Review Questions With Rationale

1. After the lungs, the kidneys work to maintain body pH.
The best explanation

of how the kidneys accomplish regulation of pH is that they
a. Secrete hydrogen ions and sodium.
b. Secrete ammonia.
c. Exchange hydrogen and sodium in the kidney tubules.
d. Decrease sodium ions, hold on to hydrogen ions, and then secrete sodium
bicarbonate.
Answer: d
Rationale: By decreasing NA+ ions, holding onto hydrogen ions, and secreting sodium
bicarbonate, the kidneys can regulate pH. Therefore, this is the most complete answer,
and while this buffer system is the slowest, it can completely compensate for acid-base
imbalance.
2. The nurse explains to a client who has just received the diagnosis of
Noninsulin-Dependent Diabetes Mellitus (NIDDM) that sulfonylureas, one
group of oral hypoglycemic agents, act by
a. Stimulating the pancreas to produce or release insulin
b. Making the insulin that is produced more available for use
c. Lowering the blood sugar by facilitating the uptake and utilization of glucose
d. Altering both fat and protein metabolism
Answer: a
Rationale: Sulfonylurea drugs, Orinase for example, lowers the blood sugar by
stimulating the beta cells of the pancreas to synthesize and release insulin.
3. Myasthenic crisis and cholinergic crisis are the major complications of

myasthenia gravis. Which of the following is essential nursing knowledge
when caring for a client in crisis?
a. Weakness and paralysis of the muscles for swallowing and breathing occur in either
crisis
b. Cholinergic drugs should be administered to prevent further complications associated
with the crisis
c. The clinical condition of the client usually improves after several days of treatment
d. Loss of body function creates high levels of anxiety and fear
Answer: a
Rationale: The client cannot handle his own secretions, and respiratory arrest may be
imminent. Atropine may be administered to prevent crisis. Anticholinergic drugs are
administered to increase the levels of acetylcholine at the myoneural junction.
Cholinergic drugs mimic the actions of the parasympathetic nervous system and would
not be used.
5. A 54-year-old client was put in Quinidine (a drug that decreases myocardial

excitability) to prevent atrial fibrillation. He also has kidney disease. The nurse
is aware that this drug, when given to a client with kidney disease, may
a. Cause cardiac arrest
b. Cause hypotension
c. Produce mild bradycardia
d. Be very toxic even in small doses
Answer: a
Rationale: Kidney disease interferes with metabolism and excretion of Quinidine,
resulting in higher drug concentrations in the body. Quinidine can depress myocardial
excitability enough to cause cardiac arrest.
6. A client is about to be discharged on the drug bishydroxycoumarin

(Dicumarol). Of the principles below, which one is the most important to teach
the client before discharge?
a. He should be sure to take the medication before meals
b. He should shave with an electric razor
c. If he misses a dose, he should double the dose at the next scheduled time
d. It is the responsibility of the physician to do the teaching for this medication
Answer: b
Rationale: Dicumarol is an anticoagulant drug and one of the dangers involved is
bleeding. Using a safety razor can lead to bleeding through cuts. The drug should be
given at the same time daily but not related to meals. Due to danger of bleeding,
missed doses should not be made up.
7. A cyanotic client with an unknown diagnosis is admitted to the emergency

room. In relation to oxygen, the first nursing action would be to
a. Wait until the client's lab work is done
b. Not administer oxygen unless ordered by the physician
c. Administer oxygen at 2 liters flow per minute
d. Administer oxygen at 10 liters flow per minute and check the client's nail beds
Answer: c
Rationale: Administer oxygen at 2 liters per minute and no more, for if the client is
emphysemic and receives too high a level of oxygen, he will develop CO2 narcosis and
the respiratory system will cease to function
8. A client with a diagnosis of gout will be taking colchicine and allopurinol bid
to prevent recurrence. The most common early sign of colchicine toxicity that
the nurse will assess for is
a. Blurred vision
b. Anorexia
c. Diarrhea
d. Fever
Answer: c
Rationale: Diarrhea is by far the most common early sign of colchicine toxicity. When
given in the acute phase of gout, the dose of colchicine is usually 0.6 mg (PO) q hr
(not to exceed 10 tablets) until pain is relieved or gastrointestinal symptoms ensue.
9. A client has chronic dermatitis involving the neck, face and antecubital
creases. She has a strong family history of varied allergy disorders. This type
of dermatitis is probably best described as
a. Contact dermatitis
b. Atopic dermatitis
c. Eczema
d. Dermatitis medicamentosa
Answer: b
Rationale: Atopic dermatitis is chronic, pruritic and allergic in nature. Typically it has a
longer course than contact dermatitis and is aggravated by commercial face or body
lotions, emotional stress, and, in some instances, particular foods.
12. The nurse would expect to find an improvement in which of the blood
values as a result of dialysis treatment?
a. High serum creatinine levels
b. Low hemoglobin
c. Hypocalcemia
d. Hypokalemia
Answer: a
Rationale: High creatinine levels will be decreased. Anemia is a result of decreased
production of erythropoietin by the kidney and is not affected by hemodialysis.
Hyperkalemia and high base bicarbonate levels are present in renal failure clients.
13. A 24-year-old client is admitted to the hospital following an automobile

accident. She was brought in unconscious with the following vital signs: BP
130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's
nose. Which of the following interventions will assist in determining the
presence of cerebrospinal fluid?
a. Obtain a culture of the specimen using sterile swabs and send to the laboratory
b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around
the blood
c. Suction the nose gently with a bulb syringe and send specimen to the laboratory
d. Insert sterile packing into the nares and remove in 24 hours
Answer: b
Rationale: The halo or "bull's eye" sign seen when drainage from the nose or ear of a
head-injured client is collected on a sterile gauze is indicative of CSF in the drainage.
The collection of a culture specimen using any type of swab or suction would be
contraindicated because brain tissue may be inadvertently removed at the same time or
other tissue damage may result.
14. A 24-year-old male is admitted with a possible head injury. His arterial
blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60
mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the
nurse would conclude that
a. Edema has resulted from a low pH state
b. Acidosis has caused vasoconstriction of cerebral arterioles
c. Cerebral edema has resulted from a low oxygen state
d. Cerebral blood flow has decreased
Answer: c
Rationale: Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral
vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg.
16. A client is admitted following an automobile accident in which he

sustained a contusion. The nurse knows that the significance of a contusion is
a. That it is reversible
b. Amnesia will occur
c. Loss of consciousness may be transient
d. Laceration of the brain may occur
Answer: d
Rationale: Laceration, a more severe consequence of closed head injury, occurs as the
brain tissue moves across the uneven base of the skull in a contusion. Contusion causes
cerebral dysfunction which results in bruising of the brain. A concussion causes
transient loss of consciousness, retrograde amnesia, and is generally reversible.
17. A client with tuberculosis is given the drug pyrazinamide (Pyrazinamide).

Which one of the following diagnostic tests would be inaccurate if the client is
receiving the drug?
a. Liver function test
b. Gall bladder studies
c. Thyroid function studies
d. Blood glucose
Answer: a
Rationale: Liver function tests can be elevated in clients taking pyrazinamide. This drug
is used when primary and secondary antitubercular drugs are not effective. Urate levels
may be increased and there is a chemical interference with urine ketone levels if these
tests are done while the client is on the drug.
18. Which one of the following conditions could lead to an inaccurate pulse
oximetry reading if the sensor is attached to the client's ear?
a. Artificial nails
b. Vasodilation
c. Hypothermia
d. Movement of the head
Answer: c
Rationale: Hypothermia or fever may lead to an inaccurate reading. Artificial nails may
distort a reading if a finger probe is used. Vasoconstriction can cause an inaccurate
reading of oxygen saturation. Arterial saturations have a close correlation with the
reading from the pulse oximeter as long as the arterial saturation is above 70 percent.
19. While on a camping trip, a friend sustains a snake bite from a poisonous
snake. The most effective initial intervention would be to
a. Place a restrictive band above the snake bite
b. Elevate the bite area above the level of the heart
c. Position the client in a supine position
d. Immobilize the limb
Answer: a
Rationale: A restrictive band 2 to 4 inches above the snake bite is most effective in
containing the venom and minimizing lymphatic and superficial venous return. Elevation
of the limb or immobilization would not be effective interventions.
20. There is a physician's order to irrigate a client's bladder. Which one of the
following nursing measures will ensure patency?
a. Use a solution of sterile water for the irrigation
b. Apply a small amount of pressure to push the mucus out of the catheter tip if the
tube is not patent
c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to
remain for 10 hour, and then siphon it out
d. Irrigate with 20mL's of normal saline to establish patency
Answer: d
Rationale: Normal saline is the fluid of choice for irrigation. It is never advisable to force
fluids into a tubing to check for patency. Sterile water and aqueous Zephiran will affect
the pH of the bladder as well as cause irritation.
21. A female client has orders for an oral cholecystogram. Prior to the test, the
nursing intervention would be to
a. Provide a high fat diet for dinner, then NPO
b. Explain that diarrhea may result from the dye tablets
c. Administer the dye tablets following a regular diet for dinner
d. Administer enemas until clear
Answer: b
Rationale: Diarrhea is a very common response to the dye tablets. A dinner of tea and
toast is usually given to the client. Each dye tablet is given at 5 minute intervals,
usually with 1 glass of water following each tablet. The number of tablets prescribed will
vary, because it is based on the weight of the client.
22. The physician has just completed a liver biopsy. Immediately following the
procedure, the nurse will position the client
a. On his right side to promote hemostasis
b. In Fowler's position to facilitate ventilation
c. Supine to maintain blood pressure
d. In Sims' position to prevent aspiration
Answer: a
Rationale: Placing the client on his right side will allow pressure to be placed on the
puncture site, thus promoting hemostasis and preventing hemorrhage. The other
positions will not be effective in achieving these goals.
23. When a client has peptic ulcer disease, the nurse would expect a priority
intervention to be
a. Assisting in inserting a Miller-Abbott tube
b. Assisting in inserting an arterial pressure line
c. Inserting a nasogastric tube
d. Inserting an IV
Answer: c
Rationale: An NG tube insertion is the most appropriate intervention because it will
determine
the presence of active gastrointestinal bleeding. A Miller-Abbott tube is a weighted,
mercury-filled ballooned tube used to resolve bowel obstructions. There is no evidence
of shock or fluid overload in the client; therefore, an arterial line is not appropriate at
this time and an IV is optional.
25. In preparation for discharge of a client with arterial insufficiency and

