Medical Surgical Nursing II Exam

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1. A 28-year-old woman is scheduled for a glucose tolerance test. She asks the nurse what
results indicate diabetes mellitus. The nurse should respond that the minimum parameter
for indication of diabetes mellitus is a 2-hour blood glucose level greater than:
A. 120 mg/dL. B. 150 mg/dL. C 200 mg/dL. D. 250 mg/dL.
2. A patient presents with diaphoresis, palpitations, jitters, and tachycardia approximately
1½ hours after taking his regular morning insulin. Which treatment option is appropriate
for this patient?
A. Blood glucose level monitoring and carbohydrate administration
B. Nitroglycerin administration and ECG
C. Pulse oximetry monitoring and oxygen therapy
D. Salt restriction, diuretic administration, and paracentesis
3. A 52-year-old patient reports weight gain and fatigue. On assessment, her vital signs
are a blood pressure of 120/74 mm Hg, a pulse rate of 52 beats/minute, a respiratory rate
of 20 breaths/minute, and a temperature of 98° F (36.7° C). Laboratory results show low
T4 and T3 levels. The nurse knows these signs and symptoms are associated with which
condition?
A. Tetany B. Hypothyroidism C. Hyperthyroidism D. Hypokalemia
4. A 37-year-old patient complains of muscle weakness, anorexia, and darkening of his
skin. The nurse reviews his laboratory data and notes findings of low serum sodium and
high serum potassium levels. The nurse recognizes that these signs and symptoms are
associated with which condition?
5.
A. Addison’s disease B. Cushing’s syndrome C. Diabetes insipidus D. Thyroid
storm
6. Which nursing diagnosis is most likely for a patient with an acute episode of diabetes
insipidus?

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 A. Imbalanced nutrition: More than body requirements
B. Deficient fluid volume
C. Impaired gas exchange
D. Ineffective tissue perfusion: Cardiopulmonary

7. A 66-year-old patient has marked dyspnea at rest, is thin, and uses accessory muscles to
breathe. He is tachypneic, with a prolonged expiratory phase. He has no cough. He leans
forward with his arms braced on his knees to support his chest and shoulders for
breathing. This patient has signs and symptoms of which respiratory disorder?
A. ARDS B. Asthma C. Chronic obstructive bronchitis D. Emphysem
8. What complication should the nurse be alert for in a diabetic patient who has been placed
in skeletal traction after a motor vehicle collision?

A. Osteoarthritis B. Osteomyelitis C. Osteoporosis D. Osteosarcoma

9. A patient has thick, discolored nails with splintered hemorrhages, easily separated from
the nail bed. There are also “ice pick” pits and ridges. The nurse explains to the patient
that these findings are most closely associated with:
A. paronychia. B. psoriasis. C. seborrhea. D. scabies.
10. A patient has an indwelling urinary catheter, and urine is leaking from a hole in the
collection bag. Which nursing intervention would be most appropriate?
A. Cover the hole with tape.
B. Remove the catheter and collection bag, replace the bag, and insert a new catheter,
using sterile technique.
C. Disconnect the drainage bag from the catheter and replace it with a new bag.
D. Place a towel under the bag to prevent spillage of urine on the floor, which could
cause the patient to slip and fall
11. The nurse is teaching a patient with chronic renal failure which foods to avoid. It would
be most accurate for the nurse to teach the patient to avoid foods high in:
A. monosaccharides. B. disaccharides. C. iron. D. protein
12. On the first day after thoracotomy, the nurse’s assessment of the patient reveals a
temperature of 100° F (37.8° C), a heart rate of 96 beats/minute, blood pressure of 136/86
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 mm Hg, and shallow respirations of 24 breaths/minute, with rhonchi heard at the lung
bases. The patient complains of incisional pain. Which nursing action takes priority?
A. Medicating the patient for pain
B. Helping the patient out of bed
C. Administering ibuprofen (Motrin) as ordered to reduce fever
D. Encouraging the patient to cough and deep-breathe
13. A 60-year-old male client comes into the Karamara general hospital, emergency
department with complaints of crushing chest pain that radiates to his shoulder and left
arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders
include oxygen by NC at 4L/minute, blood work, chest X-ray, an ECG, and two (2) mg
of morphine given intravenously. The nurse should first:
A. Administer the morphine C. Obtain the lab work
B. Obtain a 12-lead ECG. D. Order the chest x-ray.

