Med surg quiz 1 practice questions (A+ 100% VERIFIED UPDATE)

1. The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? 1. "I will be glad when this is over so I can go home today." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I can practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible."question and answer 1. "I will be glad when this is over so I can go home today."question and answer2. The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? 1. Notify the surgeon about the client's request to wear the medal 2. Tape the medal to the client and allow the client to wear the medal 3. Request the family member take the medal prior to surgery 4. Explain taking the medal to surgery is against the policyquestion and answer 2. Tape the medal to the client and allow the client to wear the medalquestion and answer3. The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? 1. The 65 year old client who cannot read or write 2. The 30 year old who does not understand English 3. The 16 year old who has a fractured ankle 4. The 8- year old who is not oriented to the dayquestion and answer 3. The 16 year old who has a fractured anklequestion and answer4. The nurse is preparing a client for surgery. Which intervention should the nurse implement first? 1. Check the permit for the spouse's signature 2. Take and document intake and output 3. Administer the on-call sedative 4. Complete the preoperative checklistquestion and answer 4. Complete the preoperative checklistquestion and answer5. The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply 1. The client has loose, decayed teeth 2. The client is experiencing anxiety 3. The client smokes two packs of cigarettes a day 4. The client has had a chest x ray which does not show infiltrates 5. The client reports using herbsquestion and answer 1. The client has loose, decayed teeth 3. The client smokes two packs of cigarettes a day 5. The client reports using herbsquestion and answer6. Which task would be most appropriate for the nurse to delegate to the UAP (unlicensed assistive personnel)? 1. Complete the preop checklist 2. Assess the client's preop vital signs 3. Teach the client about coughing and deep breathing 4. Assist the client to remove clothing and jewelryquestion and answer 4. Assist the client to remove clothing and jewelryquestion and answer7. The nurse is assessing a client in the day surgery unit who states "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse? 1. "Don't worry about your surgery. It is safe." 2. "Tell me why you're worried about the surgery." 3. "Tell me about your fears of having this surgery." 4. "I understand how you feel, surgery is frightening."question and answer 3. "Tell me about your fears of having this surgery."question and answer8. The 68 year old client is scheduled for intestinal surgery does not have clear fecal contents after 3 tap water enemas. Which intervention should the nurse implement first? 1. Notify the surgeon of the client's status 2. Continue giving enemas until clear 3. Increase the client's fluid IV rate 4. Obtain STAT serum electrolytesquestion and answer 1. Notify the surgeon of the client's statusquestion and answer9. The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply 1. Perform passive ROM exercises 2. Discuss how to cough and deep breathe effectively 3. Tell the client he can have a meal in the PACU 4. Teach ways to manage post op pain 5. Discuss events which occur in the post-anesthesia care unitquestion and answer 2. Discuss how to cough and deep breathe effectively 4. Teach ways to manage post op pain 5. Discuss events which occur in the post-anesthesia care unitquestion and answer10. The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? 1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth 2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion 3. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume 4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bedquestion and answer 4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bedquestion and answer11. The nurse is completing preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? 1. Apply an allergy bracelet on the client's wrist 2. Label the client's allergies on the front of the chair 3. Ask the client what happens when he takes codeine 4. Document the allergy on the medication administration recordquestion and answer 3. Ask the client what happens when he takes codeinequestion and answer12. Which lab result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 2. Bleeding time 2 minutes 3. Hemoglobin 15 4. Potassium 2.4question and answer 4. Potassium 2.4question and answer13. Which activities are the circulating nurse's responsibilities in the OR? 1. Monitor the position of the client, prepare the surgical site, and ensure the client's safety 2. Give preop meds in the holding area and monitor the client's response to anesthesia 3. Prepare sutures; set up the sterile fild, and count all needles and sponges and instruments 4. Prepare the meds to be administered by the anesthesiologist and change the tubing for the anesthesia machinequestion and answer 1. Monitor the position of the client, prepare the surgical site, and ensure the client's safetyquestion and answer14. The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? 