NEW GENERATION ADULT MEDICAL SURGICAL ASSESSMENT 2
WITH ANSWER KEY
Question 1 of 50
A nurse is caring for a client who is hyperventilating and has the following results: pH 7.50,
PaCo2 29mm Hg, and HCO2 25mEq/L. The nurse should recognize that the client has which
of the following acid-base imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolicalkalosis
Answer: b
Question 2 of 50
A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of
the following instructions should the nurse include?
a. Eat three large meals daily.
b. Consume high calorie foods.
c. Limit caffeinated drinks to two per day.
d. Drink fluids during mealtime
Answer: b
Question 3 of 50
A nurse is caring for a client who has a right sided pneumothorax. Following chest tube
insertion, which of the following findings indicates that the chest drainage system is
functioning correctly?
a. Circle bubbling in the suction chamber
b. Crepitus around the insertion site
c. Constant bubbling in the water seal chamber
d. Absence of breath sounds on the right side
Answer: a
Question 4 of 50
A nurse is caring for a client who has a traumatic brain injury. Which of the following
findings should indicate to the nurse the need for immediate intervention?
a. Auxiliary temperature 37.3 degrees Celsius (99 f)
b. Apical pulse 100mm
c. Respiratory rate 30/min
d. Blood pressure 140/34 mm Hg
Answer: c
Question 5 of 50
A nurse is developing a plan of care for a client who will be placed in halo traction following
surgical repair of the cervical spine. Which of the following intervention should he nurse
include in the plan?
a. Inspect the pin site every 48 hr
b. Monitor the client’s skin under the halo vest
c. Ensure two personnel hold the halo device when repositioning the chest
d. Apply powder frequently to the cline’s skin under the vest to decrease aching.
Answer: b
Question 6 of 50
A nurse is providing discharge teaching to a client who has heart failure and a prescription for
furosemide 20 mg PO two times daily. Which of the following instructions should the nurse
include in the teaching?
a. Monitor for increased blood pressure.
b. Increase intake of high potassium foods.
c. Expect an increase in swelling in the heads and feet.
d. Take off the second dose at bedtime.
Answer: b
Question 7 of 50
A nurse is teaching a client about feral occult blood testing (FOBT) for the screening of
colorectal cancer. Which of the following statements should the nurse include in the teaching?
a. “Your provider will use stool from your digital rectal examination to perform the test.”
b. “Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the
bowel.”
c. “You should begin annual decal occult blood testing for colorectal cancer screening at 40
years old.”
d. “You should avoid taking corticosteroids prior to testing.”
Answer: d
Question 9 of 50
A nurse is assessing a client who has meningitis. The nurse should identify which of the
following findings as a positive Kerning’s sign?
a. After striking the literal area of the foot, the client’s toes contract and draw together.
b. After hip flexion, the cline tis unable to extend their leg completely without pain
c. The client’s voluntary movement is not coordinated.
d. The Clint reports pain and stiffness when flexing their neck.
Answer: b
Question 10 of 50
A nurse is assessing a client who reports a possible exposure to HIV. Which of the following
findings should the nurse identify as an early manifestation of HIV infection?
a. Stomatitis
b. Fatigue
c. Wasting syndrome
d. Lipodystrophy
Answer: b
Question 11 of 50
A nurse is caring for a client who has rheumatoid arthritis and has been taking prednisone.
Which of the following findings should the nurse identify as an adverse effect of this
medication?
a. Weight loss
b. Hypoglycaemia
c. Hypertension
d. Hyperkalemia
Answer: c
Question 12 of 50
A nurse in an emergency department is caring for a client who has sustained multiple injuries.
The nurse observes the client’s thorax moving inward during inspiration and outward during
expiration. The nurse should suspect which of the following injuries?
a. Flat chest
b. Hemothorax
c. Pulmonary convulsion
d. Pneumothorax
Answer: a
Question 13 of 50
A nurse is planning care for a client who has Meniere’s disease and is experiencing episodes
of vertigo. Which of the following interventions should the nurse include in the plan?
a. Maintain strict bed rest
b. Restrict fluid intake to the morning hours.
c. Administer aspirin
d. Provide a low sodium diet.
Answer: d
Question 14 of 50
A nurse at a providers office is interviewing a client who has multiple sclerosis and has been
taking dantrolene for several months. Which of the following client statement should the
nurse identify as an indication that the medication is effective?
a. “I don’t have muscle spasms as frequently.”
b. “I haven’t gotten any colds, even though it is a flu season.”
c. “I feel like my nerve pain has improved’”
d. “It is easier to urinate now.”
Answer: a
Question 15 of 50
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the
following findings should the nurse identify as a possible complication of TPN
administration?
a. Fixing edema of bilateral lower extremities
b. Hypoactive bowel sounds in all four quarters.
c. Weight is the same as the day before
d. Bilateral posterior lung sounds are diminished.