Raynaud's disease, client teaching instructions should include
a. Walking several times each day as a part of an exercise routine
b. Keeping the heat up so that the environment is warm
c. Wearing TED hose during the day
d. Using hydrotherapy for increasing oxygenation
Answer: b
Rationale: The client's instructions should include keeping the environment warm to
prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful in
preventing vasoconstriction, but TED hose would not be therapeutic. Walking will most
likely increase pain.
26. When a client asks the nurse why the physician says he "thinks" he has
tuberculosis, the nurse explains to him that diagnosis of tuberculosis can take
several weeks to confirm. Which of the following statements supports this
answer?
a. A positive reaction to a tuberculosis skin test indicates that the client has active
tuberculosis, even if one negative sputum is obtained
b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the
bacillus
c. Because small lesions are hard to detect on chest x-rays, x-rays usually need to be
repeated during several consecutive weeks
d. A client with a positive smear will have to have a positive culture to confirm the
diagnosis
Answer: b
Rationale: Answer b is correct because the culture takes 3 weeks to grow. Usually even
very small lesions can be seen on x-rays due to the natural contrast of the air in the
lungs; therefore, chest x-rays do not need to be repeated frequently (c). Clients may
have positive smears but negative cultures if they have been on medication (d). A
positive skin test indicates the person only has been infected with tuberculosis but may
not necessarily have active disease (a).
27. The nurse is counseling a client with the diagnosis of glaucoma. She
explains that if left untreated, this condition leads to
a. Blindness
b. Myopia
c. Retrolental fibroplasia
d. Uveitis
Answer: a
Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion
cells and the optic nerve, and leads eventually to blindness.
28. A nursing assessment for initial signs of hypoglycemia will include

a. Pallor, blurred vision, weakness, behavioral changes
b. Frequent urination, flushed face, pleural friction rub
c. Abdominal pain, diminished deep tendon reflexes, double vision
d. Weakness, lassitude, irregular pulse, dilated pupils
Answer: a
Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common
symptoms when there is too much insulin or too little food - hypoglycemia. The signs
and symptoms in answers (b) and (c) are indicative of hyperglycemia.
29. The physician has ordered a 24-hour urine specimen. After explaining the
procedure to the client, the nurse collects the first specimen. This specimen is
then
a. Discarded, then the collection begins
b. Saved as part of the 24-hour collection
c. Tested, then discarded
d. Placed in a separate container and later added to the collection
Answer: a
Rationale: The first specimen is discarded because it is considered "old urine" or urine
that was in the bladder before the test began. After the first discarded specimen, urine
is collected for 24 hours.
30. Following an accident, a client is admitted with a head injury and

concurrent cervical spine injury. The physician will use Crutchfield tongs. The
purpose of these tongs is to
a. Hypoextend the vertebral column
b. Hyperextend the vertebral column
c. Decompress the spinal nerves
d. Allow the client to sit up and move without twisting his spine
Answer: b
Rationale: The purpose of the tongs is to decompress the vertebral column through
hyperextending it. Both (a) and (c) are incorrect because they might cause further
damage (d) is incorrect because the client cannot sit up with the tongs in place; only
the head of the bed can be elevated.
31. The most appropriate nursing intervention for a client requiring a finger
probe pulse oximeter is to
a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin
breakdown
b. Set alarms on the oximeter to at least 100 percent
c. Identify if the client has had a recent diagnostic test using intravenous dye
d. Remove the sensor between oxygen saturation readings
Answer: c
Rationale: Clients may experience inaccurate readings if dye has been used for a
diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings.
32. A client being treated for esophageal varices has a Sengstaken-Blakemore
tube inserted to control the bleeding. The most important assessment is for
the nurse to
a. Check that a hemostat is at the bedside
b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on a regular basis
Answer: c
Rationale: The respiratory system can become occluded if the balloon slips and moves
up the esophagus, putting pressure on the trachea. This would result in respiratory
distress and should be assessed frequently. Scissors should be kept at the bedside to
cut the tube if distress occurs. This is a safety intervention.
33. A 55-year-old client with sever epigastric pain due to acute pancreatitis
has been admitted to the hospital. The client's activity at this time should be
a. Ambulation as desired
b. Bedrest in supine position
c. Up ad lib and right side-lying position in bed
d. Bedrest in Fowler's position
Answer: d
Rationale: The pain of pancreatitis is made worse by walking and supine positioning.
The client is more comfortable sitting up and leaning forward.
34. Of the following blood gas values, the one the nurse would expect to see in
the client with acute renal failure is
a. pH 7.49, HCO3 24, PCO2 46
b. pH 7.49, HCO3 14, PCO2 30
c. pH 7.26, HCO3 24, PCO2 46
d. pH 7.26, HCO3 14, PCO2 30
Answer: d
Rationale: The client with acute renal failure would be expected to have metabolic
acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis
(lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45;
HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg.
35. A client in acute renal failure receives an IV infusion of 10% dextrose in

water with 20 units of regular insulin. The nurse understands that the
rationale for this therapy is to
a. Correct the hyperglycemia that occurs with acute renal failure
b. Facilitate the intracellular movement of potassium
c. Provide calories to prevent tissue catabolism and azotemia
d. Force potassium into the cells to prevent arrhythmias
Answer: b
Rationale: Dextrose with insulin helps move potassium into cells and is immediate
management therapy for hyperkalemia due to acute renal failure. An exchange resin
may also be employed. This type of infusion is often administered before cardiac
surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also
added to the infusion.
38. A client has had a cystectomy and ureteroileostomy (ileal conduit). The
nurse observes this client for complications in the postoperative period. Which
of the following symptoms indicates an unexpected outcome and requires
priority care?
a. Edema of the stoma
b. Mucus in the drainage appliance
c. Redness of the stoma
d. Feces in the drainage appliance
Answer: d
Rationale: The ileal conduit procedure incorporates implantation of the ureters into a
portion of the ileum which has been resected from its anatomical position and now
functions as a reservoir or conduit for urine. The proximal and distal ileal borders can
be resumed. Feces should not be draining from the conduit. Edema and a red color of
the stoma are expected outcomes in the immediate postoperative period, as is mucus
from the stoma.
39. A nursing care plan for a client with a suprapubic cystostomy would
include
a. Placing a urinal bag around the tube insertion to collect the urine
b. Clamping the tube and allowing the client to void through the urinary meatus before
removing the tube
c. Catheter irrigations every 4 hours to prevent formation of
urinary stones
d. Limiting fluid intake to 1500 mL per day
Answer: b
Rationale: Allowing the client to void naturally will be done prior to removal of the
catheter to ensure adequate emptying of the bladder. Irrigations are not recommended,
as they increase the chances of the client developing a urinary tract infection. Any time
a client has an indwelling catheter in place, fluids should be encouraged (unless
contraindicated) to prevent stone formation.
40. For a client who has ataxia, which of the following tests would be
performed to assess the ability to ambulate?
a. Kernig's
b. Romberg's
c. Riley-Day's
d. Hoffmann's
Answer: b
Rationale: Romberg's test is the ability to maintain an upright position without swaying
when standing with feet close together and eyes closed. Kernig's sign, a reflex
contraction, is pain in the hamstring muscle when attempting to extend the leg after
flexing the thigh.
41. A client admitted to a surgical unit for possible bleeding in the cerebrum
has vital signs taken every hour to monitor to neurological status. Which of
the following neurological checks will give the nurse the best information
about the extent of bleeding?
a. Pupillary checks
b. Spinal tap
c. Deep tendon reflexes
d. Evaluation of extrapyramidal motor system
Answer: a
Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches as
it becomes displaced by blood, tumor, etc.
42. Assessing for immediate postoperative complications, the nurse knows

that a complication likely to occur following unresolved atelectasis is
a. Hemorrhage
b. Infection
c. Pneumonia
d. Pulmonary embolism
Answer: c
Rationale: Pneumonia is a major complication of unresolved atelectasis and must be
treated along with vigorous treatment for atelectasis. Hemorrhage and infection are not
related to this condition. Pulmonary embolism could result from deep vein thrombosis.
43. A young client is in the hospital with his left leg in Buck's traction. The
team leader asks the nurse to place a footplate on the affected side at the
bottom of the bed. The purpose of this action is to
a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot
Answer: b
Rationale: The purpose of the footplate is to prevent footdrop while the client is
immobilized in traction. This will not anchor the traction, keep the client from sliding
down in bed, or prevent pressure areas.
Medical and Surgical Nursing Practice Questions with Rationale
1. Which nursing intervention would be most appropriate for promoting the environmental safety of a
client with a cognitive disorder?
A. Applying an identification bracelet on the client

