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NURSING REVIEW

MEDICAL SURGICAL INTENSIFIED EVALUATIVE EXPECTED AND UNEXPECTED CONCEPT SCREENED AND
PREPARED BY

PROF.GREYLANDO A. HISU R.N.BSEd,MAN

1ST WAVE

1. After 2 weeks of orientation Carlos, the OR murse-orientee was given the opportunity to do his first
independent scrub to assist a caesarean section delivery. He is very much excited and nervous in doing
his tanks. He reviews the basic principles of asepsis and knows a violation has occurred when:

He is in doubt regarding the sterility of an object thus render it unsterile - B. Gowns are considered
sterile by members of the team in front up to the sleeves and axillary areas.

C. Considers the edges of sterile packages unsterile once opened D. Considers that tables are sterile at
table level only
2.To reduce the anxiety of the client and his/her family about the impending surgery, the nurse should:

A. Described the details of the surgery to the client and family. B. Provide general information and
answer appropriate questions of

The client and family.

C. Empower the client to make decision by obtaining the client's consent.

Give full reassurance that the client surgical team is experienced to

handle the surgery.

3. What common side effect should the nurse monitor in a client who just received epidural anesthesia?

Fever C. Hypotension

B. Bradycardia

D. Pallor

4. Which of the following complications can result from the use of general anesthesia during surgery?

A. Fluid loss C. Atelectasis

B. Peripheral fluid retention Muscle rigidity

5. A client is noted to manifest right hemianopsia as a result of his CVA. The nurse should:

A. Instruct the client to scan his surroundings B. Corrects the client's misuse of equipment

Provide tactile stimulation to the client's affected extremities

D. Teach the client to look at the position of his right extremities

6. After thyroidectomy, which of the following interventions is the highest priority of the nurse? A.
Monitor the client's vital signs every 4 hours. B Observe the dressing at the back of the neck for the
presence of blood.

C. Press gently around the incision to assess for subcutaneous emphysema.

D. Position the client laterally to promote drainage of secretions from the mouth.

7. The nurse is teaching a patient about the use of sublingual nitroglycerine. Which statement indicates

understanding of the teaching plan?

A. "I must swallow the tablet whole without chewing."

B. "I should take the tablet about 45 minutes before initiating a strenuous activity that causes angina."

"I'll keep the nitroglycerine in its original dark, airtight container." D. "I'll take the tablet every 5 minutes
until my chest pain stops."

8. In teaching a hypertensive client about the side effects of propranol (Inderal) the nurse plans to
include
which side effect of this medication therapy?

C. Constipation

Hypokalemia B. Heart failure

D.Tachycardia

9. If Andot is having respiratory acidosis and asks for food and drink, which of the following will you NOT
give him?

A. Ice cream

B. Warm congee

Soft drinks

D. Hot milk and crackers

10. To promote bladder decompression and to prevent bladder distension after transurethral resection
of the prostate (TURP), which intervention should be the nurse's priority?

A. Monitor the client for signs of hemorrhage.

B. Checking the client's environmental status. C. Assessing the client for signs of infection.
D Ensuring the patency of the continuous bladder irrigation.

11. How should the nurse determine the urine output of a client on continuous bladder irrigation?

A. Deduct the amount of the irrigant solution instilled from the total amount of output.

B. Deduct the amount of IV fluid infusion from the total fluid intake of the client. Add the amount of all
fluid intake then deduct the amount of output.

D. Measure the amount of output from the bladder irrigation.

12. Which of the following is the most common complication of transurethral resection of the prostate
(TURP) in the early post-operative period?

Impotence

B. Infection

C. Bleeding

D. Urinary retention

13. Which of the following manifestations should the nurse instruct the client to report to the
physician ?

immediately after undergoing TURP A. Burning on urination.

BDecreased urinary stream

C. Pink-tinged urine on initial voiding

D. Urine output of 30ml/hr.

14. A postoperative client with emphysema is receiving oxygen at 2 L/min via nasal cannula when
he/she complains of feeling dyspneic. The spouse asks the nurse to increase the oxygen intake to help
him/her breathe easier. Which response by the nurse is appropriate?

A. Switch the oxygen to a 100% non-rebreather mask

B. Explain to the spouse that high concentration of oxygen may depress breathing

C. Ask the spouse to leave the room to let the client get some sleep

D. Administer pain medication

15. A client has returned to the clinic 72 hours following a tuberculin skin test with an induration of
about 5 to 6 mm at the administration site. The client is visibly upset and states: "I can't believe I have
TB!" Which statement by the nurse is appropriate?

A. "You'll need to put on a mask and wear it whenever you are around other people." "The doctor will
prescribe Isoniazid for you to take for the next 3 months." "This finding does not confirm TB; it may
indicate a recent exposure to tuberculosis."

"We'll need to do a chest x-ray. This may be falsely positive because of your history of

diabetes."

16. Which statements made by Big Boy may indicate to the nurse that the patient may be a candidate
for

thrombolytic therapy?
A. "I have had a chest pain for 2 days."" B. "My chest pain started 3 hours ago."

"My chest pain stops when I take a nitroglycerine pill." D. "I have had chest on and off whole week."

17. While performing respiratory assessment among elderly clients, the nurse was able to obtain cues
on possible cases of elderly abuse. Which client is most at risk for elderly abuse?

A. A 68 year old cognitive impaired male, living alone.

B. A 72 year old female living with spouse and children.

A 65 year old male living with a household help.

