Medical Surgical Assessment A
2024/2025
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?
A) "I apply rubbing...
2024/2025
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular
disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?
A) "I apply rubbing alcohol to my feet every day to prevent infection"
B) "I will wear clean, knee-high wool socks everyday to help improve my circulation"
C) "I use hot water bottles to keep my feet warm at night"
D) "I don't cross my legs anymore" - ansD) "I don't cross my legs anymore"
Clients who have peripheral vascular disease should not cross their legs because it can impede circulation.
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The
client reports dyspnea and urticaria. Which of the following actions should the nurse perform first?
A) Count the client's respiratory rate
B) Ask the client if chest pain is present
C) Stop the infusion
D) Administer an antihistamine - ansC) Stop the infusion
Evidence-based practice indicates the nurse should stop the infusion of the blood product as soon as
manifestations occur because they can indicate a transfusion reaction.
A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and
abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a
fecal impaction?
A) Halitosis
,B) Hemorrhoids
C) Rebound tenderness
D) Small liquid stools - ansD) Small liquid stools
Small liquid stools can be the result of fecal material being expelled around an impaction.
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer.
Which of the following information should the nurse include in the teaching?
A) Mohs surgery is a horizontal shaving of thin layers of the tumor.
B) Mohs surgery uses liquid nitrogen to destroy the cancerous tissue.
C) Mohs surgery is the preferred treatment for melanoma skin cancer.
D) Mohs surgery is a palliative treatment for metastatic skin cancer. - ansA) Mohs surgery is a horizontal
shaving of thin layers of the tumor.
Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a
horizontal shaving of thin layers of a tumor, has a high treatment rate.
A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the
nurse recommend to promote sleep?
A) Get out of bed if unable to fall asleep within 60 min.
B) Take a brisk walk before sleeping.
C) Listen to soft music before sleeping.
D) Drink adequate amounts of fluids before sleeping. - ansC) Listen to soft music before sleeping.
Listening to soft music can help the client to relax and reduces environmental stressors.
,A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider
prescriptions should the nurse implement first?
A) Collect a sputum culture
B) Administer ceftriaxone by intermittent IV bolus
C) Initiate oxygen at 4 L/min via nasal cannula
D) Obtain blood cultures - ansC) Initiate oxygen at 4 L/min via nasal cannula
When using the airway, breathing, circulation approach to client care, the first action the nurse should take is
to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2
level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation
levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the
body.
A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord
injury. Which of the following interventions should the nurse plan to implement first?
A) Determine the client's daily elimination habits.
B) Administer a suppository to the client 30 min prior to defecation time.
C) Offer the client 4 oz of warm prune juice to promote elimination.
D) Provide dietary bulk to the client to ease the passage of stool. - ansA) Determine the client's daily
elimination habits.
The first action the nurse should take using the nursing process is to collect data on the client's daily bowel
elimination habits to establish a routine defecation time.
A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal
sealed radiation implants. Which of the following information should the nurse include?
A) Restrict the time pregnant women are allowed in the client's room to 15 min
, B) Pick up a radiation implant with a double-gloved hand if it becomes dislodged
C) Limit time spent in the client's room to 2 hr during an 8 hr shift
D) Dispose of radiation implants in a lead container - ansD) Dispose of radiation implants in a lead container
Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead
container in accordance with facility protocol.
A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery.
Which of the following actions should the nurse take to prevent postprocedure complications? (Select all)
A) Monitor the insertion site for bleeding
B) Position the affected extremity at a 45 degree angle
C) Restrict the client's fluid intake
D) Maintain the pressure dressing
E) Check the client's peripheral pulses - ansA) Monitor the insertion site for bleeding
The nurse should monitor the client's insertion site for manifestations of hemorrhaging.
D) Maintain the pressure dressing.
The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the
cannulation site to heal.
E) Check the client's peripheral pulses.
The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion.
A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion.
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