B. Maintaining daily routine care for the client
C. Placing a clock and a daily schedule in the client’s room
D. Using short sentences with simple words when speaking with the client
Correct Answer: A
Rationale: Applying an identification bracelet on the client would be most effective in helping to
ensure environmental and client safety should the client wander. Other measures include installing
alarms; instituting injury, fire, and poisoning precautions; providing adequate lighting; and keeping
the bed in a low position. Maintaining a daily routine would be helpful for ensuring consistency and
promoting optimal functioning. Clocks and daily schedules would be helpful for reorienting the client
and promoting optimal cognitive function. Using short sentences with simple words would be
appropriate for maximizing effective communication.
2. Which client complaint would lead the nurse to suspect premenstrual syndrome (PMS)?
A. Fatigue and weight gain on the day prior to menses

B. Headache and mood swings occurring about 10 days prior to menses
C. Mood swings and breast tenderness with the onset of menses
D. Painful menstruation and large menstrual flow
Correct Answer: B
Rationale: Typically, PMS is manifested by complaints of headache, mood swings, irritability, weight
gain, fatigue, and full, tender breasts, occurring approximately 10 days before menses in each cycle.
Painful menstruation and a large menstrual flow are not associated with PMS.
3. When disposing of the plastic bags, tubing, syringes, and gloves used to administer antineoplastic
drugs, the nurse should implement which nursing intervention?
A. Avoiding contact with the equipment by allowing housekeeping to remove it

B. Discarding all used equipment in a container marked “isolation”
C. Disposing of all equipment in a container marked “bio-health hazard”
D. Disposing of all used equipment in the regular trash receptacles
Correct Answer: C
Rationale: Any disposable equipment and supplies used for chemotherapy must be disposed of in a
manner that protects the environment; placing the items in a container marked “bio-health hazard” is
appropriate because these containers can be incinerated at a temperature of 2,200 to 2,500° F so
that there is no residue. Only personnel trained in the proper handling of antineoplastic agents should
handle the wastes. Infectious waste is incinerated at 1,700 to 1,800° F; residue is possible after
incineration at these temperatures, making it an inappropriate method for the disposal of
antineoplastic equipment and supplies. Because the equipment has been contaminated with material
that is carcinogenic, special precautions are required.
4. Which assessment data for a client who is 1 day postabdominal surgery would warrant immediate
nursing intervention?
A. Blood pressure of 110/70 mm Hg and hematocrit of 42%

B. Complaints of abdominal pain as an
C. Hypoactive bowel sounds and a serum potassium of 3.7 mEq/L
D. Rigid, hard, boardlike abdomen and a white blood cell (WBC) count of 20,000 mm
Correct Answer: D
Rationale: One day after abdominal surgery, the client’s abdomen should be soft, not rigid or hard.
Also, the WBC count may be slightly elevated in response to the surgery, but an elevation of 20,000
mmis highly suggestive of an infectious process. A rigid, boardlike abdomen in conjunction with a
seriously elevated WBC count suggests peritonitis and requires immediate intervention. The client’s
blood pressure and hematocrit are within normal limits. One day after surgery, abdominal incisional
pain would be expected and often is rated as high when using a scale from 1 to 10. The client’s
hemoglobin level is within normal limits. Hypoactive bowel sounds would be expected 1 day after
abdominal surgery. The client’s potassium level is within normal limits.
5. The nurse would include which nursing intervention for a client diagnosed with acute diverticulitis?
A. Administration of stimulant laxatives

B. Increased fluid intake
C. Continuation of client’s nothing-by-mouth status
D. High-fiber diet
Correct Answer: C
Rationale: During an acute episode of diverticulitis, measures focus on resting the colon, such as
keeping the client on nothing-by-mouth status, administering I.V. fluids, and maintaining nasogastric
suctioning and bedrest. Administering stimulant laxatives may be appropriate for restoring the client’s
normal bowel elimination, but their use during an acute attack would only serve to irritate the bowel
further. Increased fluid intake would be appropriate for diverticulosis. A high-fiber diet would be
indicated for diverticulosis, but this type of diet would not be appropriate during an acute attack.
6. The nurse would include which nursing intervention in the care plan for a client with an L5-S1
intervertebral disc herniation?
A. Assessing the skeletal traction insertion sites for infection

B. Encouraging the client to ambulate as much as possible
C. Positioning the client with his knees slightly flexed and the head of bed elevated
D. Preparing the client for lumbar puncture
Correct Answer: C
Rationale: Positioning the client with the head of the bed elevated and his knees slightly flexed
increases the disc space and may help to decrease the client’s pain. Skeletal traction is not a
treatment of choice for a herniated disc. The client with an intervertebral disc herniation should be
kept on bedrest. A lumbar puncture is not a diagnostic procedure for intervertebral disc herniation.
7. A 16-year-old client asks the nurse, “What caused me to have acne?” Which statement would be
the nurse’s best response?
A. “Acne is caused by an excess production of sebum.”

B. “Acne is caused by not cleaning your face thoroughly every day.”
C. “Eating lots of chocolate and candy causes you to have acne.”
D. “The exact cause of acne is not really known.”
Correct Answer: D
Rationale: The exact cause of acne is not known, but evidence has shown that acne involves multiple
factors, such as genetics, hormonal factors, and bacterial infections. Excess production of sebum
results in seborrhea. Uncleanliness and dietary indiscretions, such as eating chocolate and candy, do
not cause acne.
8. Which intervention would most important in the prevention of pressure ulcers?
A. Applying external urine collection devices

B. Helping the client to maintain appropriate body position
C. Massaging reddened areas as soon as they are noted
D. Turning the client every 2 hours
Correct Answer: D
Rationale: Turning the client frequently, such as every 2 hours, is one of the single most important
interventions in preventing pressure ulcers because it helps to minimize the effects of pressure on the
skin, allowing pressure to be redistributed with each turn. Applying an external urine collection device
would be appropriate if the client is incontinent, but this action is not always relevant for every client
and thus is not the most important. Helping the client to maintain appropriate body position is
important, but it must be done in conjunction with frequent turning; maintaining body position
without frequent turning would not be beneficial. Reddened areas should never be massaged because
this increases tissue damage.
9. The client with a rectovaginal fistula is at high risk for infection. Which intervention would be the
most important aspect of preventative nursing care?
A. Administering antibiotics
B. Ensuring adequate rest to enhance healing
C. Monitoring temperature and white blood cell (WBC) count
D. Performing perineal hygiene, including irrigations
Correct Answer: D
Rationale: The client with a rectovaginal fistula may experience fecal drainage via the vagina;
preventing infection by keeping the vaginal area clean with irrigation, douches, and sitz baths would
be most important. Administering antibiotics and ensuring adequate rest may be useful in promoting
healing, but they are not preventative measures. Monitoring for symptoms of infection is important,
but perineal hygiene is more effective as a preventative measure.
10. The client with a head injury is experiencing increased intracranial pressure (ICP). Which
medication would the nurse anticipate administering?
A. Anticholinesterase agents
B. Anticonvulsants
C. Loop diuretics
D. Osmotic diuretics
Correct Answer: D
Rationale: Osmotic diuretics such as mannitol are the preferred diuretic in the management of
increased ICP to decrease cerebral edema and, therefore, decrease ICP. Anticholinesterase agents are
used in the management of myasthenia gravis and are not helpful in decreasing ICP. Anticonvulsant
medications would be used to treat seizure activity and are not helpful in decreasing ICP. Loop
diuretics can be given in cases of increased ICP, but they are not a first-line agent.
Sample Review Questions on Medical and Surgical Nursing Part 1
1. Which intervention would the nurse anticipate as the initial action to be included in the care plan for
a client experiencing a tension pneumothorax?
A. Application of on occlusive petroleum dressing

