THE ANSWERS are in the last page.
This is Medical Surgical Nursing practice Test 3. Applicable for all Nursing exams and that includes: NLCEX, CRNE, CGFNS, NLE.
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Medical
Surgical Nursing Practice Test Part 3
1. A client is scheduled for insertion of an
inferior vena cava (IVC) filter. Nurse Patricia consults the physician about
withholding which regularly scheduled medication on the day before the surgery?
a. Potassium Chloride
b. Warfarin Sodium
c. Furosemide
d. Docusate
2. A nurse is planning to assess the corneal
reflex on unconscious client. Which of the following is the safest stimulus to
touch the client’s cornea?
a. Cotton buds
b. Sterile glove
c. Sterile tongue depressor
d. Wisp of cotton
3. A female client develops an infection at
the catheter insertion site. The nurse in charge uses the term “iatrogenic”
when describing the infection because it resulted from:
a. Client’s developmental level
b. Therapeutic procedure
c. Poor hygiene
d. Inadequate dietary patterns
4. Nurse Carol is assessing a client with
Parkinson’s disease. The nurse recognize bradykinesia when the client exhibits:
a. Intentional tremor
b. Paralysis of limbs
c. Muscle spasm
d. Lack of spontaneous movement
5. A client who suffered from automobile
accident complains of seeing frequent flashes of light. The nurse should
expect:
a. Myopia
b. Detached retina
c. Glaucoma
d. Scleroderma
6. Kate with severe head injury is being
monitored by the nurse for increasing intracranial pressure (ICP). Which
finding should be most indicative sign of increasing intracranial pressure?
a. Intermittent tachycardia
b. Polydipsia
c. Tachypnea
d. Increased restlessness
7. A hospitalized client had a tonic-clonic
seizure while walking in the hall. During the seizure the nurse priority should
be:
a. Hold the clients arms and leg firmly
b. Place the client immediately to soft
surface
c. Protects the client’s head from injury
d. Attempt to insert a tongue depressor
between the client’s teeth
8. A client has undergone right
pneumonectomy. When turning the client, the nurse should plan to position the
client either:
a. Right side-lying position or supine
b. High fowlers
c. Right or left side lying position
d. Low fowler’s position
9. Nurse Jenny should caution a female
client who is sexually active in taking Isoniazid (INH) because the drug has
which of the following side effects?
a. Prevents ovulation
b. Has a mutagenic effect on ova
c. Decreases the effectiveness of oral
contraceptives
d. Increases the risk of vaginal infection
10. A client has undergone gastrectomy.
Nurse Jovy is aware that the best position for the client is:
a. Left side lying
b. Low fowler’s
c. Prone
d. Supine
11. During the initial postoperative period
of the client’s stoma. The nurse evaluates which of the following observations
should be reported immediately to the physician?
a. Stoma is dark red to purple
b. Stoma is oozes a small amount of blood
c. Stoma is lightly edematous
d. Stoma does not expel stool
12. Kate which has diagnosed with ulcerative
colitis is following physician’s order for bed rest with bathroom privileges.
What is the rationale for this activity restriction?
a. Prevent injury
b. Promote rest and comfort
c. Reduce intestinal peristalsis
d. Conserve energy
13. Nurse KC should regularly assess the
client’s ability to metabolize the total parenteral nutrition (TPN) solution
adequately by monitoring the client for which of the following signs:
a. Hyperglycemia
b. Hypoglycemia
c. Hypertension
d. Elevate blood urea nitrogen concentration
14. A female client has an acute
pancreatitis. Which of the following signs and symptoms the nurse would expect
to see?
a. Constipation
b. Hypertension
c. Ascites
d. Jaundice
15. A client is suspected to develop tetany
after a subtotal thyroidectomy. Which of the following symptoms might indicate
tetany?
a. Tingling in the fingers
b. Pain in hands and feet
c. Tension on the suture lines
d. Bleeding on the back of the dressing
16. A 58 year old woman has newly diagnosed
with hypothyroidism. The nurse is aware that the signs and symptoms of
hypothyroidism include:
a. Diarrhea
b. Vomiting
c. Tachycardia
d. Weight gain
17. A client has undergone for an ileal
conduit, the nurse in charge should closely monitor the client for occurrence
of which of the following complications related to pelvic surgery?
