MEDICAL SURGICAL NURSING c.

Perineal edema
d. Urethral discharge
1. Marco who was diagnosed with brain tumor was
scheduled for craniotomy. In preventing the 7. A client has undergone with penile implant.
development of cerebral edema after surgery, After 24 hrs of surgery, the client’s scrotum was
the nurse should expect the use of: edematous and painful. The nurse should:
a. Diuretics a. Assist the client with sitz bath
b. Antihypertensive b. Apply war soaks in the scrotum
c. Steroids c. Elevate the scrotum using a soft support
d. Anticonvulsants d. Prepare for a possible incision and
drainage.
2. Halfway through the administration of blood,
the female client complains of lumbar pain. After 8. Nurse hazel receives emergency laboratory
stopping the infusion Nurse Hazel should: results for a client with chest pain and
a. Increase the flow of normal saline immediately informs the physician. An increased
b. Assess the pain further myoglobin level suggests which of the following?
c. Notify the blood bank a. Liver disease
d. Obtain vital signs. b. Myocardial damage
c. Hypertension
3. Nurse Maureen knows that the positive d. Cancer
diagnosis for HIV infection is made based on
which of the following: 9. Nurse Maureen would expect the client with
a. A history of high risk sexual behaviors. mitral stenosis would demonstrate symptoms
b. Positive ELISA and western blot tests associated with congestion in the:
c. Identification of an associated a. Right atrium
opportunistic infection b. Superior vena cava
d. Evidence of extreme weight loss and c. Aorta
high fever d. Pulmonary

4. Nurse Maureen is aware that a client who has 10. A client has been diagnosed with hypertension.
been diagnosed with chronic renal failure The nurse priority nursing diagnosis would be:
recognizes an adequate amount of high-biologic- a. Ineffective health maintenance
value protein when the food the client selected b. Impaired skin integrity
from the menu was: c. Deficient fluid volume
a. Raw carrots d. Pain
b. Apple juice
c. Whole wheat bread 11. Nurse Hazel teaches the client with angina about
d. Cottage cheese common expected side effects of nitroglycerin
including:
5. Kenneth who has diagnosed with uremic a. high blood pressure
syndrome has the potential to develop b. stomach cramps
complications. Which among the following c. headache
complications should the nurse anticipates: d. shortness of breath
a. Flapping hand tremors
b. An elevated hematocrit level 12. The following are lipid abnormalities. Which of
c. Hypotension the following is a risk factor for the development
d. Hypokalemia of atherosclerosis and PVD?
a. High levels of low density lipid (LDL)
6. A client is admitted to the hospital with benign cholesterol
prostatic hyperplasia, the nurse most relevant b. High levels of high density lipid (HDL)
assessment would be: cholesterol
a. Flank pain radiating in the groin c. Low concentration triglycerides
b. Distention of the lower abdomen d. Low levels of LDL cholesterol.