Answer: a
Question 16 of 50
A nurse is teaching a client about using a continuous positive airway pressure (CAPD) device
to treat obstructive sleep apnea. Which of the following information should the nurse include
in the teaching?
a. It delivers a present amount of respirator pressure at the beginning of each breath.
b. It has continuous adjustment fracture that changes throughout the cycle.
c. It delivers a preset amount of airway pressure throughout the breathing cycle
d. It delivers possible pressure at the end of each breath.
Answer: c
Question 17 of 50
A nurse is providing discharge teaching to a client following a heart transplant. Which of the
following information should the nurse include in the teaching?
a. Immunopressant medication ought to be taken for up to 1 year
b. Shortness of breath might be an evaluation of transplant reception.
c. The surgical site will heal in 3 to 4 weeks after surgery
d. Begin 45 min of modern aerobic exercise per day following discharge.
Answer: b
Question 18 of 50
A nurse is caring for a client who has a peripheral inserted central catheter (PICC). For which
of the following findings should the nurse notify the provider?
a. The dressing was changed 7 days ago.
b. The circumference of the client’s upper arm has increased by 10%
c. The catheter has not been used in 8 hr
d. The catheter has been flushed with 10 ml of sterile saline after medication use
Answer: b
Question 19 of 50
A nurse is providing discharge teaching to a client who has acute leukaemia and received
chemo- therapy 12 hr ago. Which of the following instructions should the nurse include in the
teaching? (Select all that apply).
a. Use an electric shaver
b. Avoid crowds
c. Take temperature weekly
d. Consume a low residue diet
e. Monitor for bruising
Answer: a, b, and e
Question 20 of 50
A nurse is caring for a client who is at high risk for iron deficiency anemia. Which of the
following foods should the nurse instruct the client to increase in their diet?
a. Yogurt
b. Apples
c. Raisins
d. Cheddar cheese
Answer: c
Question 21 of 50
A nurse is admitting a client who has suspected appendicitis. Which of the following findings
should the nurse report to the provider immediately?
a. Distended board like abdomen
b. WBC count 15,000mm3
c. Rebound tenderness over McBurney’s point
d. Temperature 37.3 degrees Celsius (99.1 f)
Answer: a
Question 22 of 50
A nurse is providing teaching to a client who is scheduled for an electroencephalogram
(EEG). Which of the following statements by the client indicates an understanding of the
teaching?
a. “I should not wash my hair prior to the procedure.”
b. “I will receive a sedative I hour before the procedure.”
c. “I should avoid eating prior to the procedure.”
d. “I will be exposed to flushes of light during the procedure.”
Answer: d
Question 23 of 50
A nurse is providing discharge teaching to a client who is starting to take carbidogen
levodopa to treat Parkinson’s disease. Which of the following instruction should the nurse
include in the teaching?
a. “The medication can cause your urine to turn a dark color.”
b. “Expect immediate relief after taking the medication.”
c. “Take the medication with a high protein food.”
d. “Skip a dose of the medication if you experience dizziness.”
Answer: a
Question 24 of 50
A nurse is teaching a client who has hypertension about dietary modifications to help control
blood pressure. Which of the following food choices should the nurse recommend as the best
choice for the client to include in their diet?
a. 1 packet of reconstituted dry onion soup.
b. 3 oz of lean cured ham
c. 3 oz of chicken breast
d. 3 cup of canned baked beans
Answer: c
Question 25 of 50
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone
(SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following
laboratory findings should the nurse identify as an indication that the SIADH is resolving?
a. Urine specific gravity, 1,020
b. Sodium 119 mEq/L
c. BUN 8 mg/dL
d. Calcium 8.7 mg/ dL
Answer: a
Question 26 of 50
A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a
prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium
chloride to infuse over 1 hr. Which of the following actions should the nurse take first?
a. Teach the client to report findings of IV extravasation
b. Evaluate the potency of the IV
c. Consult with the pharmacist about the prescription.
d. Verify the prescription with the provider
Answer: d
Question 27 of 50
A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has
chest pain. Which of the following medications should the nurse plan to administer?
a. Lidocaine
b. Adenosine
c. Atropine
d. Verapamil
Answer: c
Question 28 of 50
A nurse is providing teaching to a client who is scheduled for electromyography (EMG). The
nurse should include which of the following information in the teaching?
a. “You will receive a fixed dose of radioisotope 2 hours before the procedure.”
b. “Momentary flushing will occur at the beginning of the procedure.”
c. “You should inform your provider if you are claustrophobic.”
d. “You should expect insertion of small needle electrodes into the muscles.”
Answer: d
Question 29 of 50
A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the
following should the nurse include as a risk factor for osteoporosis?
a. Early menopause
b. History of falls
c. African American race
d. Obesity
Answer: a
Question 30 of 50
A home health nurse is providing teaching to the family of a client who has a seizure disorder.
Which of the following interventions should the nurse include in the teaching?
a. Keep a padded tongue blade near the bedside.
b. Place a pillow under the client’s head while in bed during a seizure
c. Administer diazepam orally at the onset of seizures
d. Position the client on their side during seizure.