B. Increasing the ventilator’s tidal volume
C. Obtaining a chest X-ray
D. Removal of an occlusive dressing
Correct Answer: D
Rationale: A tension pneumothorax occurs when the pressure increases in the pleural space. Thus,
removing an occlusive dressing will release the increased pressure in the pleural space and help
resolve the tension. Typically, the health care provider will insert a large bore needle initially and then
a chest tube to aid in reinflating the lung. Applying an occlusive dressing will increase the pressure in
the chest and worsen the tension pneumothorax. An occlusive dressing would be appropriate for an
open pneumothorax. Increasing the tidal volume on the ventilator will increase the volume delivered
to the chest, worsening the tension pneumothorax. The diagnosis of a tension pneumothorax is based
on the client’s clinical presentation. It is a medical emergency that can quickly be fatal. Obtaining a
chest X-ray wastes precious minutes that may permit the client to decompensate; it may be
performed once the chest tube has been inserted and the initial build of pressure has been relieved.
2. When teaching a group of women about breast health awareness and breast self-examination (BSE)
at a local community center, the nurse follows the American Cancer Society (ACS) recommendations.
Which recommendation would the nurse include in the teaching program?
A. Bimonthly BSE and yearly mammograms beginning after the woman has had her first child
B. Optional monthly BSE, yearly clinical examination, and yearly mammograms after age 40
C. Quarterly BSE until the age of 70 after which breast health awareness is no longer necessary
D. Yearly BSE and follow up clinical examinations after onset of menses
Correct Answer: B
Rationale: The ACS recommends a yearly clinical examination and yearly mammograms in clients
older than age 40. Monthly self-breast examination is an option for women starting in their 20s. The
risk of breast cancer increases with age. At age 80, there is a 1 in 8 risk of developing breast cancer.
3. When providing postoperative care after a bowel resection to a client with a pre-existing history of
chronic obstructive pulmonary disease (COPD) with frequent exacerbations, for which complication
should the nurse be alert?
A. Acute respiratory failure

B. Airway obstruction
C. Atelectasis
D. Pneumothorax
Correct Answer: A
Rationale: The client is at high risk for developing acute respiratory failure because of his history of
chronic lung disease requiring frequent intubations, the anesthesia used during surgery, and the
experience of surgery. Airway obstruction and atelectasis are postoperative complications, but there is
no evidence that this client would be at greater risk for these complication than anyone else. The
operative procedure and the client’s medical history would not place this client at a greater risk for
postoperative pneumothorax as compared to any other postoperative client.
4. The nurse is doing preoperative teaching for a client about to have a mechanical valve replacement.
Which client statement indicates effective teaching?
A. “I need to make sure I have someone to care for me after this same-day surgery procedure.”
B. “I will always need to take anticoagulants to prevent the formation of blood clots.”
C. “I will need to take several days of steroids each time I have major dental work done.”
D. “Because my valve is from a pig, I need to take precautions to prevent rejection of the valve.”
Correct Answer: B
Rationale: Following mechanical valve replacement surgery, clients need to be educated about the
need for lifelong oral anticoagulant therapy. (Povine or bovine valve replacements do not require
anticoagulants.) Valve replacement surgery is not performed as a day surgery procedure; it requires
that the client be admitted to a critical care unit for constant monitoring due to the potential for
complications. Prophylactic antibiotics, not steroids, are needed after valve replacement surgery.
Rejection of the artificial valve is not a major problem associated with valve replacement surgery.
5. Which collaborative intervention would be included in the care plan for a client with a venous stasis
ulcer to assist with healing?
A. Antiembolism stockings
B. Plaster cast sock
C. Transcutaneous electrical nerve stimulator (TENS)
D. Unna boot
Correct Answer: D
Rationale: An Unna boot is medicated gauze applied to the affected limb from the toes to the knees
after the ulcer is cleaned. The boot is then wrapped in plastic wrap and hardens like a cast promoting
venous return and preventing stasis. Antiembolism stockings are fit tightly and can traumatize an
ulcer when applied. A plaster cast sock is usually applied to a residual limb following amputation to
reduce edema. TENS is used as a pain relief measure; it would have no effect on healing.
6. A client with pulmonary edema is receiving mechanical ventilation with positive end-expiratory
pressure (PEEP). When explaining to a student about the rationale for using PEEP, the nurse would
indicate which rationale as its major purpose?
A. Allows the client to obtain needed rest

B. Increases pulmonary capillary pressure
C. Improves area available for gas exchange
D. Increases the client’s carbon dioxide
Correct Answer: C
Rationale: PEEP helps keep the alveoli expanded, increasing the area available for gas exchange,
thus improving the client’s oxygenation. PEEP has no effect on the client’s ability to rest, decreases
pulmonary capillary pressure, and decreases the client’s carbon dioxide level by increasing the area
for gas exchange.
7. The nurse teaches a client about residual limb care following an amputation and assesses that he
understood the teaching when he demonstrates which behavior?
A. Applies lotions to keep the skin from cracking

B. Elevates the residual limb on a pillow following surgery
C. Lies prone for several hours each day
D. Wraps the residual limb in adhesive bandages
Correct Answer: C
Rationale: Lying prone for several hours each day helps prevent hip contractures and demonstrates
compliance with the treatment regimen. Using lotions keeps the skin soft; however, following an
amputation, the skin needs to become tough. New guidelines recommend elevating the foot of the bed
because a pillow can cause flexion contractures of the hip. Adhesive bandages irritate the skin, leading
to sores, breakdown, and infection.
8. A client with a history of bigeminy who is on a lidocaine drip complains of light-headedness. Which
intervention would the nurse implement
A. Calling the health care provider and getting a stat electrocardiogram (ECG)
B. Checking the rhythm strip and assessing blood pressure
C. Decreasing the lidocaine and instituting seizure precautions
D. Having the client lie down and administering atropine
Correct Answer: B
Rationale: Before doing anything else, the nurse needs to check the rhythm strip and assess the
client’s blood pressure to determine the possible cause of the client’s complaints and gather additional
data so that a full report can be made to the health care provider. An ECG is not needed for diagnosis
of arrhythmia when a rhythm strip will suffice. The client is not exhibiting signs of lidocaine toxicity
and, in fact, the lidocaine may need to be increased. Atropine is the drug of choice for sinus
bradycardia, not premature ventricular contractions.
9. The nurse knows a client with chronic obstructive pulmonary disease (COPD) understands the
discharge teaching when he makes which statement?
A. “I need to drink at least 2 liters of fluid every day.”

B. “I need to take a sleeping pill every night so I wake up rested.”
C. “I should do everything in the morning so I can rest later on.”
D. “I should smoke only when I am not having difficulty breathing.”
Correct Answer: A
Rationale: Secretions are often very thick and difficult to expectorate for clients with COPD; drinking
at least 2 liters of fluid per day will help to thin the secretions and aid in expectoration. Hypnotics and
sedatives such as sleeping pills depress respirations and should be avoided. The client needs to pace
himself and his activities to minimize energy expenditures and prevent exertion. The client should
eliminate exposure to irritants such a smoking.
10. Which assessment finding indicates that furosemide (Lasix), a loop-diuretic, ordered for an elderly
client is achieving its intended results?
A. +4 pitting edema in both legs

B. Nontender calf muscles on palpation
C. Relief of nocturnal leg cramping
D. Systolic blood pressure of 150 mm Hg
Correct Answer: D
Rationale: Furosemide is commonly used as an initial step in treating hypertension. For the elderly
client, a systolic blood pressure of 150 mm Hg would be considered normal and thus indicative that
the drug therapy is effective. Pitting edema of +4 indicates that the drug is not achieving its intended
result because fluid is still present; the client’s medication regime needs to be adjusted or changed.
Furosemide has no effect on calf muscle; relief of tenderness in the calf is seen in deep vein
thrombosis. Loop diuretics do not typically relieve cramping.
1. When caring for a client with arterial occlusive disease of the extremities, what would the nurse
include in the client’s teaching plan?
A. Changing positions frequently and elevating the legs above the heart to promote venous return in
the legs
B. Elevating the arm on a pillow with the elbow higher than the shoulder and the hand higher than the
elbow
C. Elevating the foot of the bed about 6″ (15.2 cm) while the client is sleeping to promote venous
return
D. Keeping the legs in a dependent position in relationship to the heart to improve peripheral blood
flow
Correct Answer: D
Rationale: The client with arterial occlusive disease needs to enhance the blood supply to the body
parts affected; keeping legs in a dependent position in relationship to the heart to improve peripheral
blood flow enhances the blood flow to the extremities. Changing positions frequently and elevating the
legs above the heart to promote venous return in the legs should be included in teaching for the client
with varicose veins. Elevating the arm on a pillow with the elbow higher than the shoulder and hand
higher than the elbow helps to promote lymphatic drainage. Elevating the foot of the bed about 6″
while the client is sleeping to promote venous return is appropriate for the client with deep vein
thrombosis.
2. While caring for a client with a new amputation, the dressing inadvertently comes off the stump.
Which intervention should the nurse implement first?
A. Bedside application of a large tourniquet to prevent massive hemorrhage