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b. Administering Coumadin
13. Which of the following represents a significant c. Treating the underlying cause
risk immediately after surgery for repair of aortic d. Replacing depleted blood products
aneurysm?
a. Potential wound infection 20. Which of the following findings is the best
b. Potential ineffective coping indication that fluid replacement for the client
c. Potential electrolyte balance with hypovolemic shock is adequate?
d. Potential alteration in renal perfusion a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
14. Nurse Josie should instruct the client to eat c. Diastolic blood pressure greater than 90
which of the following foods to obtain the best mmhg
supply of Vitamin B12? d. Systolic blood pressure greater than 110
a. dairy products mmhg
b. vegetables
c. Grains 21. Which of the following signs and symptoms
d. Broccoli would Nurse Maureen include in teaching plan
as an early manifestation of laryngeal cancer?
15. Karen has been diagnosed with aplastic anemia. a. Stomatitis
The nurse monitors for changes in which of the b. Airway obstruction
following physiologic functions? c. Hoarseness
a. Bowel function d. Dysphagia
b. Peripheral sensation
c. Bleeding tendencies 22. Karina a client with myasthenia gravis is to
d. Intake and out put receive immunosuppressive therapy. The nurse
understands that this therapy is effective
16. Lydia is scheduled for elective splenectomy. because it:
Before the clients goes to surgery, the nurse in a. Promotes the removal of antibodies that
charge final assessment would be: impair the transmission of impulses
a. signed consent b. Stimulates the production of
b. vital signs acetylcholine at the neuromuscular
c. name band junction.
d. empty bladder c. Decreases the production of
autoantibodies that attack the
17. What is the peak age range in acquiring acute acetylcholine receptors.
lymphocytic leukemia (ALL)? d. Inhibits the breakdown of acetylcholine
a. 4 to 12 years. at the neuromuscular junction.
b. 20 to 30 years
c. 40 to 50 years 23. A female client is receiving IV Mannitol. An
d. 60 60 70 years assessment specific to safe administration of the
said drug is:
18. Marie with acute lymphocytic leukemia suffers a. Vital signs q4h
from nausea and headache. These clinical b. Weighing daily
manifestations may indicate all of the following c. Urine output hourly
except d. Level of consciousness q4h
a. effects of radiation
b. chemotherapy side effects 24. Patricia a 20 year old college student with
c. meningeal irritation diabetes mellitus requests additional
d. gastric distension information about the advantages of using a pen
like insulin delivery devices. The nurse explains
19. A client has been diagnosed with Disseminated that the advantages of these devices over
Intravascular Coagulation (DIC). Which of the syringes include:
following is contraindicated with the client? a. Accurate dose delivery
a. Administering Heparin b. Shorter injection time
 c. Lower cost with reusable insulin
cartridges 30. A male client has undergone spinal surgery, the
d. Use of smaller gauge needle. nurse should:
a. Observe the client’s bowel movement
25. A male client’s left tibia is fractures in an and voiding patterns
automobile accident, and a cast is applied. To b. Log-roll the client to prone position
assess for damage to major blood vessels from c. Assess the client’s feet for sensation and
the fracture tibia, the nurse in charge should circulation
monitor the client for: d. Encourage client to drink plenty of fluids
a. Swelling of the left thigh
b. Increased skin temperature of the foot 31. Marina with acute renal failure moves into the
c. Prolonged reperfusion of the toes after diuretic phase after one week of therapy. During
blanching this phase the client must be assessed for signs
d. Increased blood pressure of developing:
a. Hypovolemia
26. After a long leg cast is removed, the male client b. renal failure
should: c. metabolic acidosis
a. Cleanse the leg by scrubbing with a brisk d. hyperkalemia
motion
b. Put leg through full range of motion 32. Nurse Judith obtains a specimen of clear nasal
twice daily drainage from a client with a head injury. Which
c. Report any discomfort or stiffness to the of the following tests differentiates mucus from
physician cerebrospinal fluid (CSF)?
d. Elevate the leg when sitting for long a. Protein
periods of time. b. Specific gravity
c. Glucose
27. While performing a physical assessment of a d. Microorganism
male client with gout of the great toe,
NurseVivian should assess for additional tophi 33. A 22 year old client suffered from his first tonic-
(urate deposits) on the: clonic seizure. Upon awakening the client asks
a. Buttocks the nurse, “What caused me to have a seizure?
b. Ears Which of the following would the nurse include
c. Face in the primary cause of tonic-clonic seizures in
d. Abdomen adults more the 20 years?
a. Electrolyte imbalance
28. Nurse Katrina would recognize that the b. Head trauma
demonstration of crutch walking with tripod gait c. Epilepsy
was understood when the client places weight d. Congenital defect
on the:
a. Palms of the hands and axillary regions 34. What is the priority nursing assessment in the
b. Palms of the hand first 24 hours after admission of the client with
c. Axillary regions thrombotic CVA?
d. Feet, which are set apart a. Pupil size and papillary response
b. cholesterol level
29. Mang Jose with rheumatoid arthritis states, “the c. Echocardiogram
only time I am without pain is when I lie in bed d. Bowel sounds
perfectly still”. During the convalescent stage,
the nurse in charge with Mang Jose should 35. Nurse Linda is preparing a client with multiple
encourage: sclerosis for discharge from the hospital to
a. Active joint flexion and extension home. Which of the following instruction is most
b. Continued immobility until pain subsides appropriate?
c. Range of motion exercises twice daily
d. Flexion exercises three times daily

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a. “Practice using the mechanical aids that d. A client with U.T.I

you will need when future disabilities
arise”. 42. Among the following clients, which among them
b. “Follow good health habits to change is high risk for potential hazards from the
the course of the disease”. surgical experience?
c. “Keep active, use stress reduction a. 67-year-old client
strategies, and avoid fatigue. b. 49-year-old client
d. “You will need to accept the necessity c. 33-year-old client
for a quiet and inactive lifestyle”. d. 15-year-old client