1. Place the sponge back where it was 2. Tell the technician to not waste supplies 3. Do nothing because this is the correct procedure 4. Take the sponge out of the room immediatelyquestion and answer 3. Do nothing because this is the correct procedurequestion and answer16. Which violation of surgical asepsis would require immediate intervention by the circulating nurse? 1. Surgical supplies were cleaned and sterilized prior to the case 2. The circulating nurse is wearing a long-sleeved sterile gown 3. Masks covering the mouth and nose are being worn by the surgical team 4. The scrub nurse setting up the sterile field is wearing artificial nailsquestion and answer 4. The scrub nurse setting up the sterile field is wearing artificial nailsquestion and answer17. The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing intervention should the nurse implement? 1. Avoid using the cautery unit, which does not have a biomedical tag on it 2. Carefully pad the client's elbows before covering the client with a blanket 3. Apply a warming pad on the OR table before placing the client on the table 4. Check the chart for any prescription or OTC medication usequestion and answer 2. Carefully pad the client's elbows before covering the client with a blanketquestion and answer18. The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage? 1. The 16 year old in dorsal recumbent position having an appendectomy 2. The 68 year old in the Trendlenburg position having a cholecystectomy 3. The 45 year old in the reverse trendlenburg position having a biopsy 4. The 22 year old client in the lateral postion having a nephrectomyquestion and answer 2. The 68 year old in the Trendlenburg position having a cholecystectomyquestion and answer19. Which situation demonstrates the circulating nurse acting as the client's advocate? 1. Plays the client's favorite audio book during surgery 2. Keeps the family informed of the findings of the surgery 3. Keeps the operating room door closed at all times 4. Calls the client by the first name when the client is recoveringquestion and answer 3. Keeps the operating room door closed at all timesquestion and answer20. The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? 1. The client has no injuries from the OR equipment 2. The client ahs no post op infection 3. The client has stable vital signs during surgery 4. The client recovers from anesthesiaquestion and answer 1. The client has no injuries from the OR equipmentquestion and answer21. Which nursing intervention has the highest priority when preparing the client for a surgical procedure? 1. Pad the client's elbows and knees 2. Apply soft restraint straps to the extremities 3. Prepare the client's incision site 4. Document the temperature of the roomquestion and answer 2. Apply soft restraint straps to the extremitiesquestion and answer22. The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse? 1. The client having open-heart surgery 2. The client having a biopsy of the breast 3. The client having laser eye surgery 4. The client having a laparoscopic knee repairquestion and answer 2. The client having a biopsy of the breastquestion and answer23. The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? 1. Prepare ice packs and mix dantrolene sodium 2. Request the defibrillator be brought into the OR 3. Draw a PTT and prepare a heparin drip 4. Obtain finger stick blood glucose immediatelyquestion and answer 1. Prepare ice packs and mix dantrolene sodiumquestion and answer24. The nurse is planning care of the surgical client having conscious sedation. Which intervention has highest priority? 1. Assess the client's respiratory status 2. Monitor the client's urinary output 3. Take a 12-lead ECG prior to injection 4. Attempt to keep the client focusedquestion and answer 1. Assess the client's respiratory statusquestion and answer25. The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1. Assess the client's breath sounds 2. Apply oxygen via nasal cannula 3. Take the client's BP 4. Monitor the pulse ox readingquestion and answer 1. Assess the client's breath soundsquestion and answer26. Which assessment data indicate the post op client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation at the lumbar (L5) dermatome 2. Absence of the client's posterior tibial pulse 3. The client has a respiratory rate of 8 4. The BP is within 20% of the client's baselinequestion and answer 3. The client has a respiratory rate of 8question and answer27. The surgical clients V/S are T 98 degrees, P 106, R 24, BP 88/40. The client is awake and oriented times 3 and the skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the V/S 2. Start an IV D5RL with 20 mEQ KCL at 125 ml/hr 3. Elevate the feet and lower the head of the bed 4. Monitor the vital signs every 15 minutesquestion and answer 3. Elevate the feet and lower the head of the bedquestion and answer28. The PACU nurse administers Narcan, an opioid antagonist, to a post op client. Which client problem should the nurse include to the plan of care based on this medication? 