14. When teaching a patient why spironolactone (Aldactone) and furosemide (Lasix) are
prescribed together, the nurse bases teaching on the knowledge that:

A. Moderate doses of two different types of diuretics are more effective than a large dose of
one type.

B. This combination promotes diuresis but decreases the risk of hypokalemia

C. This combination prevents dehydration and hypovolemia.

D. Using two drugs increases osmolality of plasma and the glomerular filtration rate.

15. Which assessment data would indicate to the nurse that the client would be at risk for a
hemorrhagic stroke?
A. A blood glucose level of 480 mg/dl. C. A blood pressure of 220/120 mmhg
B. B. A right-sided carotid bruit. D. The presence of bronchogenic carcinoma.
16. The goal of antihypertensive therapy in patients with uncomplicated combined systolic
and diastolic hypertension is a blood pressure of LESS THAN:

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 A. 120/80 mmHg. B. 130/80 mmHg. C. 130/90 mmHg. D. 140/90 mmHg.

.
17. While making rounds, the nurse finds a client with COPD sitting in a wheelchair,
slumped over a lunch tray. After determining the client is unresponsive and calling for
help, the nurse's first action should be to:
A. Push the “code blue” (emergency response) button.
B. Call the rapid response team.
C. Open the client's airway.
D. Call for a defibrillator

18. A 34-year-old female with a history of asthma is admitted to the emergency department.
The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal
flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished
breath sounds. Based on these findings, which action should the nurse take to initiate care of the
client

A. Initiate oxygen therapy as prescribed and reassess the client in 10 minutes.

B. Draw blood for an arterial blood gas.

C. Encourage the client to relax and breathe slowly through the mouth.

D. Administer bronchodilators as prescribed

19. Kanani is known type 1 diabetes mellitus patient. She has presented to GG(Galamso general)
hospital with RBS of 467mg/dl, dry mouth, sunken eye ball,excessive thirsty and Lab. ABG
(serum PH=6.76, HCO3 -=19mEq/L ) U/A of glucose +2,ketone +3 . Additionally kenani is
suffering from nausea and vomiting. ECG finding reveals flattened T waves, prominent U
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wave ,ST depression,and prolonged PR interval. As a nurse which sign of electrolyte imbalance
do you think kenani is experiencing?

A. Hyponatremia B. Hypokalemia C. Hyperkalemia D. Hyperchloremia

20. A 70-year-old male presented to the Emergency Department with shortness of breath,
crackles in the bases and middle of the lung fields bilaterally, +2 pitting edema bilaterally of the
lower extremities, and a weight increase of 6 lb. in one week. His heart rate is 82 and his blood
pressure is 162/90. Per physician’s order, the nurse administers 40 mg of furosemide
intravenously. The nurse knows that which of the following indicates effectiveness of the
medication?

A. A heart rate of 58 C. Urine output increase of 200 mL over the next hour

B. A blood pressure of 100/52 D. Diminished lung sounds bilaterally with crackles in the bases

21. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the
nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

A. Notify the physician C. Apply oxygen by mask

B. Recheck the O2 saturation level in 15 minutes D. Assess the pulse

22. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse
would be most concerned with the client developing which of the following?

A. Hypovolemia B. Laryngeal edema C. Hypernatremia D. Hyperkalemia

23. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the
following symptoms would you NOT expect to see in this patient?

A. Numbness in hands and feet. C. Hypoactive bowel sounds

B. Muscle cramping D. Positive Chvostek‘s sign.

24. A nurse cares for a patient who has a nasogastric tube attached to low suction because of a
suspected bowel obstruction. Which of the following arterial blood gas results might be expected
in this patient?

A. pH 7.52, PCO2 54 mmHg. C. pH 7.25, PCO2 25 mmHg

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B. pH 7.42, PCO2 40 mmHg. D. pH 7.38, PCO2 36 mmHg

25. A client who has a cold is seen in the emergency department with an inability to void.
Because the client has a history of benign prostatic hyperplasia, the nurse determines that the
client should be questioned about the use of which medication?

A. Diuretics B. Antibiotics C. Antilipemics D. Decongestants

26. The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to
limit the suctioning time to a maximum of which time period?