a. Ascites
b. Thrombophlebitis
c. Inguinal hernia
d. Peritonitis
18. Dr. Marquez is about to defibrillate a
client in ventricular fibrillation and says in a loud voice “clear”. What
should be the action of the nurse?
a. Places conductive gel pads for
defibrillation on the client’s chest
b. Turn off the mechanical ventilator
c. Shuts off the client’s IV infusion
d. Steps away from the bed and make sure all
others have done the same
19. A client has been diagnosed with
glomerulonephritis complains of thirst. The nurse should offer:
a. Juice
b. Ginger ale
c. Milk shake
d. Hard candy
20. A client with acute renal failure is
aware that the most serious complication of this condition is:
a. Constipation
b. Anemia
c. Infection
d. Platelet dysfunction
21. Nurse Karen is caring for clients in the
OR. The nurse is aware that the last physiologic function that the client loss
during the induction of anesthesia
is:
a. Consciousness
b. Gag reflex
c. Respiratory movement
d. Corneal reflex
22. The nurse is assessing a client with
pleural effusion. The nurse expect to find:
a. Deviation of the trachea towards the
involved side
b. Reduced or absent of breath sounds at the
base of the lung
c. Moist crackles at the posterior of the
lungs
d. Increased resonance with percussion of
the involved area
23. A client admitted with newly diagnosed
with Hodgkin’s disease. Which of the following would the nurse expect the
client to report?
a. Lymph node pain
b. Weight gain
c. Night sweats
d. Headache
24. A client has suffered from fall and
sustained a leg injury. Which appropriate question would the nurse ask the
client to help determine if the injury caused fracture?
a. “Is the pain sharp and continuous?”
b. “Is the pain dull ache?”
c. “Does the discomfort feel like a cramp?”
d. “Does the pain feel like the muscle was
stretched?”
25. The Nurse is assessing the client’s
casted extremity for signs of infection. Which of the following findings is
indicative of infection?
a. Edema
b. Weak distal pulse
c. Coolness of the skin
d. Presence of “hot spot” on the cast
26. Nurse Rhia is performing an otoscopic examination
on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would
expect to note which of the following if this disorder is present?
a. Transparent tympanic membrane
b. Thick and immobile tympanic membrane
c. Pearly colored tympanic membrane
d. Mobile tympanic membrane
27. Nurse Jocelyn is caring for a client
with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses
the client for symptoms of which acid-base disorder?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
28. A male adult client has undergone a
lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the
following values should be negative if the CSF is normal?
a. Red blood cells
b. White blood cells
c. Insulin
d. Protein
29. A client is suspected of developing
diabetes insipidus. Which of the following is the most effective assessment?
a. Taking vital signs every 4 hours
b. Monitoring blood glucose
c. Assessing ABG values every other day
d. Measuring urine output hourly
30. A 58 year old client is suffering from
acute phase of rheumatoid arthritis. Which of the following would the nurse in
charge identify as the lowest priority of the plan of care?
a. Prevent joint deformity
b. Maintaining usual ways of accomplishing
task
c. Relieving pain
d. Preserving joint function
31. Among the following, which client is
autotransfusion possible?
a. Client with AIDS
b. Client with ruptured bowel
c. Client who is in danger of cardiac arrest
d. Client with wound infection
32. Which of the following is not a sign of
thromboembolism?
a. Edema
b. Swelling
c. Redness
d. Coolness
33. Nurse Becky is caring for client who
begins to experience seizure while in bed. Which action should the nurse
implement to prevent aspiration?
a. Position the client on the side with head
flexed forward
b. Elevate the head
c. Use tongue depressor between teeth
d. Loosen restrictive clothing
34. A client has undergone bone biopsy.
Which nursing action should the nurse provide after the procedure?
a. Administer analgesics via IM
b. Monitor vital signs
c. Monitor the site for bleeding, swelling
and hematoma formation
d. Keep area in neutral position
35. A client is suffering from low back
pain. Which of the following exercises will strengthen the lower back muscle of
the client?
a. Tennis
b. Basketball
c. Diving
d. Swimming
36. A client with peptic ulcer is being
assessed by the nurse for gastrointestinal perforation. The nurse should
monitor for:
a. (+) guaiac stool test
b. Slow, strong pulse
c. Sudden, severe abdominal pain
d. Increased bowel sounds
37. A client has undergone surgery for
retinal detachment. Which of the following goal should be prioritized?
