Sample Review Question for Medical and

Surgical Nursing
1. When auscultating the breath sounds of a client
with bacterial pneumonia, the nurse would expect to
find which assessment data?

A. Adventitious breath sounds with

crackles and wheezes
B. Bronchial breath sounds over
consolidated lung fields
C. Decreased breath sounds with
crackles and a pleural friction rub
D. Wheezing with expiration more
prolonged than inspiration
 
Correct Answer: B
Rationale: In normal, clear lungs, bronchial breath sounds
would be heard over the large airways and vesicular breath
sounds would be heard over the clear lungs.
With pneumonia, exudate fills the air spaces producing
consolidation and bronchial breath sounds over these areas.
Adventitious breath sounds, including crackles and wheezes,
would be indicative of acute respiratory failure. Decreased
breath sounds with crackles and a pleural friction rub would
suggest a pulmonary embolism.
Wheezing with expiration that is more prolonged than
inspiration is indicative of chronic obstructive pulmonary
disease.
2. When documenting the assessment finding of a
client with emphysema who has an increase in the
anteroposterior diameter of the chest, which term
would the nurse use?

A. Barrel chest
B. Flail chest
C. Funnel chest
D. Pigeon chest
Correct Answer: A
Rationale: Barrel chest is a term that refers to an increase
in the anteroposterior diameter of the chest, resulting
from overinflation of the lungs.
A flail chest results from fractured ribs when a portion
of the chest pulls inward upon inspiration.
A funnel chest refers to a depression of the lower part
of the sternum.
A pigeon chest refers to an anterior displacement of
the sternum protruding beyond the abdominal plane.
3. When caring for a client with a chest tube inserted
in the right chest wall, which assessment data would
lead the nurse to suspect that the client is
experiencing a tension pneumothorax?
A. A cough with purulent sputum
B. Frothy pink-tinged sputum
C. Markedly decreased ventilation
in the left lung
D. D. Subcutaneous emphysema
in the chest wall
Correct Answer: C
 Rationale: Decreased ventilation in the opposite
lung is indicative of a mediastinal shift, which
leads to a tension pneumothorax.
 A cough with purulent sputum is usually seen in

clients diagnosed with pneumonia.

 Hemoptysis is indicative of lung disease, such as

pulmonary embolism and lung cancer.

 Subcutaneous emphysema, air accumulation in

the tissues giving a crackling sensation when

palpitated, is usually associated with chest
trauma.
4. When evaluating risk for developing cancer, which
client would the nurse identify as having the highest
risk?
A. An asphalt road construction worker who eats meats
and potatoes
B. A new breast-feeding mother who works in a bank

C. An oncology nurse who takes vitamins C and E daily

D. A vegetarian who works at a convenience store
Correct Answer: A
Rationale: Exposure to certain chemicals such as tar, soot,
asphalt, oils, and sunlight put this occupation at the highest
risk. Also, meats and potatoes are low in fiber, contributing
to the risk of cancer. Plus, some processed meats contain
chemicals that have been implicated in the development of
cancer.
Breast-feeding does not increase the client’s risk of developing
cancer. Office work also is not considered a risk factor.
Working with cancer clients does not increase a person’s risk
for developing cancer. Vitamins C and E have been shown to
demonstrate preventative attributes.
A vegetarian diet is considered to be a healthier diet for
deduction of cancer risk because it provides increased fiber.
Cruciferous vegetables have been shown to be preventative.
Working in a convenience store does not increase risk.
5. A client with a history of coronary artery disease
begins to experience chest pain. After putting the
client on bedrest and administering a nitroglycerin
tablet sublingually, which intervention should the
nurse implement first?

