FUNDAMENTAL NURSAING - BULLET QUESTIONS 1

                                                             BULLET QUESTIONS

1.        A blood pressure cuff that’s too narrow can cause a falsely elevated blood pressure reading.

2.        When preparing a single injection for a patient who takes regular and basal  insulin, the nurse should draw the regular insulin into the syringe first so that it does not contaminate the regular insulin.

3.        Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration.

4.        Gavaage  is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth).

5.        According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority.

6.        The safest and surest way to verify a patient’s identity is to check the identification band on his wrist.

7.        In the therapeutic environment, the patient’s safety is the primary concern.

8.        Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly.

9.        The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position.

10.     The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery. Hand and finger spasms that occur during occlusion indicate Trousseau’s sign and suggest hypocalcemia.

11.     For blood transfusion in an adult, the appropriate needle size is 16 to 20G.

12.     Intractable pain is pain that incapacitates a patient and can’t be relieved by drugs.

13.     In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic means.

14.     Decibel is the unit of measurement of sound.

15.     Informed consent is required for any invasive procedure.

16.     A patient who can’t write his name to give consent for treatment must make an X in the presence of two witnesses, such as a nurse, priest, or physician.

17.     The Z-track I.M. injection technique seals the drug deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that’s 1″ (2.5 cm) or longer.

18.     In the event of fire, the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attempt to contain the fire by closing the door. (E) Extinguish the fire if it can be done safely.

19.     A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration.

20.     If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention.

21.     The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity.

22.     To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2″ (5 cm) to that measurement.

23.     Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies.

24.     The appropriate needle size for insulin injection is 25G and 5/8″ long.

25.     Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml.

26.     The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation.

27.     Assessment is the stage of the nursing process in which the nurse continuously collects data to identify a patient’s actual and potential health needs.

28.     Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.

29.     Planning is the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan.

30.     Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions.

31.     Evaluation is the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan.

32.     Before administering any “as needed” pain medication, the nurse should ask the patient to indicate the location of the pain.

33.     Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people.

34.     To test visual acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate.

35.     When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side.

36.     During assessment of distance vision, the patient should stand 20′ (6.1 m) from the chart.

37.     For a geriatric patient or one who is extremely ill, the ideal room temperature is 66° to 76° F (18.8° to 24.4° C).

38.     Normal room humidity is 30% to 60%.

39.     Hand washing is the single best method of limiting the spread of microorganisms. Once gloves are removed after routine contact with a patient, hands should be washed for 10 to 15 seconds.

40.     To perform catheterization, the nurse should place a woman in the dorsal recumbent position.

41.     A positive Homan’s sign may indicate thrombophlebitis.

42.     Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent is the number of milligrams per 100 milliliters of a solution.

43.     Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase).

44.     The basal metabolic rate is the amount of energy needed to maintain essential body functions. It’s measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment.

45.     The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight.

46.     Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits.

47.     Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs.

48.     Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage.

49.     Purpura is a purple discoloration of the skin that’s caused by blood extravasation.

50.     According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use. Most needle sticks result from missed needle recapping.

medical & surgical nursing MCQ 6

1. Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of:

a. 45 units/L
b. 100 units/L
c. 300 units/L
d. 500 units/L 

2. A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet. The nurse would offer which full liquid item to the client?

a. Tea
b. Gelatin
c. Custard
d. Popsicle 

3. Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intension to increase the intake of:

a. Pork
b. Milk
c. Chicken
d. Broccoli 

4. Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take?

a. Hold the feeding
b. Reinstill the amount and continue with administering the feeding
c. Elevate the client’s head at least 45 degrees and administer the feeding
d. Discard the residual amount and proceed with administering the feeding 

5. A nurse is inserting a nasogastric  tube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action?

a. Quickly insert the tube
b. Notify the physician immediately
c. Remove the tube and reinsert when the respiratory distress subsides
d. Pull back on the tube and wait until the respiratory distress subsides 

6. Nurse Ryan is assessing for correct placement of a nosogartric tube. The nurse aspirates the stomach contents and check the contents for pH. The nurse verifies correct tube placement if which pH value is noted?

a. 3.5
b. 7.0
c. 7.35
d. 7.5 

7. A nurse is preparing to remove a nasogartric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube?

a. Exhale
b. Inhale and exhale quickly
c. Take and hold a deep breath
d. Perform a Valsalva maneuver 

8. Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would:

a. Position the client supine to assist in medication absorption
b. Aspirate the nasogastric tube after medication administration to maintain patency
c. Clamp the nasogastric tube for 30 minutes following administration of the medication
d. Change the suction setting to low intermittent suction for 30 minutes after medication administration 

9. A nurse is preparing to care for a female client with esophageal varices who has just has a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times?

a. An obturator
b. Kelly clamp
c. An irrigation set
d. A pair of scissors 

10. Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?

a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D 

11. A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis?

a. Elevated hemoglobin level
b. Elevated serum bilirubin level
c. Elevated blood urea nitrogen level
d. Decreased erythrocycle sedimentation rate 

12. The nurse is reviewing the physician’s orders written for a male client admitted to the hospital with acute pancreatitis. Which physician order should the nurse question if noted on the client’s chart?

a. NPO status
b. Nasogastric tube inserted
c. Morphine sulfate for pain
d. An anticholinergic medication 

13. A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test?

a. Fast for 8 hours before the test
b. Eat a regular supper and breakfast
c. Continue to take all oral medications as scheduled
d. Monitor own bowel movement pattern for constipation 