D. A 67 year old female living on her own.

18. The nurse instructing a patient about the use of antiembolism stockings is aware that they may help

prevent deep vain thrombosis (DVT) by:

Encouraging ambulation to prevent pooling of blood. B. Providing warmth to the extremity.

C. Elevating the extremity to prevent pooling of blood.

D. Forcing the blood into the deep venous system.

19. The nurse is providing pre-operative instructions in diaphragmatic breathing to a client with COPD.

An indication that the client understands the nurse's instructions is that he:

A. Coughs before breathing.

B Inhales through the nose and holds breath for 1-2 sec before he exhales.

Exhales completely before increasing the rate of breathing.

D. Inhales through the mouth.

20. To limit the client's oxygen needs, a client with COPD should be: Served three large meals a day.

BGiven six small meals a day.

C. Forced to drink large amount of fluids.

D. Instructed to immediately sleep after meals.

21. The client is providing care to a client with a tracheostomy tube in place. The nurse notes that
his/her breathing has become noisy. Which intervention is a nursing priority?

A. Adjust the cuff pressure. B Reposition the client.

C. Suction the tracheostomy.

D. Notify the physician.

22. A 57 year old patient reports experiencing leg pain whenever he walks several blocks. The patient
has type I diabetes and has smoke 2 packs of cirgarettes per day for the past 40 years. The physician
diagnoses intermittent claudication. The nurse should provide which instruction about long-term care?

Practice meticulous foot care.

B Consider cutting down on your smoking

C. Reduce your exercise level. D. See the physician if the symptoms bother you.

23. The nurse is caring for a client with skeletal traction. It is most important that the nurse monitors

which of the following? The pin site for unusual redness, swelling, purulent drainage, and foul odor

B. The distance between the client's hip and the traction C. The number of times the client exercises the
affected limb

D. How the client is coping with immobilization

24. A client complains of pain and cramping after short periods of walking that stop when he rests. The
nurse concludes he is describing which of the following symptoms of peripheral arterial disease?

A. Arterial-venous shunting

B. Phlebitis
Intermittent claudication D. Raynaud's phenomenon

25. The nurse assesses for hyperkalemia in a client with which of the following problems?

C. Nausea and vomiting

Renal failure B. Excessive laxative use

D. Loop diuretic use

26. A client had a bee sting on the mouth. Which interventions can help to reduce the discomfort?

A. Reassure the client that it will subside without treatment. B Give the client ice cubes to reduce the
pain and swelling.

C. Instruct the client to apply guava leaves on the site. D. Apply a moisturizer on the sting site.

27. Apart from pain relief, which of the following needs should have the highest priority for a child with
vaso-occlusive crisis?

A. Hydration B. Exercise

C. Nutrition Rest

28 A client is to receive 30mg of morphine sulfate P.O. What is the equianalgesic dose (in mg) of this
drug if it is to be administered intramuscularly. 30

A. 10

B. 20

D. 60

29. The WHO analgesic ladder provides a step-by-step approach for pain management. According to the
Agency for Healthcare Policy and Research (AHCPR), clinical guidelines for pain management, the first
drug of choice for mild to moderate pain is:

Acetaminophen B Codeine

C. Morphine

D. Meperidine

30. A client who is scheduled for radiation therapy asks the nurse, "Will I get a radiation burn?" The best
response of the nurse would be:

A. "No, there won't be any burn."

B. "Yes, second degree burn is expected."

C. "We can prevent it."

D"Usually, a localized skin reaction occurs." 31. To reduce pain from a jelly fish sting, which solution
should the nurse pour over the sting site?

A Vinegar

B. Warm water C. Sprite

D. Betadine

32. Which of the following parts of plants is considered poisonous and considered inedible?

A. Malunggay leaves

B. Tomato leaves Jackfruit seeds

Umbrella tree nuts

33. The nurse is providing instructions on foot care to a diabetic client. Which statement is INCORRECT?

A. "Wear snuggly fitting shoes."

B. "Wear shoes that are slightly larger." "Avoid wearing the same shoes for two consecutive days."

"Buy your shoes in the afternoon for better sizing."

34. Which of these statements does NOT reflect a manifestation of diabetes mellitus?
"I'm always thirsty. I always bring a bottle of water with me." B. "I cat a lot."

C. "I always go to the bathroom to urinate."

D. "I've been gaining so much weight."

35. A client complains of cold clammy skin, hunger, dizziness and irritability. He has been diagnosed with
insulin-dependent diabetes mellitus for several years now. Based on these symptoms, the nurse should
suspect that the client's serum glucose levels (in mg/dl) is:

A. More than 300

B. Between 150 and 200

C. Approximately, 80-100 D. Below 50

36. When a client experiences hypoglycemia, the nurse should initially administer.

A. Insulin B. Metformin

Glass of orange juice

Toblerone chocolate bar

37. A newly hired nurse verbalized to her preceptor that she fears contracting Hepatitis B when
performing hemogluco test in clients with diabetes. Based on research, which of the following areas in
the hospital are nurses most at risk for acquiring hepatitis B?

A Emergency room B. Critical care unit

Operating room

Dialysis unit

38. A client with Cushing's disease was admitted for adrenalectomy. As a result of the surgery, he
developed Addison's disease. Which of the following goals of care is the priority for him?

A. Decreasing the blood pressure B. Preventing infection

Promoting the client's safety

D Restoring fluid balance

39. What should be the nurse's immediate action in the client who just underwent adrenalectomy?

A. Insert a nasogastric tube. B. Monitor severityof post-op pain.

C. Chart number of changes in position.

D Monitor the vital signs.

40. Which of the following activities would best for a client in vaso-occlusive crisis?

Scuba diving