1. Alteration in comfort 2. Risk for depressed respiratory pattern 3. Potential for infection 4. Fluid and electrolyte imbalancequestion and answer 2. Risk for depressed respiratory patternquestion and answer29. The 26 year old male client in the PACU has a HR of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? Select all 1. Give a backrub to the client to relieve stiffness 2. Apply ice packs to the axillary and groin areas 3. Prepare an ice slush for the client to drink 4. Prepare to administer dantrolene, a smooth-muscle relaxant 5. Reposition the client on a warming blanketquestion and answer 2. Apply ice packs to the axillary and groin areasquestion and answer30. Which data indicate to the nurse the client who is one day post op right total hip replacement is progressing as expected? 1. Urine output was 160 ml in the past 8 hours 2. Paralysis and parasthesia of the Right leg 3. T 99, P 98, R 20, and BP 100/60 4. Lungs are clear bilaterally in all lobesquestion and answer 4. Lungs are clear bilaterally in all lobesquestion and answer31. The nurse and the UAP are working on a surgical unit. Which task can the nurse delegate to the UAP? 1. Take routine V/S on clients 2. Check the Jackson Pratt insertion site 3. Hang the client's next IV bag 4. Ensure the client obtains pain reliefquestion and answer 1. Take routine V/S on clientsquestion and answer32. The charge nurse is making shift assignments. Which post op client should be assigned to the most experienced nurse? 1. The 4 year old who had a tonsillectomy and is able to swallow fluids 2. The 74 year old with a repair of the left hip who is unable to ambulate 3. The 24 year old who had an uncomplicated appendectomy the previous day 4. The 80 year old client with small bowel obstruction and CHFquestion and answer 4. The 80 year old client with small bowel obstruction and CHFquestion and answer33. Which statement would be an expected outcome for the post op client who had general anesthesia? 1. The client will be able to sit in the chair for 30 minutes 2. The client will have a pulse ox reading of 97 on room air 3. The client will have urine output of 30 ml per hour 4. The client will be able to distinguish sharp from dull sensationsquestion and answer 2. The client will have a pulse ox reading of 97 on room airquestion and answer34. The post op client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1. Apply antiembolism hose to the client 2. Attach the drain to 20 cm suction 3. Assess the clients V/S 4. Listen to the report from the anesthesiologistquestion and answer 3. Assess the clients V/Squestion and answer35. Which problem should the nurse identify as priority for client who is one day post op? 1. Potential for hemorrahaging 2. Potential for injury 3. Potential for fluid volume excess 4. Potential for infectionquestion and answer 1. Potential for hemorrahagingquestion and answer36. The UAP reports the vital signs for first day post op client T 100.8, P 80, R 24, BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled 2. Change the dressing over the wound 3. Have the client turn, cough, and deep breathe Q2 hrs. 4. Encourage the client to ambulate in the hallquestion and answer 3. Have the client turn, cough, and deep breathe Q2 ion and answerA nurse working in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temp is 100.6 orally. The client is afraid he has HIV. Which of the following actions should the nurse take? Select all 1. Perform a physical assessment 2. Determine when current symptoms began 3. Teach the client about HIV transmission 4. Draw blood for HIV testing 5. Obtain a sexual historyquestion and answer 1. Perform a physical assessment 2. Determine when current symptoms began 5. Obtain a sexual historyquestion and answerA nurse is caring for a client who is suspected of having HIV. Which of the following diagnostic tests and lab values are used to confirm HIV infection? Select all 1.Western blot 2. Indirect immunofluorescence assay 3. CD4 T lymphocyte count 4. CD4 T lymph percentage of total lymphocytes 5. CSF analysisquestion and answer 1.Western blot 2. Indirect immunofluorescence assayquestion and answerA nurse is assessing a client for HIV. Which of the following are risk factors associated with this virus? Select all 1. Perinatal Exposure 2. Pregnancy 3. Monogamous sex partner 4. Older Adult woman 5. Occupational exposurequestion and answer 1. Perinatal Exposure 4. Older Adult woman 5. Occupational exposurequestion and answerA nurse is completing discharge instructions with a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? 