a. Prevent an increase intraocular pressure
b. Alleviate pain
c. Maintain darkened room
d. Promote low-sodium diet
38. A Client with glaucoma has been
prescribed with miotics. The nurse is aware that miotics is for:
a. Constricting pupil
b. Relaxing ciliary muscle
c. Constricting intraocular vessel
d. Paralyzing ciliary muscle
39. When suctioning an unconscious client,
which nursing intervention should the nurse prioritize in maintaining cerebral
perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
d. Hyperoxygenate before and after
suctioning
40. When discussing breathing exercises with
a postoperative client, Nurse Hazel should include which of the following
teaching?
a. Short frequent breaths
b. Exhale with mouth open
c. Exercise twice a day
d. Place hand on the abdomen and feel it
rise
41. Louie, with burns over 35% of the body,
complains of chilling. In promoting the client’s comfort, the nurse should:
a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees
42. Nurse Trish is aware that temporary
heterograft (pig skin) is used to treat burns because this graft will:
a. Relieve pain and promote rapid
epithelialization
b. Be sutured in place for better adherence
c. Debride necrotic epithelium
d. Concurrently used with topical antimicrobials
43. Mark has multiple abrasions and a
laceration to the trunk and all four extremities says, “I can’t eat all this
food”. The food that the nurse should suggest to be eaten first should be:
a. Meat loaf and coffee
b. Meat loaf and strawberries
c. Tomato soup and apple pie
d. Tomato soup and buttered bread
44. Tony returns form surgery with permanent
colostomy. During the first 24 hours the colostomy does not drain. The nurse
should be aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
45. When teaching a client about the signs
of colorectal cancer, Nurse Trish stresses that the most common complaint of
persons with colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
46. Louis develops peritonitis and sepsis
after surgical repair of ruptures diverticulum. The nurse in charge should
expect an assessment of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds
47. Immediately after liver biopsy, the
client is placed on the right side, the nurse is aware that that this position
should be maintained because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary
ducts
c. Position with greatest comfort
d. Promote circulating blood volume
48. Tony has diagnosed with hepatitis A. The
information from the health history that is most likely linked to hepatitis A
is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
49. Nurse Trish is aware that the laboratory
test result that most likely would indicate acute pancreatitis is an elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level
50. Dr. Marquez orders serum electrolytes.
To determine the effect of persistent vomiting, Nurse Trish should be most
concerned with monitoring the:
a. Chloride and sodium levels
b. Phosphate and calcium levels
c. Protein and magnesium levels
d. Sulfate and bicarbonate levels
Answers
and Rationale Medical Surgical Nursing Practice Test Part 3
1. B. In preoperative
period, the nurse should consult with the physician about withholding Warfarin
Sodium to avoid occurrence of hemorrhage.
2. D.
A client who is unconscious is at greater risk for corneal abrasion. For this
reason, the safest way to test the cornel reflex is by touching the cornea
lightly with a wisp of cotton.
3. B.
Iatrogenic infection is caused by the heath care
provider or is induced inadvertently by medical treatment or procedures.
4. D.
Bradykinesia is slowing down from the initiation and execution of movement.
5. B.
This symptom is caused by stimulation of retinal cells by ocular movement.
6. D.
Restlessness indicates a lack of oxygen to the brain stem which impairs the
reticular activating system.
7. C.
Rhythmic contraction and relaxation associated with tonic-clonic seizure can
cause repeated banging of head.
8. A.
Right side lying position or supine position permits ventilation of the
remaining lung and prevent fluid from draining into sutured bronchial stump.
9. C.
Isoniazid (INH) interferes in the effectiveness of oral
contraceptives and clients of childbearing age should be counseled to
use an alternative form of birth control while
taking this drug.
10. B.
A client who has had abdominal surgery is best
placed in a low fowler’s position. This relaxes abdominal
muscles and provides maximum respiratory and cardiovascular function.
11. A.
Dark red to purple stoma indicates inadequate blood supply.
12. C.
The rationale for activity restriction is to help reduce the hypermotility of
the colon.
13. A.
During Total Parenteral Nutrition (TPN) administration, the client should be
monitored regularly for hyperglycemia.
14. D.
Jaundice may be present in acute pancreatitis owing to obstruction of the
biliary duct.
