COMPREHENSIVE EXAMINATION 1-C Medical Surgical Nursing May 14, 2009

09:42 Middle East Time 2:42 Philippine Time

Question 1. Which initial assessment is essential for the nurse to make when a client is admitted for treatment of a left CVA? 1. Strength of hand grasps 2. Presence of breath sounds 3. Response to verbal stimulation 4. Presence of peripheral pulses Question 2. Following a carotid endarterectomy, the nurse notes that the client is having difficulty managing saliva, and the tongue appears to deviate to one side. These findings would indicate damage to which cranial nerves? 1. Facial and vagus 2. Hypoglossal and spinal accessory 3. Spinal accessory and facial 4. Hypoglossal and facial Question 3. Following a surgical repair of a fractured hip, for which common complication should the nurse observe? 1. Peripheral arterial occlusion 2. Hypostatic pneumonia 3. Paralytic ileus 4. Thromboembolism Question 4. Nursing care to prevent autonomic dysreflexia in a client with a spinal cord injury includes: 1. Small daily doses of an antihypertensive medication 2. Inserting an indwelling urinary catheter regardless of level of injury 3. Positioning the client in high-Fowlers while awake 4. Using topical anesthetic if manual rectal (digital) stimulation is used Question 5. Following a spinal anesthetic, the nurse should ensure that the client receives adequate fluids, to prevent which complication? 1. Spinal fluid loss 2. Dehydration 3. Spinal headache 4. Urinary retention

Question 6. A client with a casted fracture of the lower leg complains that the pain medication is not working. The nurse assesses that the toes are cool and pale, and when the limb is elevated, there is increased pain. The nurse should suspect what potential complication? 1. Thrombophlebitis 2. Compartment syndrome 3. Fat emboli 4. Gas gangrene infection Question 7. Which neurological response would the nurse expect to be affected by a lumbar injury? 1. Pupillary response 2. Romberg test 3. Patellar reflex 4. Abdominal reflex Question 8. For what sign of metabolic alkalosis should the nurse observe? 1. Ankle edema 2. Confusion 3. Hyperventilation 4. Diarrhea Question 9. A client has been admitted to ICU with a severe head injury. The clients intracranial pressure is being monitored. Which signs would alert the nurse that the clients intracranial pressure is rising? -SELECT ALL THAT APPLY1. Increased pulse rate 2. Decreased pulse rate 3. Widening pulse pressure 4. Change in respiratory pattern 5. Increased respiratory rate Question 10. Which snack should the nurse suggest as the best nutritional choice when a client with a slow healing wound is discharged home? 1. Lemon Jello 2. Graham crackers 3. Applesauce 4. Hard boiled egg Question 11. Which measure should be included in client teaching to prevent constipation? 1. Drinking 1000 mL of apple juice daily 2. Eating high-residue foods

3. Using glycerin suppositories daily 4. Taking a mild cathartic at bedtime Question 12. Following a partial gastrectomy, dumping syndrome may occur. To avoid dumping syndrome, the nurse should teach the importance of: 1. Following a low fat diet 2. Avoiding concentrated carbohydrates 3. Increasing fluids with meals 4. Walking after meals Question 13. Dietary health teaching should include which condiment on a low sodium diet? 1. Barbecue sauce 2. Mayonnaise 3. Vinegar 4. Prepared mustard Question 14. The nurse tells the client that withholding food before surgery prevents which complication? 1. Gastric distention postoperatively 2. Vomiting and aspiration during surgery 3. Nausea and paralytic ileus after surgery 4. A food-drug interaction with anesthesia Question 15. The nurse is counseling a client who has lactose intolerance. What type of diet would the nurse recommend? 1. Restricted protein and sodium 2. Low fat 3. Avoid nuts, whole grains, seeds, raw vegetables, celery, and corn 4. Avoid dairy products Question 16. The client had a knee repair and the physician ordered: no weight bearing on the affected leg. What method of ambulation will the nurse teach the client? 1. Use of a 4-prong cane 2. Crutch walking using a 3-point gait 3. Crutch walking using a 4-point gait 4. Use of a walker Question 17. Which food would be permitted on a full liquid diet? 1. Pureed squash 2. Mashed potatoes 3. Vanilla ice cream 4. Creamed corn