1. "I will wear gloves while changing the pet litter box." 2. "I will rinse raw fruits with water before eating them." 3. "I will wear a mask around family members who are ill." 4. "I will cook vegetables before eating them"(This will help with transmission of bacteria)question and answer 4. "I will cook vegetables before eating them"(This will help with transmission of bacteria)question and answerThe school nurse is preparing to teach a health class to ninth graders regarding STD's. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1. Females taking birth control pills are protected from becoming infected with HIV 2. Protected sex is no longer an issue because there is a vaccine for the HIV virus 3. Adolescents with a normal immune system are not at risk for developing AIDS 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.question and answer 4. Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.question and answerThe nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should the nurse's first intervention? 1. Asses the client's body weight and ask what the client has been able to eat 2. Place in contact isolation and don a mask and gown before entering the room 3. Check the HCP's orders and determine what lab tests will be done. 4. Teach the client about TPN and monitor the subclavian IV sitequestion and answer 1. Asses the client's body weight and ask what the client has been able to eatquestion and answerWhich type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections? 1. Contact 2. Airborne 3. Droplet 4. Standardquestion and answer 4. Standardquestion and answerThe nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in 2. The HIV virus can be eradicated from the host body with the correct medical regimen 3. It is difficult for the HIV virus to replicate in humans because it is a monkey virus 4. The HIV virus uses the client's own red blood cells to reproduce the virus in the bodyquestion and answer 1. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live inquestion and answerThe client who has engaged in needle-sharing activities has developed a flu-like infection. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding? 1. The client is fortunate not to have contracted HIV from an infected needle 2. The client must be repeatedly exposed to HIV before becoming infected 3. The client may be in the primary infection phase of an HIB infection 4. The antibody test is negative because the client has a different flu virusquestion and answer 3. The client may be in the primary infection phase of an HIB infectionquestion and answerThe nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? 1. The client who has flushed, warm skin with tented turgor (Dehydration) 2. The client who states the staff ignores the call light 3. The client whose Vital signs are 99.9, pulse 101, R 26, and BP 110/68 4. The client who is unable to provide a sputum specimenquestion and answer 1. The client who has flushed, warm skin with tented turgor (Dehydration)question and answer37. The 26 year old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which lab test should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests 2. CBC and ANA tests 3. Cholesterol and lipid profile tests 4. BUN and GFR testsquestion and answer 2. CBC and ANA testsquestion and answer38. The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply 1. Use a sunscreen of SPF 30 or greater when in the sunlight 2. Notify the HCP immediately when developing a low-grade fever 3. Some dyspnea is expected and does not need immediate attention 4. The hands and feet may change color if exposed to cold or heat 5. Explain the client can be cure with continued therapyquestion and answer 1. Use a sunscreen of SPF 30 or greater when in the sunlight 2. Notify the HCP immediately when developing a low-grade fever 4. The hands and feet may change color if exposed to cold or heatquestion and answer39. The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability 2. The client will verbalize feelings of body-image changes 3. The client will have no deterioration of organ function 4. The client's skin will remain intact and have no ion and answer 3. The client will have no deterioration of organ functionquestion and answer40. The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs 2. Muscle spasticity and bradykinesia 3. Hirsutism and clubbing of the fingers 4. Somnolence and weight gainquestion and answer 1. Pericardial friction rub and crackles in the lungsquestion and answer41. The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection 2. The steroids will decrease the chance of SLE spreading to other organs 3. The steroids will suppress tissue inflammation, which reduces damage to the organs 4. The steroids will prevent scarring of skin tissues associated with SLEquestion and answer 3. The steroids will suppress tissue inflammation, which reduces damage to the organsquestion and answer42. The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response? 