A. Calling the health care provider

B. Checking the heart’s creatine kinase MB
(CK-MB) level
C. Getting a 12-lead electrocardiogram (ECG)
D. Preparing the client for angioplasty
Correct Answer: C
Rationale: For the client experiencing chest pain,
obtaining a 12-lead ECG is a priority to reveal
possible changes occurring during an acute
anginal attack that will be helpful in treatment.
Before calling the health care provider, the nurse
should obtain the results of the 12-lead ECG so
that these results can be communicated to him.
A CK-MB level may be ordered later and the client
may need angioplasty in the near future, but
getting the 12-lead ECG during the chest pain is
the most important priority.
6. Which signs and symptoms would alert the nurse
to the possibility of a major complication in a client
with pericarditis?
A. Crushing chest pain and diaphoresis
B. Dyspnea and copious blood-tinged, frothy
sputum
C. Hypotension and muffled heart sounds
D. Tachycardia and oliguria
Correct Answer: C
Rationale: A major complication associated with pericarditis is
pericardial effusion or cardiac tamponade manifested by
hypotension and muffled heart sounds.
Crushing chest pain and diaphoresis are signs of myocardial
infarction.
Dyspnea and copious blood-tinged, frothy sputum are signs of
acute pulmonary edema, a complication of left-sided heart
failure.
Tachycardia and oliguria are signs of hemorrhagic shock.
7. Which assessment finding would the nurse identify
as indicative of a client’s altered peripheral vascular
function?

A. Ankle arm index pressure of 0.4

B. Capillary refill time of less than 3 seconds
C. Diastolic blood pressure of 84 mm Hg
D. Pulses graded as being +4
Correct Answer: A
Rationale: The ankle arm index is an objective indicator of
arterial disease. Normal value is 1.0. Values less than 0.5
indicate ischemic rest pain.
A capillary refill time of less than 3 seconds is considered
normal.
A diastolic blood pressure of 84 mm Hg is considered within
the normal range.
Pulses graded as +4 are considered normal.
8. Which valvular disorder would the nurse suspect in
a client presenting with fatigue, hemoptysis, and
dyspnea on exertion?

A. Aortic insufficiency
B. Aortic stenosis
C. Mitral insufficiency
D. Mitral stenosis
Correct Answer: D
Rationale: Mitral stenosis is an obstruction of blood flowing from the
left atrium into the left ventricle, commonly manifested by
progressive fatigue due to low cardiac output, hemoptysis, and
dyspnea on exertion secondary to pulmonary venous hypertension.
Aortic insufficiency refers to the backflow of blood from the aorta
into the left ventricle during diastole; most clients are
asymptomatic, except for a complaint of a forceful heartbeat.
Aortic stenosis refers to a narrowing of the orifice between the left
ventricle and the aorta; many clients experience no symptoms early
on, but eventually develop exertional dyspnea, dizziness, and
fainting.
Mitral insufficiency refers to the backflow of blood from the left
ventricle and aorta; many clients experience no symptoms early on,
but eventually develop exertional dyspnea, dizziness, and fainting.
9. When developing a teaching plan for clients with
chronic obstructive pulmonary disease (COPD) about
the prevention of acute exacerbations, which topic
should be included?