B. Elevation of the limb above heart level to promote venous return
C. Maintenance of the client in a supine position to improve peripheral blood flow
D. Immediate application of an elastic compression bandage wrapped around the limb
Correct Answer: D
Rationale: Because excessive edema will develop in a short time, resulting in delays in rehabilitation,
the nurse should wrap the limb with an elastic compression bandage immediately. Before a tourniquet
would be applied, the nurse would need to assess the client for signs and symptoms of bleeding
because applying a tourniquet could compromise the circulatory and neurologic status of the limb.
Elevating the limb above heart level could cause contractures; in this case, venous return is not a
major concern. The supine position is contraindicated. The nurse needs to keep the stump elevated by
raising the foot of the bed.
3. Which assessment finding would the nurse expect to assess in a client with emphysema?
A. Copious sputum
B. Cor pulmonale
C. Anemia
D. Distant breath sounds
Correct Answer: D
Rationale: With emphysema, air trapping and chronic hyperexpansion of the lungs lead to distant
breath sounds. Copious amounts of sputum are produced with chronic bronchitis; with emphysema,
sputum production is usually scant. Cor pulmonale (right-sided heart failure) is more commonly
associated with chronic bronchitis than emphysema. Polycythemia, an increase in red blood cells, may
occur, but emphysema does not lead to anemia.
4. Following a thoracentesis, which assessment finding would warrant immediate intervention by the
nurse?
A. Auscultation of crackles bilaterally

B. Complaints of pain at the needle insertion site
C. Prolonged periods of uncontrolled coughing
D. Symmetrical respirations
Correct Answer: C
Rationale: Uncontrolled coughing in the client following a thoracentesis may indicate the
development of pulmonary edema that requires immediate attention. Bilateral crackles may indicate
underlying inflammation or congestion, but immediate attention is not necessary. Complaints of pain
at the needle insertion site and symmetrical respirations are normal findings.
5. A client arrives in the emergency department following a motor vehicle accident with multiple
injuries to the head, chest, and extremities with minimal bleeding. Which would the nurse assess first?
A. Airway status
B. Blood pressure
C. Level of consciousness
D. Quality of peripheral pulses
Correct Answer: A
Rationale: When dealing with an emergency, the ABCs — airway, breathing, and circulation — are
the priorities and must be maintained first. Blood pressure, neurological, and neurovascular
assessments are important, but in this case, airway is the priority.
6. A client receiving nasogastric tube feedings for the past 48 hours develops a hacking cough, a fever
of 100.6° F (38.1° C), and is moderately dyspneic. Which complication would the nurse suspect?
A. Aspiration pneumonia
B. Chronic obstructive pulmonary disease (COPD)
C. Pleural effusion
D. Pneumoconioses
Correct Answer: A
Rationale: Nasogastric tube feedings may result in aspiration leading to pneumonia, suggested by
the hacking cough, low-grade fever, and moderate dyspnea. Clients with COPD have a chronic cough
and usually are afebrile. Clients with pleural effusion usually have no cough and are afebrile. Clients
with pneumoconioses present with chronic cough and progressive dyspnea.
7. A client is admitted to the health care facility with a diagnosis of acute arterial occlusion. While
performing a physical assessment, what would the nurse expect to observe?
A. Cramping
B. Elephatism
C. Phantom pain
D. Pulselessness
Correct Answer: D
Rationale: Pulselessness is one of the common manifestations of acute arterial occlusion secondary
to cessation of blood flow distal to the occlusion. Cramping is a common complaint associated with
varicose veins. Elephantism is an indication of secondary lymphedema. Phantom pain is pain noted
following a limb amputation.
8. A client with leukemia is undergoing radiation therapy to the brain and spinal cord. In planning care
for this client, the nurse would include which nursing intervention?
A. A scalp ointment to prevent dryness B. Avoiding washing off the target’s marksC. Not allowing the
client to use a hat or scarf
D. A dandruff shampoo twice daily
Correct Answer: B
Rationale: The marks made by the radiation oncologist guide the technician in configuring the
external beam to irradiate the area in question without causing damage to other tissues. These marks
must remain in place and should not be washed off. Ointments, which are petroleum-based, could
cause a radiation burn to the area. The client should be encouraged to use a hat or scarf when in the
sun to prevent damage to the scalp skin and at night to prevent loss of body heat through the scalp;
hats and scarves also help to foster a positive body image. Dandruff shampoo includes harsh
chemicals that could damage already fragile skin; the area being irradiated should be washed with
water and the skin patted dry.
9. Which intervention would the nurse include in the teaching plan for a client diagnosed with
gastroesophageal reflux disease (GERD)?
A. Avoiding eating within 2 hours of bedtime

B. Eating a high-fat, low-fiber diet
C. Completing all antibiotics
D. Sleeping with the head of the bed flat
Correct Answer: A
Rationale: Clients with GERD should avoid eating prior to retiring or lying down to decrease the
incidence of reflux. The client with GERD will be prescribed a low-fat, high-fiber diet. Antibiotics are
not used to treat GERD, although antibiotics are used for clients with <i>Helicobacter pylori</i>
infection and peptic ulcer disease. The client with GERD should elevate the head on pillows or use
blocks under the head of the bed to minimize reflux.
10. Which would the nurse include in the discharge teaching plan for an elderly client diagnosed with
pneumonia?
A .Demonstration of postural drainage techniques

B. Demonstration of pursed lip breathing
C. Discussion of proper use of oxygen therapy
D. Instructions about increasing fluid intake
Correct Answer: D
Rationale: Pneumonia typically causes thick secretions that may be difficult for the elderly client to
expectorate; increasing fluid intake will help thin secretions, ultimately aiding in their removal.
Postural drainage usually is recommended for clients diagnosed with bronchitis and emphysema.
Pursed lip breathing and oxygen therapy usually are recommended for clients with chronic obstructive
pulmonary disease. A client with pneumonia typically does not require oxygen at home.
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.
1. A client who is complaining of right lower quadrant pain, nausea, and vomiting has a low-grade
fever, rebound tenderness, and an elevated white blood cell (WBC) count. Which intervention should
the nurse perform first?
A. Administering antacids for gastroenteritis

B. Advising the client to assume a high Fowler’s position for a peptic ulcer
C. Calling the surgeon in anticipation of an appendectomy
D. Suggesting a course of antibiotics to treat peritonitis
Correct Answer: C
Rationale: The client is exhibiting classic findings associated with appendicitis, which requires surgery
as soon as possible; notifying the surgeon should be the nurse’s first action. Rebound tenderness is
not associated with gastroenteritis, which is characterized by generalized abdominal cramping,
diarrhea, fever, and malaise. A high Fowler’s position would not alleviate pain produced by a peptic
ulcer, which includes burning, aching, and gnawing pain. Nausea and vomiting are not generally
associated with peritonitis, which is indicated by diffuse abdominal pain, rebound tenderness, fever,
and an elevated WBC count.
2. Which assessment finding would be an appropriate indicator for evaluating a client with heart
failure and a nursing diagnosis of decreased cardiac output?
A. Decreased intermittent claudication

B. Increased ability to walk to the bathroom without fatigue
C. Increased heart rate by 10 beats per minute
D. Weight gain of 3 pounds in one day
Correct Answer: B
Rationale: Fatigue may be associated with decreased cardiac output; an increase in the client’s
ability to ambulate to the bathroom without fatigue indicates improvement in cardiac output. A
decrease in intermittent claudication indicates improved peripheral perfusion, but it does not
demonstrate increased cardiac output. The body normally responds to a decrease in cardiac output by
increasing the heart rate. Weight gain indicates fluid retention and a worsening of the client’s heart
failure.
3. A client who has frostbite is complaining of pain. In addition to giving medication, which nursing
intervention should the nurse implement?
A. Administration of sodium bicarbonate

B. Elevation of the body part
C. Gentle massage of the affected area
D. Administration of warmed, humidified oxygen
Correct Answer: B
Rationale: Elevation of the body part helps to reduce the edema associated with frostbite. Sodium
bicarbonate is indicated for the treatment of hypothermia. Massaging the affected area may result in
further tissue damage. Warm, humidified oxygen is used as treatment for hypothermia.
4. A client scheduled for a biopsy of a mass asks the nurse to explain why this surgery is necessary.
Which statement would be the nurse’s best response?
A. “The physician removes the precancerous mass to prevent cancer from occurring.”
B. “This is diagnostic surgery done to confirm or rule out malignancy.”
C. “This will provide a more realistic look to the body part.”
D. “This will relieve your distress and help you to be more comfortable.”
Correct Answer: B
Rationale: A biopsy is performed to aid in diagnosing whether a mass is benign or malignant.
Preventative surgery is done to remove tissue prior to its becoming cancerous; whether or not the
mass is precancerous has yet to be determined. Reconstructive surgery provides a more realistic look
to a body part. Palliative surgery is used to relieve the client’s distress and help make him more
comfortable.
5. A client with deep venous thrombosis develops a sudden onset of severe leg pain. The limb
becomes pale, cold, numb, and pulseless. What medical condition would the nurse suspect?
A. Acute arterial occlusion