1. "I know you are upset, but stress makes the SLE worse." 2. "Please explain to me why you are crying." 3. "I recommend going to an SLE support group." 4. " I see you are crying. We can talk if you would like."question and answer 4. " I see you are crying. We can talk if you would like."question and answer43. The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented? 1. Use astringent lotion on the face and skin 2. Inspect the skin weekly for open areas or rashes 3. Dry the skin thoroughly by patting 4. Apply anti-itch medication between the toesquestion and answer 3. Dry the skin thoroughly by pattingquestion and answer45. The nurse and a female UAP are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP washes her hands before and after performing vital signs on a client 2. The UAP dons sterile gloves prior to removing an indwelling catheter from a client 3. The UAP raises the head of the bed to a high Fowlers position for a client about to eat 4. The UAP uses a fresh plastic bag ot get ice for a clients water pitcherquestion and answer 2. The UAP dons sterile gloves prior to removing an indwelling catheter from a clientquestion and answer46. The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response? 1. SLE occurs because the kidneys do not filter antibodies from the blood 2. SLE occurs after a viral illness as a result of damage to the endocrine system 3. There is no known identifiable reason for a client to develop SLE 4. This is an autoimmune disease that may have a genetic or hormonal componentquestion and answer 4. This is an autoimmune disease that may have a genetic or hormonal componentquestion and answer47. The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing? 1. Tapering the medication prevents the client from having withdrawal symptoms 2. So thyroid gland starts working, because this medication stops it from working 3. Tapering the dose allows the adrenal glands to begin to produce cortisol again 4. This is the HCP personal choice in prescribing medicationsquestion and answer 3. Tapering the dose allows the adrenal glands to begin to produce cortisol againquestion and answer48. The nurse is discussing autoimmune disease with a class of nursing students. Which s/s are shared by RA and SLE? 1. Nodules in the subq layer and bone deformity 2. Renal involvement and pleural effusions 3. Joint stiffness and pain 4. Raynauds phenomenon and skin rashquestion and answer 3. Joint stiffness and painquestion and answer1. The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? 1. Hold all venipuncture sites for at least 5 minutes 2. Limit fresh fruits and flowers 3. Place all clients in reverse isolation 4. Have the clients use a soft-bristle toothbrushquestion and answer 2. Limit fresh fruits and flowersquestion and answer2. The nurse is assessing a client diagnosed with acute leukemia. Which assessment data support this diagnosis? 1. Fever and infections 2. N+V 3. Excessive energy and high platelet counts 4. Cervical lymph node enlargement and positive acid-fast bacillusquestion and answer 1. Fever and infectionsquestion and answer3. The client diagnosed with leukemia has CNS involvement. Which instruction should the nurse teach? 1. Sleep with the HOB elevated to prevent increased intracranial pressure 2. Take an analgesic medication for pain only when the pain becomes severe 3. Explain radiation therapy to the head may result in permanent hair loss 4. Discuss end of life decisions prior to cognitive deteriorationquestion and answer 3. Explain radiation therapy to the head may result in permanent hair lossquestion and answer4.The client diagnosed with leukemia is scheduled for bone marrow transplantation. Which interventions should be implemented to prepare the client for this procedure? Select all 1. Administer high-dose chemo 2. Teach the client about autologous transfusions 3. Have the family members HLA typed 4. Monitor the CBC daily 5. Provide central line care per protocolquestion and answer 1. Administer high-dose chemo 3. Have the family members HLA typed 4. Monitor the CBC daily 5. Provide central line care per protocolquestion and answer9. The nurse writes a nursing problem of "altered nutrition" for a client diagnosed with leukemia who has received a treatment regimen of chemo and radiation. Which nursing intervention should be implemented? 1. Administer and antidiarrheal medication prior to meals 2. Monitor the client's serum albumin levels 3. Asses for signs and symptoms of infection 4. Provide skin care to irradiated areasquestion and answer 2. Monitor the client's serum albumin levelsquestion and answer11. The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed? 1. Infection 2. Anemia 3. Nutrition 4. Grievingquestion and answer 4. Grievingquestion and answer12. The nurse is caring for a client diagnosed with acute leukemia