A. 5 seconds B. 10 seconds C. 30 seconds D. 60 second

27. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary
disease to deliver a precise oxygen concentration. Which oxygen delivery system would the
nurse prepare for the client?

A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar

28. A client has been taking isoniazid for 2 months. The client complains to the nurse about
numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is
experiencing which problem?

A. Hypercalcemia C. Small blood vessel spasm

B. Peripheral neuritis D. Impaired peripheral circulation

29. A 29 years old Female Patient is presented to the emergency department with profuse bright-
red hematemesis. During the initial care of the patient, what is the nurse’s first priority?
A. Establish two IV sites with large-gauge catheters.
B. Perform a focused nursing assessment of the patient’s status.
C. Obtain a thorough health history to assist in determining the cause of the bleeding.
D. Perform a gastric lavage with cool tap water in preparation for endoscopic
examination.
30. When caring for a patient who has had most of the stomach surgically removed, what is
important for the nurse to teach the patient?

A. Extra iron will need to be taken to prevent anemia.

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 B. Avoid foods with lactose to prevent bloating and diarrhea.
C. Lifelong supplementation of cobalamin (vitamin B12) will be needed.
D. Because of the absence of digestive enzymes, protein malnutrition is likely

31. An 58-year-old female patient with anorexia nervosa is admitted to the hospital for
treatment. On admission she weighs 82 lb (37 kg) and is 5 ft, 3 in (134.6 cm). Her laboratory test
results include the following: K+ 2.8 mEq/L (2.8 mmol/L), Hgb 8.9 g/dL (89 g/L), and BUN 64
mg/dL (22.8 mmol/L). In planning care for the patient, the nurse gives the highest priority to
which of the following nursing diagnoses?

A. Risk for injury related to dizziness and weakness resulting from anemia.
B. Imbalanced nutrition: less than body requirements related to inadequate food intake.
C. Risk for impaired urinary elimination related to elevated Blood urea nitrogen
resulting from renal failure.
D. Risk for decreased cardiac output (CO) related to dysrhythmias resulting from
hypokalemia.

32. A patient with a gastric outlet obstruction has been treated with NG decompression. After
the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds.
What is the best action by the nurse?

A. Check the patency of the NG tube.

B. Place the patient in a recumbent position.
C. Assess the patient’s vital signs and circulatory status.
D. Encourage the patient to deep breath and consciously relax.

33. The adolescent patient has symptoms: nuchal rigidity, fever, vomiting, and lethargy. The
nurse knows to prepare for the following which test?
A. Blood culture C. Throat and ear culture
B. Computed tomograpgy scan(CT scan) D. Lumbar puncture

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34. The patient asks the nurse why she needs to have surgery for a femoral, strangulated hernia.
What is the best explanation the nurse can give the patient?
A. The surgery will relieve her constipation.
B The abnormal hernia must be replaced into the abdomen.
B. The surgery is needed to allow intestinal flow and prevent necrosis.
D.The hernia is because the umbilical opening did not close after birth as it should
have.
35. To Treat a Cirrhotic patient with hepatic Encephalopathy, Lactulose, rifaximin, and a Proton
pump inhibitor are ordered. The patient’s family wants to know why the Lactulose is ordered.
What is the best explanation the nurse can give to the patient’s family?

A. It traps ammonia and eliminates it in the feces.

B. It eliminates blood from the GI tract.
C. It reduces portal venous pressure.
D. It decreases bacteria to decrease ammonia formation

36. The family members of a patient with hepatitis A ask if there is anything that will prevent
them from developing the disease. What is the best response by the nurse?

A. “No immunization is available for hepatitis A, nor are you likely to get the disease.”
B. “All family members should receive the hepatitis A vaccine to prevent or modify the
infection.”
C. “Those who have had household or close contact with the patient should receive
immune globulin.”
D. “Only those individuals who have had sexual contact with the patient should receive
immunization.”

37. The nurse admits a patient who has a head injury and is at risk for increased intracranial
pressure. Which of the following interventions will she perform to help this patient?
A. Use the Glasgow Coma Scale to assess level of consciousness hourly
B. Assess pupils for size, movement, and response to light
C. Administer acetaminophen every 3–4 hours for headache
D. Elevate the head of the bed approximately 30 degrees
38. A 39 years old Female patient is admitted to the unit after a Cerebro-Vascular Accident that
damaged the right side of her brain. The nurse knows which position appropriate for her?

