Answers and Rationale Medical Surgical Nursing Practice Test Part 3
1. B. In preoperative period, the nurse should consult with the physician about withholding Warfarin Sodium to avoid occurrence of hemorrhage.
2. D. A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest way to test the cornel reflex is by touching the cornea lightly with a wisp of cotton.
3. B. Iatrogenic infection is caused by the heath care provider or is induced inadvertently by medical treatment or procedures.
4. D. Bradykinesia is slowing down from the initiation and execution of movement.
5. B. This symptom is caused by stimulation of retinal cells by ocular movement.
6. D. Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
7. C. Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.
8. A. Right side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump.
9. C. Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of childbearing age should be counseled to use an alternative form of birth control while taking this drug.
10. B. A client who has had abdominal surgery is best placed in a low fowler’s position. This relaxes abdominal muscles and provides maximum respiratory and cardiovascular function.
11. A. Dark red to purple stoma indicates inadequate blood supply.
12. C. The rationale for activity restriction is to help reduce the hypermotility of the colon.
13. A. During Total Parenteral Nutrition (TPN) administration, the client should be monitored regularly for hyperglycemia.
14. D. Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.
15. A. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed.
16. D. Typical signs of hypothyroidism includes weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, constipation and numbness.
17. B. After a pelvic surgery, there is an increased chance of thrombophlebitits owing to the pelvic manipulation that can interfere with circulation and promote venous stasis.
18. D. For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel must stand back and be clear of all the contact with the client or the client’s bed.
19. D. Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.
20. C. Infection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as medical induced acute renal failure (ARF)
21. C. There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present.
22. B. Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
23. C. Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever, malaise and night sweats.
24. A. Fractured pain is generally described as sharp, continuous, and increasing in frequency.
25. D. Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of “hot spot” which are areas on the cast that are warmer than the others.
26. B. Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or without perforation.
27. D. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid in the body.
28. A. The adult with normal cerebrospinal fluid has no red blood cells.
29. D. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus.
30. B. The nurse should focus more on developing less stressful ways of accomplishing routine task.
31. C. Autotransfusion is acceptable for the client who is in danger of cardiac arrest.
32. D. The client with thromboembolism does not have coolness.
33. A. Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.
34. C. Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma formation.
35. D. Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain.
36. C. Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.
37. A. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.
38. A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of aqueous humor.
39. D. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.
40. D. Abdominal breathing improves lungs expansion
41. C. A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.
42. A. The graft covers the nerve endings, which reduces pain and provides framework for granulation
43. B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.
44. C. This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.
45. D. Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal cancer.
46. B. With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
47. A. Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy.
48. B. Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.
49. B. Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems.
50. A. Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will accompany.