A. Administration of antibiotics
B. Administration of oxygen as needed
C. Performance of deep-breathing and
coughing exercises
D. Elimination of exposure to pulmonary
irritants
Correct Answer: D
Rationale: One aspect of exacerbation prevention focuses
on eliminating the causes and contributory factors
associated with COPD, such as pulmonary irritants (e.g.,
smoke, air pollution, occupational irritants, and
allergies).
Prevention would focus on eliminating these irritants.
Antibiotics are used to treat bronchial infection during
exacerbations, but they are not used prophylactically.
Although oxygen is used in managing acute
exacerbations, it is not a preventative measure.
Coughing and deep breathing may help clients clear their
airways and prevent further atelectasis, but they will not
prevent exacerbation.
10. Which medication would the nurse expect the health care
provider to order immediately for a client who is newly
diagnosed with chronic obstructive pulmonary disease (COPD)?
A. A bronchodilator
B. A corticosteroid
C. An anticoagulant
D. An antitussive agent
Correct Answer: A
Rationale: Initially, for the client newly diagnosed with COPD,
the health care provider would order a bronchodilator to open
the airways and ease dyspnea.
Corticosteroids may be ordered for the client with COPD, but
they are usually used for acute exacerbations, not as an initial
drug.
Anticoagulants interfere with the clotting cascade and would be
ordered for a client with an embolic disorder such as
pulmonary embolism.
An antitussive agent would be used for the client with
coughing, such as that occurring with pneumonia
1. For a client receiving oral anticoagulant therapy for chronic
atrial fibrillation, the nurse would be correct in withholding the
medication if which assessment data is present?
A. Apical heart rate below 60 beats per minute
B. Elevated erythrocyte sedimentation rate
(ESR)
C. International Normalized Ratio (INR) above 5
D. Partial thromboplastin time (PTT) of 25
seconds
Correct Answer: C
 Rationale: The INR value for a client with chronic atrial
fibrillation receiving oral anticoagulants should be kept
between 2 and 3; any value above 3 would place the client at
risk for hemorrhage, especially if anticoagulant therapy was
continued.
 Anticoagulant therapy is given to prevent clots from forming
in the atria. It should not be held related to heart rate.
(Digoxin is sometimes held for heart rates below 60 beats per
minute.)
 ESR is not an indicator of anticoagulant effectiveness and has
no bearing on whether or not the drug should be held.
 Prothrombin time, not PTT, is used to monitor the
effectiveness of oral anticoagulants; also, a PTT value of 25
seconds is considered within the normal range.
2. Which discharge teaching would be most appropriate to
promote vasodilation in a client with arterial occlusion?

A. Mechanically squeezing the affected tissue

B. Using antiembolism stockings
C. Using warm water when bathing
D. Walking with a heel-toe gait
Correct Answer: C
Rationale: Using warm water when bathing is helpful because
heat causes vessels to dilate, thereby increasing blood flow;
make sure that the client knows not to use hot water because
of his decreased temperature sensation.
Mechanical squeezing of the tissues is performed for
lymphedema.
Antiembolism hose are not indicated for use with arterial
occlusions and should be avoided. Walking with a heel-toe
gait is suggested for clients with deep vein thrombosis.
3. Which intervention should the nurse include in the discharge
plan for a client who has experienced a myocardial infarction
(MI)?

A. Assisting the client in planning for retirement

activities
B. Encouraging the client’s family to take a
cardiopulmonary resuscitation (CPR) course
C. Instructing the client to have cardiac enzymes
checked monthly
D. Teaching the client about food choices for a high-
fiber, high-protein diet
Correct Answer: B
Rationale: Encouraging the client’s family to take a CPR
course is important to ensure that the family is prepared
to give CPR should the client experience another MI. The
client should participate in a cardiac rehabilitation
program, not plan for retirement activities.
The nurse should discuss ways to prevent complications
secondary to coronary artery disease, but monthly
testing of cardiac enzymes is unnecessary.
Typically, a low-sodium, low-cholesterol, and low-fat diet
is recommended after an MI. Although high fiber is
encouraged to minimize straining with stool, protein
intake does not need to be increased.
4. Which client statement would indicate a possible
problem with peripheral vascular function?

A. “I can feel my heart beating in my abdomen

when I am lying down.”
B. “I get pain in my legs when I walk down the
street more than two blocks.”
C. “I often have pain near my upper right rib and
back after eating a heavy meal.”
D. “I stopped smoking last year, but I still have
difficulty breathing sometimes.”
Correct Answer: B

Rationale: Complaints of pain in the legs with

activity are a cardinal sign of arterial insufficiency.
Reports of feeling the heart beating in the abdomen
when lying down are commonly seen with aortic
aneurysm.
Complaints of pain in the right upper rib region
and back, especially after eating a heavy meal,
suggest biliary colic.
Difficulty breathing even after smoking cessation
may suggest pulmonary problems that are
unrelated to peripheral vascular function.
5. A client diagnosed with pneumonia is experiencing
pleuritic pain located on the right side of his chest.
Which nursing intervention would be most
appropriate for relieving the pain?
A. Administrating oxygen during
episodes of pain
B. Encouraging the client to cough and
deep-breathe
C. Encouraging the client to lay on the
right side
D. Giving an ordered opioid analgesic
around the clock
Correct Answer: C
 Rationale: Splinting the affected side, such as by
having the client lie on the right side, restricts
expansion and reduces friction between pleurae,
which helps decrease the pain.
 Oxygen will not help relieve pain, but it will help to

relieve dyspnea and hypoxemia.