36. The nurse is aware the early indicator of hypoxia 43. Nurse Jon assesses vital signs on a client
in the unconscious client is: undergone epidural anesthesia.
a. Cyanosis 44. Which of the following would the nurse assess
b. Increased respirations next?
c. Hypertension a. Headache
d. Restlessness b. Bladder distension
c. Dizziness
37. A client is experiencing spinal shock. Nurse d. Ability to move legs
Myrna should expect the function of the bladder
to be which of the following? 45. Nurse Katrina should anticipate that all of the
a. Normal following drugs may be used in the attempt to
b. Atonic control the symptoms of Meniere's disease
c. Spastic except:
d. Uncontrolled a. Antiemetics
b. Diuretics
38. Which of the following stage the carcinogen is c. Antihistamines
irreversible? d. Glucocorticoids
a. Progression stage
b. Initiation stage 46. Which of the following complications associated
c. Regression stage with tracheostomy tube?
d. Promotion stage a. Increased cardiac output
b. Acute respiratory distress syndrome
39. Among the following components thorough pain (ARDS)
assessment, which is the most significant? c. Increased blood pressure
a. Effect d. Damage to laryngeal nerves
b. Cause
c. Causing factors 47. Nurse Faith should recognize that fluid shift in a
d. Intensity client with burn injury results from increase in
the:
40. A 65 year old female is experiencing flare up of a. Total volume of circulating whole blood
pruritus. Which of the client’s action could b. Total volume of intravascular plasma
aggravate the cause of flare ups? c. Permeability of capillary walls
a. Sleeping in cool and humidified d. Permeability of kidney tubules
environment
b. Daily baths with fragrant soap 48. An 83-year-old woman has several ecchymotic
c. Using clothes made from 100% cotton areas on her right arm. The bruises are probably
d. Increasing fluid intake caused by:
a. increased capillary fragility and
41. Atropine sulfate (Atropine) is contraindicated in permeability
all but one of the following client? b. increased blood supply to the skin
a. A client with high blood c. self-inflicted injury
b. A client with bowel obstruction d. elder abuse
c. A client with glaucoma
 49. Nurse Anna is aware that early adaptation of
client with renal carcinoma is:
a. Nausea and vomiting
b. flank pain
c. weight gain
d. intermittent hematuria

50. A male client with tuberculosis asks Nurse Brian

how long the chemotherapy must be continued.
Nurse Brian’s accurate reply would be:
a. 1 to 3 weeks
b. 6 to 12 months
c. 3 to 5 months
d. 3 years and more

51. A client has undergone laryngectomy. The

immediate nursing priority would be:
a. Keep trachea free of secretions
b. Monitor for signs of infection
c. Provide emotional support
d. Promote means of communication