14. The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse performs which assessment technique next?

a. Palpates the abdomen for size
b. Palpates the liver at the right rib margin
c. Listens to bowel sounds in all for quadrants
d. Percusses the right lower abdominal quadrant 

15. Polyethylene glycol-electrlyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate?

a. Start an IV infusion
b. Administer an enema
c. Cancel the diagnostic test
d. Explain that diarrhea is expected 

16. The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency?

a. Vitamin A
b. Vitamin B12
c. Vitamin C
d. Vitamin E 

17. The nurse is reviewing the medication record of a female client with acute gastritis. Which medication, if noted on the client’s record, would the nurse question?

a. Digoxin (Lanoxin)
b. Furosemide (Lasix)
c. Indomethacin (Indocin)
d. Propranolol hydrochloride (Inderal) 

18. The nurse is assessing a male client 24 hours following a cholecystectomy. The nurse noted that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate?

a. Clamp the T tube
b. Irrigate the T tube
c. Notify the physician
d. Document the findings 

19. The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer?

a. Bradycardia
b. Numbness in the legs
c. Nausea and vomiting
d. A rigid, board-like abdomen 

20. A male client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. Which response by the nurse best describes the purpose of a vagotomy?

a. Halts stress reactions
b. Heals the gastric mucosa
c. Reduces the stimulus to acid secretions
d. Decreases food absorption in the stomach 

21. The nurse is caring for a female client following a Billroth II procedure. Which postoperative order should the nurse question and verify?

a. Leg exercises
b. Early ambulation
c. Irrigating the nasogastric tube
d. Coughing and deep-breathing exercises 

22. The nurse is providing discharge instructions to a male client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome?

a. Ambulate following a meal
b. Eat high carbohydrate foods
c. Limit the fluid taken with meal
d. Sit in a high-Fowler’s position during meals 

23. The nurse is monitoring a female client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence?

a. Sweating and pallor
b. Bradycardia and indigestion
c. Double vision and chest pain
d. Abdominal cramping and pain 

24. The nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair. What should the nurse include in the plan?

a. Irrigating the drain
b. Avoiding coughing
c. Maintaining bed rest
d. Restricting pain medication 

25. The nurse is instructing the male client who has an inguinal hernia repair how to reduce postoperative swelling following the procedure. What should the nurse tell the client?

a. Limit oral fluid
b. Elevate the scrotum
c. Apply heat to the abdomen
d. Remain in a low-fiber diet 

26. The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

a. Hypotension
b. Bloody diarrhea
c. Rebound tenderness
d. A hemoglobin level of 12 mg/dL 

27. The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?

a. Sexual dysfunction
b. Body image, disturbed
c. Fear related to poor prognosis
d. Nutrition: more than body requirements, imbalanced 

28. The nurse is reviewing the record of a female client with Crohn’s disease. Which stool characteristics should the nurse expect to note documented in the client’s record?

a. Diarrhea
b. Chronic constipation
c. Constipation alternating with diarrhea
d. Stools constantly oozing form the rectum 

29. The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

a. Notify the physician
b. Stop the irrigation temporarily
c. Increase the height of the irrigation
d. Medicate for pain and resume the irrigation 

30. The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

a. Increase fluid intake
b. Place heat on the abdomen
c. Perform the irrigation in the evening
d. Reduce the amount of irrigation solution

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answers 

1.    Answer C. The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options A and B are within normal limits. Option D is an extremely elevated level seen in acute pancreatitis. 

2.    Answer C. Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in options A, B, and D are clear liquids. 

3.    Answer A. The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid 

4.    Answer A. Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. Therefore options B, C, and D are incorrect. Additionally, the feeding is not discarded unless its contents are abnormal in color or characteristics. 

5.    Answer D. During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options B and C are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus. 

6.    Answer A. If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option B indicates a slightly acidic pH. Option C indicates a neutral pH. Option D indicates an alkaline pH. 

7.    Answer C. When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull. 

8.    Answer C. If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. The client should not be placed in the supine position because of the risk for aspiration. 

9.    Answer C. When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client’s bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item. 

10.    Answer A. Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids. 

11.    Answer B. Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis. 

12.    Answer C.  Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in the sphincter of Oddi. Options A, B, and D are appropriate interventions for the client with acute pancreatitis. 

13.    Answer A. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test. After the procedure, the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract. 

14.    Answer C. The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds. 

15.    Answer D. The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours. Options A, B, and C are inappropriate actions. 

16.    Answer B. Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency. 

17.    Answer C. Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is a cardiac medication. Propranolol (Inderal) is a β-adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders. 

18.    Answer D. Following cholecystectomy, drainage from the T tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output. 

19.    Answer D. Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. 

20.    Answer C. A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options A, B, and D are incorrect descriptions of a vagotomy. 

21.    Answer C. In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation, the nurse should clarify the order. Options A, B, and D are appropriate postoperative interventions. 

22.    Answer C. Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler’s position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. 

23.    Answer A. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. 

24.    Answer B. Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity, which can occur because of the location of this surgical procedure. Bed rest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. 

25.    Answer B. Following inguinal hernia repair, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to apply a scrotal support when out of bed. Heat will increase swelling. Limiting oral fluids and a low-fiber diet can cause constipation. 

26.    Answer C. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician. 

27.    Answer B. Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options A and C. Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis. 

28.    Answer A. Crohn’s disease is characterized by non bloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options B, C, and D are not characteristics of Crohn’s disease. 

29.    Answer B. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. The physician does not need to be notified. Increasing the height of the irrigation will cause further discomfort. Medicating the client for pain is not the appropriate action in this situation. 

30.    Answer A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options B, C and D will not enhance the effectiveness of this procedure.