15. A.
Tetany may occur after thyroidectomy if the parathyroid glands are accidentally
injured or removed.
16. D.
Typical signs of hypothyroidism includes weight gain, fatigue, decreased
energy, apathy, brittle nails, dry skin, cold intolerance, constipation and
numbness.
17. B.
After a pelvic surgery, there is an increased chance of thrombophlebitits owing
to the pelvic manipulation that can interfere with circulation and promote
venous stasis.
18. D.
For the safety of all personnel, if the defibrillator paddles are being
discharged, all personnel must stand back and be clear of all the contact with
the client or the client’s bed.
19. D.
Hard candy will relieve thirst and increase carbohydrates but does not supply
extra fluid.
20. C.
Infection
is responsible for one third of the traumatic or surgically induced death of
clients with renal failure as well as medical induced acute renal failure (ARF)
21. C.
There is no respiratory movement in stage 4 of anesthesia, prior to this stage,
respiration is depressed but present.
22. B.
Compression of the lung by fluid that accumulates at the base of the lungs
reduces expansion and air exchange.
23. C.
Assessment of a client with Hodgkin’s disease most often reveals enlarged,
painless lymph node, fever, malaise and night sweats.
24. A.
Fractured pain is generally described as sharp, continuous, and increasing in
frequency.
25. D.
Signs and symptoms of infection under a
casted area include odor or purulent drainage and the presence of “hot spot”
which are areas on the cast that are warmer than the others.
26. B.
Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick
and immobile tymphanic membrane with or without perforation.
27. D.
Loss of gastric fluid via nasogastric suction or vomiting causes metabolic
alkalosis because of the loss of hydrochloric acid which is a potent acid in
the body.
28. A.
The adult with normal cerebrospinal fluid has no red
blood cells.
29. D.
Measuring the urine output to detect excess amount and checking the specific
gravity of urine samples to determine urine concentration are appropriate
measures to determine the onset of diabetes insipidus.
30. B.
The nurse should focus more on developing less stressful ways of accomplishing
routine task.
31. C.
Autotransfusion is acceptable for the client who is in danger of cardiac arrest.
32. D.
The client with thromboembolism does not have coolness.
33. A.
Positioning the client on one side with head flexed forward allows the tongue
to fall forward and facilitates drainage secretions therefore prevents
aspiration.
34. C.
Nursing care after bone biopsy includes close monitoring of the punctured site
for bleeding, swelling and hematoma formation.
35. D.
Walking and swimming are very helpful in strengthening back muscles for the
client suffering from lower back pain.
36. C.
Sudden, severe abdominal
pain is the most indicative sign of perforation. When perforation of an ulcer
occurs, the nurse maybe unable to hear bowel sounds at all.
37. A.
After surgery to correct a detached retina, prevention of increased intraocular
pressure is the priority goal.
38. A.
Miotic agent constricts the pupil and contracts ciliary muscle. These effects
widen the filtration angle and permit increased out flow of aqueous humor.
39. D.
It is a priority to hyperoxygenate the client before and after suctioning to
prevent hypoxia and to maintain cerebral perfusion.
40. D.
Abdominal
breathing improves lungs expansion
41. C.
A Client with burns is very sensitive to temperature changes because heat is
loss in the burn areas.
42. A.
The graft covers the nerve endings, which reduces pain and provides framework
for granulation
43. B.
Meat provides proteins and the fruit proteins vitamin C that both promote wound
healing.
44. C.
This is primarily caused by the trauma of intestinal manipulation and the
depressive effects anesthetics and analgesics.
45. D.
Constipation, diarrhea, and/or constipation alternating with diarrhea are the
most common symptoms of colorectal cancer.
46. B.
With increased intraabdominal pressure, the abdominal
wall will become tender and rigid.
47. A.
Pressure applied in the puncture site indicates that a biliary vessel was
puncture which is a common complication after liver biopsy.
48. B.
Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may
harbor the virus.
49. B.
Amylase concentration is high in the pancreas and is elevated in the serum when
the pancreas becomes acutely inflamed and also it distinguishes pancreatitis
from other acute abdominal
problems.
50. A.
Sodium, which is concerned with the regulation of extracellular fluid volume,
it is lost with vomiting. Chloride, which balances cations in the extracellular
compartments, is also lost with vomiting, because sodium and chloride are
parallel electrolytes, hyponatremia will accompany.