Question 18. The client is experiencing right-sided hemiplegia following a stroke. What would the nurse report to the MD as an improvement in the clients condition? 1. Inattention to the right hand 2. Outbursts of laughing and crying 3. Shrugging shoulders bilaterally 4. Grimacing and resisting passive ROM Question 19. To replace potassium lost while taking furosemide (Lasix), the client should be guided to select what high potassium food? 1. Tangerines 2. Cottage cheese 3. Cranberry salad 4. 7-grain bread Question 20. The nurse would know that the client understands the restriction for the 2 gm sodium-restricted diet when the client identifies which food is high in sodium? 1. Cottage cheese 2. Gelatin 3. Aged cheddar cheese 4. Sherbet Question 21. The nurse would conclude the client has a dislocated hip rather than a fractured hip if the limb is: 1. Shorter and externally rotated 2. Partially immobilized with diminished pulses 3. Discolored and swollen 4. Numb and deformed Question 22. In addition to excitability, the nurse should monitor a client with hyperthyroidism for: 1. Ankle edema, skin discoloration, and drowsiness 2. Tremors, sweating, and rapid pulse 3. Difficulty breathing, jaundice, and hirsutism 4. Slow breathing, flat affect, and cool skin Question 23. A client with severe pain in both hands from rheumatoid arthritis needs to gain weight. What would be the best nursing approach to increase intake? 1. Offer to feed the client 2. Offer utensils 3. Offer favorite foods 4. Offer finger foods

Question 24. A client has had a craniotomy involving the frontal lobe. During the immediate postop period, what is the most important responsibility of the nurse? 1. Keep the client flat in bed 2. Prevent head movement with sandbags 3. Assess the clients level of consciousness 4. Encourage coughing and deep breathing Question 25. What is the most important nursing measure for a client placed in Bucks extension traction before surgery to repair a fractured hip? 1. Turning every 2 hours to unaffected side 2. Elevating the head of the bed to maintain alignment 3. Checking skin condition regularly 4. Teaching isometric exercises to prevent muscle atrophy Question 26. Which nursing action is indicated if the weights of Bucks extension traction are almost touching the floor? 1. Remove a few weights from the traction 2. Slide the client up in bed 3. Shorten the rope length of the weights 4. Elevate the affected leg on a pillow Question 27. The nurse explains that treatment for Parkinsons disease may include which intervention? 1. Hormonal replacement 2. Dopamine supplement 3. Myelin stimulation 4. Genetic counseling Question 28. When transferring the client from the bed to a chair following a right total hip replacement, where should the chair be placed? 1. In front of the client who sits on the edge of the bed 2. On the clients left side, with the opening of the chair facing the client, and the side up against the bed 3. On the clients right side, with the opening of the chair facing the client, and the side up against the bed 4. On either side of the client, depending on whether the client is right or left handed Question 29. In dietary health teaching, which food should the nurse teach the client to avoid in a low sodium diet? 1. Halibut steak 2. Corned beef brisket 3. Chicken breast 4. Pork roast

Question 30. Which change in laboratory data would the nurse expect for a client with Addisons disease? 1. Increased potassium, decreased sodium and glucose 2. Decreased potassium, increased sodium and glucose 3. Increased potassium, sodium and hematocrit 4. Decreased potassium, sodium and hematocrit Question 31. The nurse would recommend a diet low in phosphorus for a client with: 1. Diverticulosis 2. Hepatic failure 3. Chronic renal failure 4. Hyperthyroidism Question 32. The nurse would know that the client understands the teaching about a low cholesterol diet when the client selects: 1. Crab legs 2. Baked chicken 3. Broiled hamburger 4. Cream of broccoli soup Question 33. A client on a liquid diet has finished lunch: pint of milk; 4 oz of apple juice; 6 oz of broth, and 6 Tbs. of Jello. The nurse would calculate the total oral intake for this meal to be: 1. 450 ml 2. 630 ml 3. 750 ml 4. 900 ml Question 34. The nurse is developing a plan for rehabilitation for a client with a C7 spinal cord injury. The nurse should expect that the client will be: 1. Ventilator dependent 2. Able to independently use a wheelchair 3. Able to drive a car using hand controls 4. Able to stand and walk with leg braces Question 35. Which food should the nurse suggest that the client choose when on a low fat diet? 1. Peanut butter 2. Oatmeal raisin cookies 3. Angel food cake 4. Butterscotch pudding