A. On her right side with the head of the bed slightly elevated.

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 B. On her left side with the head of the bed slightly elevated.
C. In the prone position.
D. Supine with the bed in trendelenberg.

39. The nurse happens to be at the scene of an accident where an unconscious man who is not
breathing is lying next to a ladder. Suspecting a possible neck injury, the nurse initiates rescue
breathing using, by which maneuver?

A. Jaw lift C. Breathing through nose and mouth

B. Head tilt D. Tongue sweep

40. The patient has persistent and continuous pain at McBurney’s point. The nursing assessment
reveals rebound tenderness and muscle guarding with the patient preferring to lie still with the
right leg flexed. What should the nursing interventions for this patient include?

A. Laxatives to move the constipated bowel

B. NPO status in preparation for possible appendectomy

C. Parenteral fluids and antibiotic therapy for 6 hours before surgery

D. NG tube inserted to decompress the stomach and prevent aspiration.

41. Which assessment finding may indicate to the nurse an acute peripheral neurovascular
dysfunction for the patient recovering from surgery of the foot?

A. Pale skin, atrophy of the limb, with capillary refill of 2 seconds

B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin

C. Atrophy of limb, increased motion, and thickened toe nails

D. Pale skin, weakness in motion, and loss of toe hairs

43. A 22-year-old man is admitted to the emergency department with a crush injury to both
lower legs. He was pinned under a car for 3 hours. On admission, his vital signs are stable; he is
alert and oriented and complaining of extreme pain in his legs. Popliteal pulses are strong; pedal
and posterior tibial pulses are weak. The ankle and feet appear dusky; the skin is tense, but the

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skin envelope is not broken. X-rays show no broken bones. Based upon these data, what
interventions are most appropriate?

A. Notify the provider and anticipate that a stat scan will be performed to rule out Fat
emboli.

B. Notify the provider and prepare to set up skin traction to decrease the pressure on the
Calf muscle.

C. Notify the provider and anticipate that the provider will measure the pressure in the
Compartment and possibly perform a fasciotomy if elevated pressure is noted.

D. Notify the provider and prepare to give iv antibiotics stat to decrease the risk of
Osteomyelitis.

44. During assessment of a patient admitted to the emergency room after a motor vehicle
collision, he becomes semiconscious and continues moaning with pain. His blood pressure has
now decreased to 100/42, and his pulse has increased to 122. What is the most immediate life-
threatening problem for this patient?

A. Arrhythmias due to hypokalemia

B. Hypovolemia

C. Respiratory depression from pain medication

D. Fat embolus to the lung

45. A 73-year-old patient is placed in skeletal traction prior to surgery for an ORIF(Open
reduction and internal fixation ) of fractured femur. She develops chest pain, tachypnea, and
tachycardia the second day in traction. What additional symptom would indicate her symptoms
are related to a fat emboli rather than a pulmonary thromboembolic event?

A. Hypotension

B. Restlessness

C. Petechiae of the anterior chest wall

D. Warm, reddened areas in her leg

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46. A 23-year-old patient, experienced an open fracture of the left tibia with major soft tissue
damage of his lower leg in a bicycle accident. Surgical reduction and fixation of the tibia were
performed with debridement of nonviable tissue and drain placement in the damaged soft tissue.
Which finding by the nurse would most likely indicate the development of the osteomyelitis?

A. Tachycardia

B. Elevated ESR

C. Numbness in the left leg and toes

D. Muscle spasms around the affected bone

47. A patient is admitted to the emergency department with a wood splinter imbedded in
the right eye. Which intervention by the nurse is most appropriate?

A. Irrigate the eye with a large amount of sterile saline.

B. Carefully remove the splinter with a pair of sterile forceps.

C. Cover the eye with a dry sterile patch and a protective shield.

D. Apply light pressure on the closed eye to prevent bleeding or loss of aqueous
humor

48. Which statement by the patient diagnosed with viral conjunctivitis indicates
that more teaching is necessary?

A. “I will wash my hands frequently.”

B. “I will use a washcloth to clean both my eyes, starting with the infected eye
and moving to the uninfected eye.”

C. “I will avoid contact with other people until my symptoms are gone.”

D. “I will discard any leftover eye medication when the infection is gone

49. A 60-year-old patient is being prepared for outpatient cataract surgery. When
obtaining admission data from the patient, what would the nurse expect to find in the
patient’s history?