 Coughing and deep-breathing is necessary, but

these typically will increase the client’s pain, not

relieve it.
 Opioid analgesics should be administered with

caution to prevent depression of the cough reflex

and respiratory drive.
6. Which electrocardiogram change would the nurse
expect to assess in a client complaining of chest pain
and experiencing myocardial ischemia?

A. Inverted T waves
B. Prolonged PR intervals
C. ST-segment elevation
D. Widening QRS complexes
Correct Answer: A
 Rationale: Inverted T waves are a sign of
ischemic changes.
 Prolonged PR intervals signal a delay in

atrioventricular junction. ST-segment

elevation suggests cardiac muscle injury.
 Widened QRS complexes suggest bundle-

branch blocks and ventricular beats.

7. Which data would the nurse expect to assess in a
client admitted with right-sided heart failure?

A. Heart sound and

tachycardia
B. Decreased urinary
output and restlessness
C. Nausea and anorexia
D. Orthopnea and crackles
Correct Answer: C
 Rationale: In right-sided heart failure, the viscera
and peripheral tissues become congested.
 Venous engorgement and venous stasis in the

abdominal organs lead to nausea and anorexia in

right-sided heart failure.
 A heart sound, tachycardia, decreased blood flow to

the kidneys causing decreased urinary output, and

restlessness due to impaired gas exchange and
tissue oxygenation occur with left-sided heart
failure.
 Congestion in the lungs in left-sided heart failure

produces orthopnea and crackles.

8. Two days following insertion of a temporary demand
pacemaker set at 60 beats per minute, the nurse assesses the
client’s heart rate at 85 beats per minute. Which intervention
should the nurse implement?

A. Further monitoring of the client’s vital

signs as ordered
B. Getting an electrocardiogram (ECG) to
verify pacemaker capture
C. Increasing the pacemaker setting to 70
beats per minute
D. Notifying the health care provider of
possible pacer malfunction
Correct Answer: A
 Rationale: The client’s pacemaker is a demand type
pacemaker that senses the heart’s intrinsic rhythm; it will
only function if the client’s own heart rate falls below the
predetermined set rate. There is nothing wrong in this
situation. Nothing should be changed and there is no need to
contact the health care provider.
 Because the client’s heart rate is 85, the pacemaker will not
fire and there will be no pacemaker spikes to see on an ECG.
(However, if a problem occurs, the nurse would not change
any settings without the health care provider’s order.)
9. Which instruction would the nurse include when teaching
clients diagnosed with irritable bowel syndrome (IBS)?

A. Decrease fluid intake during meals.

B. Eat a bland diet.
C. Eat high-fiber, low gas-forming foods.
D. Take antianxiety agents.
Correct Answer: C
 Rationale: Clients with IBS should eat a high-
fiber, low gas-producing diet and increase,
not decrease, their fluid intake.
 No supportive evidence exists that a bland

diet helps to alleviate the symptoms of IBS.

 Stress can cause exacerbations of IBS, but

administration of antianxiety agents is

usually not necessary.
10. A client has a diagnosis of hypertension based on three
systolic blood pressure readings above 90 mm Hg. Which data
would the nurse expect to find on assessment?

A. Ankle edema
B. Bluish-white skin
C. Chronic swollen limbs
D. No abnormal symptoms
Correct Answer: D
 Rationale: Hypertension usually produces no
symptoms until vascular changes occur.
 Ankle edema is typically seen with varicose veins.
 Bluish-white skin is typically seen with frostbite.
 Chronic swollen limbs are associated with chronic
venous insufficiency.