B. Dissecting aneurysm
C. Postphlebitic syndrome
D. Raynaud’s phenomenon
Correct Answer: A
Rationale: The change in color, temperature, sensation, and pulse accompanied by the sudden onset
of pain (the classic “P’s” of assessment) all suggest an acute arterial occlusion. A dissecting aneurysm
usually occurs in the chest, not the legs; a tearing or ripping sensation of pain in the anterior chest,
back, epigastric region, or abdomen is common. Postphlebitic syndrome is characterized by a
brownish discoloration of the skin, the hallmark sign. Raynaud’s phenomenon involves the episodic
constriction of the small arteries or arterioles of the extremities, resulting in intermittent pallor and
cyanosis of the skin, fingers, toes and, possibly, the ears or nose, followed by hyperemia, which may
produce rubor.
6. When obtaining the history of a client admitted with endocarditis, which information from the client
interview would the nurse consider as most significant?
A. Dental surgery in the recent past

B. History of coronary artery disease (CAD)
C. History of marijuana use
D. Prolonged use of steroid therapy
Correct Answer: A
Rationale: Dental surgery is one of the predisposing factors for the development of endocarditis
because it may create a portal of entry for microorganisms. A history of valvular heart disease (not
CAD), I.V. drug use (not marijuana use), and prolonged I.V. antibiotic therapy (not steroid therapy)
are predisposing factors for endocarditis.
7. When assessing a client diagnosed with an abdominal aortic aneurysm, the nurse monitors the
client for which signs and symptoms?
A. Intermittent episodes of high fever with chills

B. Paresthesias and loss of position sense
C. Positive Homans’ sign and calf pain
D. Pulsatile mass and systolic bruit
Correct Answer: D
Rationale: A pulsatile mass and systolic bruit are classic signs of an abdominal aortic aneurysm.
Intermittent episodes of high fever with chills are associated with secondary lymphedema or other
infections. Paresthesias and loss of position sense are associated with peripheral arterial occlusive
disease as well as neurovascular and neurologic conditions. A positive Homans’ sign and calf pain are
symptoms of deep vein thrombosis.
8. Which scientific rationale must the nurse keep in mind when administering oxygen to a client with
chronic obstructive pulmonary disease (COPD)?
A. A facemask is necessary for delivery of adequate

B. Oxygen is reserved for use when the client is short of breath.
C. The client is encouraged to remove the oxygen as often as possible.
D. The oxygen must be administered at a low rate.
Correct Answer: D
Rationale: The primary stimulus to breathe for the client with COPD is hypoxia. If oxygen were
administered at too high a rate, the client’s respiratory drive would be depressed. The increased
effectiveness of using a facemask as opposed to a nasal cannula has not been proven. Due to loss of
supporting structures and narrowing of airways, the condition is irreversible; intermittent oxygen is
not effective.
9. Which client would require the nurse to be on highest alert for the development of a pulmonary
embolism (PE)?
A. A woman who has taken hormonal contraceptives for the past 2 years
B. A client who has had laparoscopic gallbladder surgery
C. A client with arterial vascular disease and difficulty walking
D. A client who has experienced multiple trauma and fractures
Correct Answer: D
Rationale: A client with massive trauma and multiple orthopedic injuries is at increased risk for
developing a PE. The injury may predispose the client to fat emboli and bony fragments that can
become emboli, and the prolonged period of immobility that results from the injuries and their
treatment further compounds the client’s risk. Women on hormonal contraceptives have a slightly
higher risk for PE, but this risk is not as great as that for the client experiencing multiple trauma and
fractures. The risk for cardiovascular complications increases after age 35 in women who smoke and
after age 40 in women who do not smoke. Laparoscopic cholecystectomy is now considered a
relatively minor procedure requiring a short hospitalization, usually in an outclient department. A
client with arterial vascular disease may be at increased risk for pulmonary emboli but PE usually
develops in the venous system.
10. Which assessment finding would be the most appropriate indicator for evaluating the adequacy of
gas exchange for the postoperative client with a thoracotomy?
A. Effective coughing and deep-breathing

B. Oxygen saturation level of 98%
C. Report of breathing without difficulty
D. Report of pain relief
Correct Answer: B
Rationale: Following a thoracotomy, the goal is to promote adequate gas exchange, evidenced by
objective parameters including oxygen saturation, normal blood gases, and breath sounds. Effective
coughing and deep breathing help to maintain a patent airway and promote lung expansion, but they
do not ensure adequate gas exchange. Although client reports of breathing without difficulty are an
important assessment, adequacy of gas exchange is best evaluated by objective findings. Assessment
and pain relief is important, but pain relief is not a reliable indicator of adequate gas exchange.
Sample Review Question for Medical and Surgical Nursing Part 5
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. 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.
Sample Nursing Board Exam Review Questions 1
1. Which element in the circular chain of infection can be eliminated by preserving skin integrity?
1. Host
2. Reservoir
3. Mode of transmission
4. Portal of entry
Correct Answer: D. In the circular chain of infection, pathogens must be able to leave their
reservoir and be transmitted to a susceptible host through a portal of entry, such as broken
skin
2. Which of the following will probably result in a break in sterile technique for respiratory
isolation?
1. Opening the patient’s window to the outside environment
2. Turning on the patient’s room ventilator
3. Opening the door of the patient’s room leading into the hospital corridor
4. Failing to wear gloves when administering a bed bath
Correct Answer: C. Respiratory isolation, like strict isolation, requires that the door to the door
patient’s room remain closed. However, the patient’s room should be well ventilated, so
opening the window or turning on the ventricular is desirable. The nurse does not need to
wear gloves for respiratory isolation, but good hand washing is important for all types of
isolation.
3. Which of the following patients is at greater risk for contracting an infection?

1. A patient with leukopenia
2. A patient receiving broad-spectrum antibiotics
3. A postoperative patient who has undergone orthopedic surgery
4. A newly diagnosed diabetic patient
Correct Answer: A. Leukopenia is a decreased number of leukocytes (white blood cells), which
are important in resisting infection. None of the other situations would put the patient at risk
for contracting an infection; taking broad-spectrum antibiotics might actually reduce the
infection risk.
4. Effective hand washing requires the use of:

1. Soap or detergent to promote emulsification
2. Hot water to destroy bacteria
3. A disinfectant to increase surface tension
4. All of the above
Correct Answer: A. Soaps and detergents are used to help remove bacteria because of their
ability to lower the surface tension of water and act as emulsifying agents. Hot water may
lead to skin irritation or burns.
5. After routine patient contact, hand washing should last at least:

1. 30 seconds
2. 1 minute
3. 2 minute
4. 3 minutes
Correct Answer: A. Depending on the degree of exposure to pathogens, hand washing may
last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds
effectively minimizes the risk of pathogen transmission.
6. Which of the following procedures always requires surgical asepsis?

1. Vaginal instillation of conjugated estrogen
2. Urinary Catherization
3. Nasogastric tube insertion
4. Colostomy Irrigation
Correct Answer: B. The urinary system is normally free of microorganisms except at the
urinary meatus. Any procedure that involves entering this system must use surgically aseptic
measures to maintain a bacteria-free state.
7. Sterile technique is used whenever:

