Detailed Answer Key
Medical Surgical, A+
1. A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements should the nurse
make?
A. "Uric acid levels drop and calcium forms precipitate."
Rationale: With gout, clients have hyperuricemia, rather than a reduction in uric acid.
B. "Tophi form in the kidneys and they impair the excretion of uric acid."
Rationale: Tophi, or deposits in tissues near a joint, develop in chronic, late-stage gout. They are not part of
the primary disease process.
C. "The intra-articular deposition of urate crystals causes inflammation."
Rationale: Gout, or gouty arthritis, develops when urate crystals deposit in joints and tissues and cause
inflammation and pain.
D. "Articular cartilage thins, leading to splitting and fragmentation."
Rationale: Gout does not thin and fragment cartilage.
2. A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the
nurse include in the teaching?
A. Use Echinacea to manage joint pain.
Rationale: The nurse may include the use of complementary and alternative therapies in the teaching.
However, Echinacea is used for the treatment of the common cold, not osteoarthritis. Alternative
therapies that are used for osteoarthritis include glucosamine, chondroitin, and topical capsaicin.
B. Apply ice to the joint before exercising.
Rationale: The nurse should recommend that the clients begin exercising immediately following the
application of heat. This reduces pain and improves mobility, allowing for increased
range-of-motion during exercises. Cold application may be applied following exercise to
decrease discomfort and inflammation.
C. Maintain a recommended body weight.
Rationale: Obesity is a risk factor for the development of osteoarthritis. Maintenance of an ideal weight is
one way a client can prevent added wear and tear on joints and promote overall joint health.
D. Reduce the amount of purine in the diet.
Rationale: The nurse should recognize that limiting purine in the diet, which is often found in organ meats,
is recommended for clients who have gout.
3. A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he
tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the
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,Detailed Answer Key
Medical Surgical, A+
damage is done. Which of the following is the correct nursing response?
A. "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous
level of activity safely."
Rationale: With this response, the nurse uses the therapeutic communication technique of presenting
reality by indicating her perception of the situation for the client.
B. "It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it."
Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of giving
reassurance, thus discouraging the client from further communication.
C. "Exercise is good for you and good for your heart."
Rationale: With this response, the nurse illustrates the nontherapeutic communication techniques of
disagreeing and giving advice.
D. "Your doctor is the expert here, and I’m sure he would only recommend what is best for you."
Rationale: With this response, the nurse illustrates the nontherapeutic communication technique of
defending.
4. A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify
which of the following medications as the cause of the client’s low potassium level?
A. Furosemide
Rationale: Furosemide is a loop (high-ceiling) diuretic that inhibits the reabsorption of sodium and chloride
and results in diuresis, which decreases potassium through excretion in the distal nephrons.
Hypokalemia is an adverse effect of furosemide.
B. Nitroglycerin
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of nitroglycerin. Nitroglycerin is a
vasodilator medication to treat angina.
C. Metoprolol
Rationale: A potassium level of 2.4 mEq/L is not an adverse effect of metoprolol. Metoprolol is a
beta-blocker that slows the heart rate and improves contractility of the heart muscle.
D. Spironolactone
Rationale: Spironolactone is a potassium-sparing diuretic medication; therefore, hyperkalemia is an
adverse effect of this medication.
5. A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur
fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of
the client's affected extremity? (Select all that apply.)
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,Detailed Answer Key
Medical Surgical, A+
A. Color
B. Temperature
C. Ecchymosis
D. Skin integrity
E. Sensation
Rationale: Color is correct. Clients who have sustained trauma to an extremity, such as a fracture, are at
increased risk for neurovascular compromise. The nurse should check the color of the client's
affected extremity as part of this assessment. The nurse should identify pallor or cyanosis of the
extremity as an indication of peripheral neurovascular dysfunction and should notify the
provider.Temperature is correct. Clients who have sustained trauma to an extremity, such as a
fracture, are at increased risk for neurovascular compromise. The nurse should monitor the
temperature of the extremity as a part of this assessment and identify skin that is cool or cold to
the touch as having decreased perfusion to the tissues of the extremity, which is an indication of
peripheral neurovascular dysfunction. The nurse should report skin that is cool to the touch to
the provider.Ecchymosis is incorrect. Ecchymosis, or bruising, is an expected finding with leg
injuries and is not a component of a neurovascular check.Skin integrity is incorrect. While the
nurse should assess the incision of a client who is postoperative following an open reduction
and internal fixation of the femur, it is not a component of a neurovascular check.Sensation is
correct. Clients who have sustained trauma to an extremity, such as a fracture, are at increased
risk for neurovascular compromise. The nurse should assess the client's extremity for numbness
or tingling. The nurse should recognize diminished pain or paresthesia as an indication of
damage to the nerves or peripheral neurovascular dysfunction and should report it to the
provider.
6. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following
manifestations as a complication and contact the provider immediately?
A. Serosanguineous drainage from the puncture site
Rationale: A small amount of serosanguineous drainage at the puncture site is expected after a
thoracentesis.
B. Discomfort at the puncture site
Rationale: Mild discomfort at the puncture site is expected after a thoracentesis.
C. Increased heart rate
Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal
content shift after the aspiration of a large amount of fluid from the client's pleural space.
Therefore, the client may experience an increase in heart and respiratory rate, along with
coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require
notification of the provider immediately.
D. Decreased temperature
Rationale: Infection is possible after any invasive procedure; however, it takes time to develop and
increases the body temperature.
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, Detailed Answer Key
Medical Surgical, A+
7. A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis.
Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active
pulmonary TB?
A. Chest x-ray
Rationale: A chest x-ray may be helpful for detecting old or new lesions that are large enough to be
visualized. However, the client who has an HIV infection may have a normal x-ray or show
infiltrates which would be expected in the client who has pneumonia.
B. Sputum culture for acid-fast bacillus
Rationale: Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the
presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only
method that can actually confirm the diagnosis.
C. Sputum smear
Rationale: A sputum smear is able to detect the presence of mycobacterium, but it does not distinguish
between mycobacterium tuberculosis and other strains of mycobacterium.
D. Mantoux test
Rationale: The Mantoux skin test is an effective screening tool, but it is unable to distinguish between an
active case of TB and a client who has been, at some time in the past, exposed to TB. The
results are also variable, depending upon the skill of the nurse administrating and reading the
test.
8. A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her
knees. Which of the following client statements indicates an understanding of the teaching?
A. "I can use either heat or ice to help relieve the discomfort."
Rationale: The nurse should reinforce that different treatment modalities, such as heat or cold therapy, can
be tried to determine which one is more effective for the client. Heat application can help with
muscle relaxation in the area around the affected joint. The application of cold numbs nerve
endings and decreases joint inflammation.
B. "Ibuprofen is the first step in medication therapy for osteoarthritis."
Rationale: The nurse should instruct the client that the primary medication of choice for the treatment of
osteoarthritis is acetaminophen. NSAIDS, such as celecoxib and ibuprofen, might be tried if
acetaminophen does not control discomfort.
C. "I should limit physical activity to prevent further injury."
Rationale: The nurse should encourage the client to include aerobic exercise and lower extremity strength
training into her daily regimen. These activities have been shown to slow the progression of
osteoarthritis and relieve the manifestations of the disorder.
D. "I will elevate my legs by placing two pillows under my knees when I go to bed."
Rationale:
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