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ANSWERS AND RATIONALE – MEDICAL SURGICAL 14. A. Good source of vitamin B12 are dairy
NURSING products and meats.
15. C. Aplastic anemia decreases the bone marrow
1. C. Glucocorticoids (steroids) are used for their production of RBC’s, white blood cells, and
anti-inflammatory action, which decreases the platelets. The client is at risk for bruising and
development of edema. bleeding tendencies.
2. A. The blood must be stopped at once, and then 16. B. An elective procedure is scheduled in advance
normal saline should be infused to keep the line so that all preparations can be completed ahead
patent and maintain blood volume. of time. The vital signs are the final check that
3. B. These tests confirm the presence of HIV must be completed before the client leaves the
antibodies that occur in response to the room so that continuity of care and assessment
presence of the human immunodeficiency virus is provided for.
(HIV). 17. A. The peak incidence of Acute Lymphocytic
4. D. One cup of cottage cheese contains Leukemia (ALL) is 4 years of age. It is uncommon
approximately 225 calories, 27g of protein, 9g of after 15 years of age.
fat, 30mg cholesterol, and 6g of carbohydrate. 18. D. Acute Lymphocytic Leukemia (ALL) does not
Proteins of high biologic value (HBV) contain cause gastric distention. It does invade the
optimal levels of amino acids essential for life. central nervous system, and clients experience
5. A. Elevation of uremic waste products causes headaches and vomiting from meningeal
irritation of the nerves, resulting in flapping irritation.
hand tremors. 19. B. Disseminated Intravascular Coagulation (DIC)
6. B. This indicates that the bladder is distended has not been found to respond to oral
with urine, therefore palpable. anticoagulants such as Coumadin.
7. C. Elevation increases lymphatic drainage, 20. A. Urine output provides the most sensitive
reducing edema and pain. indication of the client’s response to therapy for
8. B. Detection of myoglobin is a diagnostic tool to hypovolemic shock. Urine output should be
determine whether myocardial damage has consistently greater than 30 to 35 mL/hr.
occurred. 21. C. Early warning signs of laryngeal cancer can
9. D. When mitral stenosis is present, the left vary depending on tumor location. Hoarseness
atrium has difficulty emptying its contents into lasting 2 weeks should be evaluated because it is
the left ventricle because there is no valve to one of the most common warning signs.
prevent back ward flow into the pulmonary vein, 22. C. Steroids decrease the body’s immune
the pulmonary circulation is under pressure. response thus decreasing the production of
10. A. Managing hypertension is the priority for the antibodies that attack the acetylcholine
client with hypertension. Clients with receptors at the neuromuscular junction
hypertension frequently do not experience pain, 23. C. The osmotic diuretic mannitol is
deficient volume, or impaired skin integrity. It is contraindicated in the presence of inadequate
the asymptomatic nature of hypertension that renal function or heart failure because it
makes it so difficult to treat. increases the intravascular volume that must be
11. C. Because of its widespread vasodilating effects, filtered and excreted by the kidney.
nitroglycerin often produces side effects such as 24. A. These devices are more accurate because
headache, hypotension and dizziness. they are easily to used and have improved
12. A. An increased in LDL cholesterol concentration adherence in insulin regimens by young people
has been documented at risk factor for the because the medication can be administered
development of atherosclerosis. LDL cholesterol discreetly.
is not broken down into the liver but is 25. C. Damage to blood vessels may decrease the
deposited into the wall of the blood vessels. circulatory perfusion of the toes, this would
13. D. There is a potential alteration in renal indicate the lack of blood supply to the
perfusion manifested by decreased urine output. extremity.
The altered renal perfusion may be related to 26. D. Elevation will help control the edema that
renal artery embolism, prolonged hypotension, usually occurs.
or prolonged aortic cross-clamping during the 27. B. Uric acid has a low solubility, it tends to
surgery. precipitate and form deposits at various sites
 where blood flow is least active, including 43. B. The last area to return sensation is in the
cartilaginous tissue such as the ears. perineal area, and the nurse in charge should
28. B. The palms should bear the client’s weight to monitor the client for distended bladder.
avoid damage to the nerves in the axilla. 44. D. Glucocorticoids play no significant role in
29. A. Active exercises, alternating extension, disease treatment.
flexion, abduction, and adduction, mobilize 45. D. Tracheostomy tube has several potential
exudates in the joints relieves stiffness and pain. complications including bleeding, infection and
30. C. Alteration in sensation and circulation laryngeal nerve damage.
indicates damage to the spinal cord, if these 46. C. In burn, the capillaries and small vessels
occurs notify physician immediately. dilate, and cell damage cause the release of a
31. A. In the diuretic phase fluid retained during the histamine-like substance. The substance causes
oliguric phase is excreted and may reach 3 to 5 the capillary walls to become more permeable
liters daily, hypovolemia may occur and fluids and significant quantities of fluid are lost.
should be replaced. 47. A. Aging process involves increased capillary
32. C. The constituents of CSF are similar to those of fragility and permeability. Older adults have a
blood plasma. An examination for glucose decreased amount of subcutaneous fat and
content is done to determine whether a body cause an increased incidence of bruise like
fluid is a mucus or a CSF. A CSF normally contains lesions caused by collection of extravascular
glucose. blood in loosely structured dermis.
33. B. Trauma is one of the primary causes of brain 48. D. Intermittent pain is the classic sign of renal
damage and seizure activity in adults. Other carcinoma. It is primarily due to capillary erosion
common causes of seizure activity in adults by the cancerous growth.
include neoplasms, withdrawal from drugs and 49. B. Tubercle bacillus is a drug resistant organism
alcohol, and vascular disease. and takes a long time to be eradicated. Usually a
34. A. It is crucial to monitor the pupil size and combination of three drugs is used for minimum
papillary response to indicate changes around of 6 months and at least six months beyond
the cranial nerves. culture conversion.
35. C. The nurse most positive approach is to 50. A. Patent airway is the most priority; therefore
encourage the client with multiple sclerosis to removal of secretions is necessary
stay active, use stress reduction techniques and
avoid fatigue because it is important to support
the immune system while remaining active.
36. D. Restlessness is an early indicator of hypoxia.
The nurse should suspect hypoxia in unconscious
client who suddenly becomes restless.
37. B. In spinal shock, the bladder becomes
completely atonic and will continue to fill unless
the client is catheterized.
38. A. Progression stage is the change of tumor from
the preneoplastic state or low degree of
malignancy to a fast growing tumor that cannot
be reversed.
39. D. Intensity is the major indicative of severity of
pain and it is important for the evaluation of the
treatment.
40. B. The use of fragrant soap is very drying to skin
hence causing the pruritus.
41. C. Atropine sulfate is contraindicated with
glaucoma patients because it increases
intraocular pressure.
42. A. A 67 year old client is greater risk because the
older adult client is more likely to have a less-
effective immune system.

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