1. Strict isolation is required
2. Terminal disinfection is performed
3. Invasive procedures are performed
4. Protective isolation is necessary
Correct Answer:C. All invasive procedures, including surgery, catheter insertion, and
administration of parenteral therapy, require sterile technique to maintain a sterile
environment. All equipment must be sterile, and the nurse and the physician must wear sterile
gloves and maintain surgical asepsis. In the operating room, the nurse and physician are
required to wear sterile gowns, gloves, masks, hair covers, and shoe covers for all invasive
procedures. Strict isolation requires the use of clean gloves, masks, gowns and equipment to
prevent the transmission of highly communicable diseases by contact or by airborne routes.
Terminal disinfection is the disinfection of all contaminated supplies and equipment after a
patient has been discharged to prepare them for reuse by another patient. The purpose of
protective (reverse) isolation is to prevent a person with seriously impaired resistance from
coming into contact who potentially pathogenic organisms.
8. Which of the following constitutes a break in sterile technique while preparing a sterile field for
a dressing change?
1. Using sterile forceps, rather than sterile gloves, to handle a sterile item
2. Touching the outside wrapper of sterilized material without sterile gloves
3. Placing a sterile object on the edge of the sterile field
4. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a
sterile container
Correct Answer: C. The edges of a sterile field are considered contaminated. When sterile
items are allowed to come in contact with the edges of the field, the sterile items also become
contaminated.
9. A natural body defense that plays an active role in preventing infection is:
1. Yawning
2. Body hair
3. Hiccupping
4. Rapid eye movements
Correct Answer: B. Hair on or within body areas, such as the nose, traps and holds particles
that contain microorganisms. Yawning and hiccupping do not prevent microorganisms from
entering or leaving the body. Rapid eye movement marks the stage of sleep during which
dreaming occurs.
10. All of the following statement are true about donning sterile gloves except:
1. The first glove should be picked up by grasping the inside of the cuff.
2. The second glove should be picked up by inserting the gloved fingers under the cuff
outside the glove.
3. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and
pulling the glove over the wrist
4. The inside of the glove is considered sterile
Correct Answer: D. The inside of the glove is always considered to be clean, but not sterile.
1. When removing a contaminated gown, the nurse should be careful that the first thing she
touches is the:
1. Waist tie and neck tie at the back of the gown
2. Waist tie in front of the gown
3. Cuffs of the gown
4. Inside of the gown
Correct Answer: A. The back of the gown is considered clean, the front is contaminated. So,
after removing gloves and washing hands, the nurse should untie the back of the gown;
slowly move backward away from the gown, holding the inside of the gown and keeping the
edges off the floor; turn and fold the gown inside out; discard it in a contaminated linen
container; then wash her hands again.
2. Which of the following nursing interventions is considered the most effective form or universal
precautions?
1. Cap all used needles before removing them from their syringes
2. Discard all used uncapped needles and syringes in an impenetrable protective
container
3. Wear gloves when administering IM injections
4. Follow enteric precautions
Correct Answer: B. According to the Centers for Disease Control (CDC), blood-to-blood
contact occurs most commonly when a health care worker attempts to cap a used needle.
Therefore, used needles should never be recapped; instead they should be inserted in a
specially designed puncture resistant, labeled container. Wearing gloves is not always
necessary when administering an I.M. injection. Enteric precautions prevent the transfer of
pathogens via feces.
3. All of the following measures are recommended to prevent pressure ulcers except:
1. Massaging the reddened are with lotion
2. Using a water or air mattress
3. Adhering to a schedule for positioning and turning
4. Providing meticulous skin care
Correct Answer: A. Nurses and other health care professionals previously believed that
massaging a reddened area with lotion would promote venous return and reduce edema to the
area. However, research has shown that massage only increases the likelihood of cellular
ischemia and necrosis to the area.
4. Which of the following blood tests should be performed before a blood transfusion?
1. Prothrombin and coagulation time
2. Blood typing and cross-matching
3. Bleeding and clotting time
4. Complete blood count (CBC) and electrolyte levels.
Correct Answer: B. Before a blood transfusion is performed, the blood of the donor and
recipient must be checked for compatibility. This is done by blood typing (a test that
determines a person’s blood type) and cross-matching (a procedure that determines the
compatibility of the donor’s and recipient’s blood after the blood types has been matched). If
the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur.
5. The primary purpose of a platelet count is to evaluate the:

1. Potential for clot formation
2. Potential for bleeding
3. Presence of an antigen-antibody response
4. Presence of cardiac enzymes
Correct Answer: A. Platelets are disk-shaped cells that are essential for blood coagulation. A
platelet count determines the number of thrombocytes in blood available for promoting
hemostasis and assisting with blood coagulation after injury. It also is used to evaluate the
patient’s potential for bleeding; however, this is not its primary purpose. The normal count
ranges from 150,000 to 350,000/mm3. A count of 100,000/mm3 or less indicates a potential
for bleeding; count of less than 20,000/mm3 is associated with spontaneous bleeding.
6. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
1. 4,500/mm³
2. 7,000/mm³
3. 10,000/mm³
4. 25,000/mm³
Correct Answer: D. Leukocytosis is any transient increase in the number of white blood cells
(leukocytes) in the blood. Normal WBC counts range from 5,000 to 100,000/mm3. Thus, a
count of 25,000/mm3 indicates leukocytosis.
7. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to
exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate
that the patient is experiencing:
1. Hypokalemia
2. Hyperkalemia
3. Anorexia
4. Dysphagia
Correct Answer: A. Fatigue, muscle cramping, and muscle weaknesses are symptoms of
hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic
therapy. The physician usually orders supplemental potassium to prevent hypokalemia in
patients receiving diuretics. Anorexia is another symptom of hypokalemia. Dysphagia means
difficulty swallowing.
8. Which of the following statements about chest X-ray is false?

1. No contradictions exist for this test
2. Before the procedure, the patient should remove all jewelry, metallic objects, and
buttons above the waist
3. A signed consent is not required
4. Eating, drinking, and medications are allowed before this test
Correct Answer: A. Pregnancy or suspected pregnancy is the only contraindication for a chest
X-ray. However, if a chest X-ray is necessary, the patient can wear a lead apron to protect the
pelvic region from radiation. Jewelry, metallic objects, and buttons would interfere with the X-
ray and thus should not be worn above the waist. A signed consent is not required because a
chest X-ray is not an invasive examination. Eating, drinking and medications are allowed
because the X-ray is of the chest, not the abdominal region.
9. The most appropriate time for the nurse to obtain a sputum specimen for culture is:
1. Early in the morning
2. After the patient eats a light breakfast
3. After aerosol therapy
4. After chest physiotherapy
Correct Answer: A. Obtaining a sputum specimen early in this morning ensures an adequate
supply of bacteria for culturing and decreases the risk of contamination from food or
medication
10. A patient with no known allergies is to receive penicillin every 6 hours. When administering
the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate
nursing action would be to:
1. Withhold the moderation and notify the physician
2. Administer the medication and notify the physician
3. Administer the medication with an antihistamine
4. Apply corn starch soaks to the rash
Correct Answer: A. Initial sensitivity to penicillin is commonly manifested by a skin rash, even
in individuals who have not been allergic to it previously. Because of the danger of
anaphylactic shock, he nurse should withhold the drug and notify the physician, who may
choose to substitute another drug. Administering an antihistamine is a dependent nursing
intervention that requires a written physician’s order. Although applying corn starch to the
rash may relieve discomfort, it is not the nurse’s top priority in such a potentially life-
threatening situation.
1. All of the following nursing interventions are correct when using the Z-track method of drug
injection except:
1. Prepare the injection site with alcohol
2. Use a needle that’s a least 1” long
3. Aspirate for blood before injection
4. Rub the site vigorously after the injection to promote absorption
Correct Answer: D. The Z-track method is an I.M. injection technique in which the patient’s
skin is pulled in such a way that the needle track is sealed off after the injection. This
procedure seals medication deep into the muscle, thereby minimizing skin staining and
irritation. Rubbing the injection site is contraindicated because it may cause the medication to
extravasate into the skin.
2. The correct method for determining the vastus lateralis site for I.M. injection is to:
1. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm
below the iliac crest
2. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the
arm
3. Palpate a 1” circular area anterior to the umbilicus
4. Divide the area between the greater femoral trochanter and the lateral femoral
condyle into thirds, and select the middle third on the anterior of the thigh
Correct Answer: D. The vastus lateralis, a long, thick muscle that extends the full length of
the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has
relatively few major nerves and blood vessels. The middle third of the muscle is recommended
as the injection site. The patient can be in a supine or sitting position for an injection into this
site.
3. The mid-deltoid injection site is seldom used for I.M. injections because it:
1. Can accommodate only 1 ml or less of medication
2. Bruises too easily
3. Can be used only when the patient is lying down
4. Does not readily parenteral medication
Correct Answer: A. The mid-deltoid injection site can accommodate only 1 ml or less of
medication because of its size and location (on the deltoid muscle of the arm, close to the
brachial artery and radial nerve).
4. The appropriate needle size for insulin injection is:

1. 18G, 1 ½” long
2. 22G, 1” long
3. 22G, 1 ½” long
4. 25G, 5/8” long
Correct Answer: D. A 25G, 5/8” needle is the recommended size for insulin injection because
insulin is administered by the subcutaneous route. An 18G, 1 ½” needle is usually used for
I.M. injections in children, typically in the vastus lateralis. A 22G, 1 ½” needle is usually used
for adult I.M. injections, which are typically administered in the vastus lateralis or
ventrogluteal site.
5. The appropriate needle gauge for intradermal injection is:

1. 20G
2. 22G
3. 25G
4. 26G
Correct Answer: D. Because an intradermal injection does not penetrate deeply into the skin,
a small-bore 25G needle is recommended. This type of injection is used primarily to
administer antigens to evaluate reactions for allergy or sensitivity studies. A 20G needle is
usually used for I.M. injections of oil-based medications; a 22G needle for I.M. injections; and
a 25G needle, for I.M. injections; and a 25G needle, for subcutaneous insulin injections.
6. Parenteral penicillin can be administered as an:

1. IM injection or an IV solution
2. IV or an intradermal injection
3. Intradermal or subcutaneous injection
4. IM or a subcutaneous injection
Correct Answer: A. Parenteral penicillin can be administered I.M. or added to a solution and
given I.V. It cannot be administered subcutaneously or intradermally.
7. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
1. 0.6 mg
2. 10 mg
3. 60 mg
4. 600 mg
Correct Answer: D. gr 10 x 60mg/gr 1 = 600 mg

8. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the
flow rate be if the drop factor is 15 gtt = 1 ml?
1. 5 gtt/minute
2. 13 gtt/minute
3. 25 gtt/minute
4. 50 gtt/minute
Correct Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
9. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?

