1. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L (22 mmol/L). What action would the nurse take first? a. Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the client’s nose and mouth. c. Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin. ...

MULTIPLE CHOICE 1. A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology? a. “I don’t need to manually calculate IV infusion rates with smart pumps.” b. “Responding to IV pump alarms is a high priority for client safety.” c. “The hospital can preprogram the pumps for high-alert drug limits.” d. “These pumps have a system to prevent fluids from free-flowin...

MULTIPLE CHOICE 1. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic. ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in ...

MULTIPLE CHOICE 1. A postoperative client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer? a. Flumazenil 0.2 to 1 mg b. Flumazenil 2 to 10 mg c. Naloxone 0.4 to 2 mg d. Naloxone 4 to 20 mg ANS: C The nurse would prepare to administer naloxone, an opioid antagonist, at a dose of between 0.04 and 0.05 mg up to 2 mg, depending on the client’s symptoms. Flumazenil is a benzodiazepine antagonist. DIF: R...

MULTIPLE CHOICE 1. A nurse cares for victims during a community-wide disaster drill. One of the victims asks, “Why are the individuals with black tags not receiving any care?” How does the nurse respond? a. “To do the greatest good for the greatest number of people, it is necessary to sacrifice some.” b. “Not everyone will survive a disaster, so it is best to identify those people early and move on.” c. “In a disaster, extensive resources are not used for one person at th...