Question 36. In the early stages of treatment, which nursing diagnosis is a priority for a client with hyperthyroidism? 1. Hypothermia 2. Altered nutrition 3. Colonic constipation 4. Altered tissue perfusion

Question 37. Which snack would be best for a client on a low-protein diet? 1. Lemon Jello (1 cup) 2. Ice cream (1 cup) 3. Vanilla yogurt (1 cup) 4. Rice pudding (1 cup) Question 38. The nurse should advise a client with AIDS to eat snacks high in potassium, such as bananas, because: 1. Potassium is lost through night sweats 2. The diarrhea lowers the serum potassium 3. Infection destroys cellular potassium 4. Fatigue will improve with potassium Question 39. Which finding would first alert the nurse to increasing intracranial pressure (ICP)? 1. Falling blood pressure 2. Irregular breathing rhythm 3. Presence of Babinski reflex 4. Decorticate posturing Question 40. In which position would the nurse expect the intracranial pressure of client with a head injury to be the lowest? 1. Semi-Fowlers 2. Dorsal recumbent 3. Supine 4. High-Fowlers Question 41. Which change after discharge should the nurse teach the client with Parkinsons disease to make? 1. Avoiding time spent in sunlight 2. Discontinuing volunteer services at church 3. Hiring someone to do housekeeping 4. Removing loose rugs from floors in the house

Question 42. Which meal selection would have the most positive effect on tissue healing? 1. Beef broth 2. Sliced peaches 3. Flavored gelatin 4. Egg custard Question 43. The nurse would know that a client who is experiencing an acute episode of diverticulitis understands the health teaching that was done when the client selects: 1. Cream of Wheat cereal 2. Oat bran cereal 3. Sliced bananas and orange wedges 4. Fresh spinach salad Question 44. The client receiving TPN is at greatest risk of initially developing which imbalance? 1. Metabolic Alkalosis 2. Metabolic Acidosis 3. Hyperglycemia 4. Septicimia Question 45. Which food should a client on a low-cholesterol diet be instructed to avoid? 1. Liver 2. Turkey 3. Ham 4. Beef Question 46. The nurse observes clear drainage on the pillow of a client with a head injury. What should be the first nursing action? 1. Culture the drainage 2. Clean the nose with normal saline 3. Apply a sterile dressing 4. Test the drainage for glucose Question 47. What is the most important consideration in planning the diet for a client admitted with an acute flare-up of rheumatoid arthritis? 1. Three regular meals with increased dairy products 2. Six smaller meals with protein, fruits, and vegetables 3. Soft consistency, well-balanced until inflammation subsides 4. Low calorie, low fat to assist in weight loss

Question 48. What assessment data would indicate to the nurse that the clients hyperthyroid state was returning to normal? 1. Pulse rate increased 2. Serum thyroxin level was normal 3. Thyroid gland was palpable 4. Hair became coarse and dry Question 49. When supine, what is the best position for the paralyzed upper extremity of a client who had a stroke? 1. Arm adducted to side, hand extended, finger flexed 2. Elbow flexed, fingers grasping a hand roll 3. Abducted arm, forearm and wrist on pillows by head 4. Arm resting on chest, hand and fingers extended Question 50. The client has chronic congestive heart failure and is on a 2 Gm sodium diet. The nurse has been successful in teaching when the client eliminates which foods from the diet? -SELECT ALL THAT APPLY1. Lean, roasted ham 2. Cooked cereal 3. Tomato juice 4. Tuna, canned, water pack 5. Frozen vegetables