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 A. A painless, sudden, severe loss of vision

B. Blurred vision, colored halos around lights, and eye pain

C. A gradual loss of vision with abnormal color perception and glare

D. Light flashes, floaters, and a “cobweb” in the field of vision with loss of
central or peripheral vision

50. Nurse Hunde is performing a WEBERS TEST. He placed the tuning fork in the
patient’s forehead after tapping it onto his knee. The client states that the fork is louder in
the LEFT EAR. Which of the following is a correct conclusion for nurse Hunde to make?

A. He might have a sensory hearing loss in the left ear

B. Conductive hearing loss is possible in the right ear

C. He might have a sensory hearing loss in the right hear, and/or a conductive
hearing loss in the left ear.

D. He might have a conductive hearing loss in the right ear, and/or a sensory
hearing loss in the left ear

A patient with early cataracts tells the nurse that he is afraid cataract surgery may
cause permanent visual damage. What should the nurse teach the patient?

a. the cataracts will only worsen with time and should be removed as early as
possible to prevent blindness.

b.cataract surgery is very safe and with the implantation of an intraocular lens, the
need for glasses will be eliminated.

c. progression of the cataracts can be prevented by avoidance of ultraviolet (UV)

light and good dietary management.

d. vision enhancement techniques may improve vision until surgery becomes an

acceptable option to maintain desired activities.

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ANSWER: D

Following change of shift report, which patient should the nurse

assessed first.

A. A 58-year-old male experiencing phantom pain and requesting

analgesic

B. A 72-year-old male being transferred to a skilled nursing unit

following repair of a hip fracture

C. A 25-year-old female in left leg skeletal traction asking for the

weights to be lifted for a few minutes

D. A 68-year-old male with a new lower leg cast complaining that the
cast is too tight if he cannot feel his toes

D. A 68-year-old male with a new lower leg cast complaining that the
cast is too tight if he cannot feel his toes

d. A 68-year-old male with a new lower leg cast reporting the cast is too
tight and he cannot feel his toes

A patient is admitted with an open fracture of the tibia following a

bicycle accident. During assessment of the patient, what specifically
should the nurse question the patient about?

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a. Any previous injuries to the leg

b. The status of tetanus immunization

c. The use of antibiotics in the last month

d. Whether the injury was exposed to dirt or gravel

b. Infection is the greatest risk with an open fracture and all open
fractures are considered contaminated. Tetanus prevention is always
indicated if the patient has not been immunized or does not have current

A patient with chronic cholecystitis asks the nurse whether she will need
to continue a low-fat diet after she has a

cholecystectomy. What is the best response by the nurse?

a. "A low-fat diet will prevent the development of further gallstones and
should be continued."

b. "Yes; because you will not have a gallbladder to store bile, you will
not be able to digest fats adequately."

c. "A low-fat diet is recommended for a few weeks after surgery until
the intestine adjusts to receiving a continuous

flow of bile."

d. "Removal of the gallbladder will eliminate the source of your pain

associated with fat intake, so you may eat

whatever you like."

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Correct Answer: c. After removal of the gallbladder, bile drains directly

from the liver into the duodenum and a low-fat diet is

recommended until adjustment to this change occurs. Most

patients tolerate a regular diet with moderate fats but should

avoid excessive fats, as large volumes of bile previously

stored in the gallbladder are not available. Steatorrhea could

occur with a large fat intake

Answer sheet
Name ________________________________________________________ IDNO_________
1_____ 29______
2_____ 30______
3_____ 31_____
4_____ 32_____
5_____ 33_____
6_____ 34_____
7_____ 35_____
8_____ 36_____
9 _____ 37_____
10_____ 39_____

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11_____ 40_____
12_____ 41_____
13_____ 42_____
14_____ 43_____
15_____ 44_____
16_____ 45_____
17____ 46_____
18____ 47_____
19____ 48_____
20____ 49_____
21____ 50____
22____
23____
24____
25____
26____
27____
28____

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