1. Hemoglobinuria
2. Chest pain
3. Urticaria
4. Distended neck veins
Correct Answer: A. Hemoglobinuria, the abnormal presence of hemoglobin in the urine,

indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this
reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are
hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in
ABO incompatibilities than in Rh incompatibilities. Chest pain and urticaria may be symptoms
of impending anaphylaxis. Distended neck veins are an indication of hypervolemia
10. Which of the following conditions may require fluid restriction?

1. Fever
2. Chronic Obstructive Pulmonary Disease
3. Renal Failure
4. Dehydration
Correct Answer: C. In renal failure, the kidney loses their ability to effectively eliminate
wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be
necessary. Fever, chronic obstructive pulmonary disease, and dehydration are conditions for
which fluids should be encouraged.
1. All of the following are common signs and symptoms of phlebitis except:
1. Pain or discomfort at the IV insertion site
2. Edema and warmth at the IV insertion site
3. A red streak exiting the IV insertion site
4. Frank bleeding at the insertion site
Correct Answer: D. Phlebitis, the inflammation of a vein, can be caused by chemical irritants
(I.V. solutions or medications), mechanical irritants (the needle or catheter used during
venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. Signs
and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion
site, and a red streak going up the arm or leg from the I.V. insertion site.
2. The best way of determining whether a patient has learned to instill ear medication properly is
for the nurse to:
1. Ask the patient if he/she has used ear drops before
2. Have the patient repeat the nurse’s instructions using her own words
3. Demonstrate the procedure to the patient and encourage to ask questions
4. Ask the patient to demonstrate the procedure
Correct Answer: D. Return demonstration provides the most certain evidence for evaluating
the effectiveness of patient teaching.
3. Which of the following types of medications can be administered via gastrostomy tube?
1. Any oral medications
2. Capsules whole contents are dissolve in water
3. Enteric-coated tablets that are thoroughly dissolved in water
4. Most tablets designed for oral use, except for extended-duration compounds
Correct Answer: D. Capsules, enteric-coated tablets, and most extended duration or

sustained release products should not be dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid reasons, and altering them destroys
their purpose. The nurse should seek an alternate physician’s order when an ordered
medication is inappropriate for delivery by tube.
4. A patient who develops hives after receiving an antibiotic is exhibiting drug:

1. Tolerance
2. Idiosyncrasy
3. Synergism
4. Allergy
Correct Answer: D. A drug-allergy is an adverse reaction resulting from an immunologic

response following a previous sensitizing exposure to the drug. The reaction can range from a
rash or hives to anaphylactic shock. Tolerance to a drug means that the patient experiences a
decreasing physiologic response to repeated administration of the drug in the same
dosage. Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other
substance; it appears to be genetically determined. Synergism, is a drug interaction in which
the sum of the drug’s combined effects is greater than that of their separate effects.
5. A patient has returned to his room after femoral arteriography. All of the following are
appropriate nursing interventions except:
1. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
2. Check the pressure dressing for sanguineous drainage
3. Assess a vital signs every 15 minutes for 2 hours
4. Order a hemoglobin and hematocrit count 1 hour after the arteriography
Correct Answer: D. A hemoglobin and hematocrit count would be ordered by the physician if
bleeding were suspected. The other answers are appropriate nursing interventions for a
patient who has undergone femoral arteriography.
6. The nurse explains to a patient that a cough:

1. Is a protective response to clear the respiratory tract of irritants
2. Is primarily a voluntary action
3. Is induced by the administration of an antitussive drug
4. Can be inhibited by “splinting” the abdomen
Correct Answer: A. Coughing, a protective response that clears the respiratory tract of
irritants, usually is involuntary; however it can be voluntary, as when a patient is taught to
perform coughing exercises. An antitussive drug inhibits coughing. Splinting the abdomen
supports the abdominal muscles when a patient coughs.
7. An infected patient has chills and begins shivering. The best nursing intervention is to:
1. Apply iced alcohol sponges
2. Provide increased cool liquids
3. Provide additional bedclothes
4. Provide increased ventilation
Correct Answer: C. In an infected patient, shivering results from the body’s attempt to
increase heat production and the production of neutrophils and phagocytotic action through
increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to
feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature
and stop the chills. Attempts to cool the body result in further shivering, increased
metabloism, and thus increased heat production.
8. A clinical nurse specialist is a nurse who has:

1. Been certified by the National League for Nursing
2. Received credentials from the Philippine Nurses’ Association
3. Graduated from an associate degree program and is a registered professional nurse
4. Completed a master’s degree in the prescribed clinical area and is a registered
professional nurse.
Correct Answer: D. A clinical nurse specialist must have completed a master’s degree in a
clinical specialty and be a registered professional nurse. The National League of Nursing
accredits educational programs in nursing and provides a testing service to evaluate student
nursing competence but it does not certify nurses. The American Nurses Association identifies
requirements for certification and offers examinations for certification in many areas of
nursing., such as medical surgical nursing. These certification (credentialing) demonstrates
that the nurse has the knowledge and the ability to provide high quality nursing care in the
area of her certification. A graduate of an associate degree program is not a clinical nurse
specialist: however, she is prepared to provide bed side nursing with a high degree of
knowledge and skill. She must successfully complete the licensing examination to become a
registered professional nurse.
9. The purpose of increasing urine acidity through dietary means is to:

1. Decrease burning sensations
2. Change the urine’s color
3. Change the urine’s concentration
4. Inhibit the growth of microorganisms
Correct Answer: D. Microorganisms usually do not grow in an acidic environment.
10. Clay colored stools indicate:

1. Upper GI bleeding
2. Impending constipation
3. An effect of medication
4. Bile obstruction
Correct Answer: D. Bile colors the stool brown. Any inflammation or obstruction that impairs
bile flow will affect the stool pigment, yielding light, clay-colored stool. Upper GI bleeding
results in black or tarry stool. Constipation is characterized by small, hard masses. Many
medications and foods will discolor stool – for example, drugs containing iron turn stool
black.; beets turn stool red.

Review Questions With Rationale

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Review Questions With Rationale

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1. After the lungs, the kidneys work to maintain body pH.

The best explanation

3. Myasthenic crisis and cholinergic crisis are the major complications of

5. A 54-year-old client was put in Quinidine (a drug that decreases myocardial

6. A client is about to be discharged on the drug bishydroxycoumarin

7. A cyanotic client with an unknown diagnosis is admitted to the emergency

13. A 24-year-old client is admitted to the hospital following an automobile

16. A client is admitted following an automobile accident in which he

17. A client with tuberculosis is given the drug pyrazinamide (Pyrazinamide).

25. In preparation for discharge of a client with arterial insufficiency and

28. A nursing assessment for initial signs of hypoglycemia will include

30. Following an accident, a client is admitted with a head injury and

35. A client in acute renal failure receives an IV infusion of 10% dextrose in

42. Assessing for immediate postoperative complications, the nurse knows

Medical and Surgical Nursing Practice Questions with Rationale

A. Applying an identification bracelet on the client

A. Fatigue and weight gain on the day prior to menses

A. Avoiding contact with the equipment by allowing housekeeping to remove it

A. Blood pressure of 110/70 mm Hg and hematocrit of 42%

A. Administration of stimulant laxatives

A. Assessing the skeletal traction insertion sites for infection

A. “Acne is caused by an excess production of sebum.”

8. Which intervention would most important in the prevention of pressure ulcers?

A. Applying external urine collection devices

Sample Review Questions on Medical and Surgical Nursing Part 1

A. Application of on occlusive petroleum dressing

A. Acute respiratory failure

A. Allows the client to obtain needed rest

A. Applies lotions to keep the skin from cracking

A. “I need to drink at least 2 liters of fluid every day.”

A. +4 pitting edema in both legs

Sample Review Questions on Medical and Surgical Nursing Part 2

A. Bedside application of a large tourniquet to prevent massive hemorrhage

A. Auscultation of crackles bilaterally

A. Avoiding eating within 2 hours of bedtime

A .Demonstration of postural drainage techniques

Sample Review Questions on Medical and Surgical Nursing Part 3

A. Apical heart rate below 60 beats per minute

A. Mechanically squeezing the affected tissue

B. Using antiembolism stockings

A. Assisting the client in planning for retirement activities

A. “I can feel my heart beating in my abdomen when I am lying down.”

A. Administrating oxygen during episodes of pain

A. Heart sound and tachycardia

A. Further monitoring of the client’s vital signs as ordered

A. Decrease fluid intake during meals.

Sample Review Questions on Medical and Surgical Nursing Part 4

A. Administering antacids for gastroenteritis

A. Decreased intermittent claudication

A. Administration of sodium bicarbonate

A. Acute arterial occlusion

A. Dental surgery in the recent past

A. Intermittent episodes of high fever with chills

A. A facemask is necessary for delivery of adequate

A. Effective coughing and deep-breathing

Sample Review Question for Medical and Surgical Nursing Part 5

A. Adventitious breath sounds with crackles and wheezes

A. A cough with purulent sputum

A. An asphalt road construction worker who eats meats and potatoes

A. Calling the health care provider

A. Crushing chest pain and diaphoresis

A. Ankle arm index pressure of 0.4

Sample Nursing Board Exam Review Questions 1