Answer: d
Question 31 of 50
A nurse is planning care for a client who has acute pancreatitis. Which of the following
interventions should the nurse include in the client’s plan? (Select all that apply)
a. Institute insulin drops
b. Monitor blood glucose levels
c. Continue regular diet as tolerated
d. Maintain NPO status until pain-free
e. Manage acute pain
Answer: b, d, and e
Question 32 of 50
A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney failure
(CKD). Which of the following referrals should the nurse plan to initiate?
a. Respiratory therapy
b. Hospice care
c. Occupational therapy
d. Dietary services
Answer: d
Question 33 of 50
A nurse is planning care for a client who has acute post-streptococcal glomerulonephritis.
Which of the following interventions should the nurse include in the client’s plan?
a. Encourage a high protein diet for the client
b. Increase the client’s fluid intake
c. Administer diuretics to the client
d. Weigh the client twice a week
Answer: c
Question 34 of 50
A nurse is teaching a group of assistive personnel (AP) about caring for clients who have
Alzheimer’s disease. Which of the following information should the nurse include in the
teaching?
a. Explain procedure in full details to a client before initiating care.
b. Limit a client’s activities to minimise emotional outbursts
c. Speak clearly and loudly to a client who is unable to form words or sentences
d. Provide supervision to prevent a client from becoming injured or lost.
Answer: d
Question 35 of 50
A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for
discharge. Which of the following client statements indicates that the client is coping
effectively?
a. “I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a
league.”
b. “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.”
c. “I’m so upset that this happened to me. What did I do to deserve this, and why am I not
getting better?”
d. “I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my
family.”
Answer: a
Question 36 of 50
A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following
precautions should the nurse initiate to prevent transmission of the disease
a. Contact precautions
b. Airborne precautions
c. Droplet precautions
d. Protective precautions
Answer: b
Question 37 of 50
A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome.
Which of the following statements should indicate to the nurse that the client understands the
teaching?
a. “I can expect swelling in my hands and on my face.”
b. “The amount of protein in my blood is high.”
c. “I might have some pain and gas in my stomach from the condition.”
d. “I will use a soft twistable toothbrush so my gums don’t bleed.”
Answer: a
Question 38 of 50
A nurse is preparing a client for a colonoscopy. Which of the following medications should
the nurse anticipate the provider to prescribe as an anaesthetic for the procedure?
a. Propofol
b. Pancurelum
c. Promethazine
d. Pentoxifyline.
Answer: a
Question 39 of 50
A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following
findings should the nurse expect?
a. Decreased deep-tendon reflexes
b. Positive Troposseaul’s sign
c. Hypoactive bowel sounds
d. Sticky mucous membranes
Answer: a
Question 40 of 50
A nurse is caring for a client who has chronic kidney disease. Which of the following diets
should the nurse anticipate the provider to prescribe?
a. 4 g sodium diet
b. Potassium-restricted diet
c. High-phosphorus diet
d. High-protein diet
Answer: b
Question 41 of 50
A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia. Which of
the following statements by the client indicates an understanding of the teaching?
a. “Exercise reduces the risk for hypoglycemia.”
b. “I can skip my insulin when I don’t eat.”
c. “I can drink 4 ounces of soda if my blood sugar is low.”
d. “Diabetic pills don’t cause hypoglycaemia, only insulin does.”
Answer: c
Question 42 of 50
A nurse in a rural community centre is providing education to a group of clients about first
aid intervention for snake bites to prevent further injury. Which of the following instructions
should the nurse include in the teaching?
a. Apply an ice pack directly to the affected areas.
b. Immobilise the affected extremity with a splint.
c. Place a tourniquent above and blow the affected areas
d. Elevate the affected extremity.
Answer: b
Question 43 of 50
A nurse is caring for a client who has burn injuries covering their upper body and I concerned
about their altered appearance. Which of the following statements should the nurse make?
a. “It is okay to not want to touch the burned areas of your body.”
b. “Cosmetic surgery should be performed within the next year to be effective.”
c. “Reconstructive surgery can completely restore your previous appearance.”
d. “It could be helpful for you to attend a support group for people who have burn injuries.”
Answer: d
Question 44 of 50
A nurse is planing care for a group of postoperative clients. Which of the following
interventions should the nurse identify as the priority?
a. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10.
b. Administer oxygen to a client who has an oxygen saturation of 91%
c. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises.
d. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal
surgery.
Answer: b
Question 45 of 50
A nurse is providing discharge instructions to a client who has GERD. Which of the
following statements by the client demonstrates an understanding of the discharge?
a. “I should take my medication with orange juice.”
b. “A bedtime snack will prevent heartburn.”
c. “I will be down after meal.”
d. “I will limit activities that require bending at the waist.”
Answer: d
Question 46 of 50
A nurse is caring for a client who has been experiencing repeated tonic clonic seizures over
the course of 30 min. After maintaining the client’s airway and turning the client on their side.
Which of the following medications should the nurse administer?
a. Diazepam IV
b. Lorazepam PO
c. Doitizem IV
d. Clonazepam PO
Answer: a
Question 47 of 50
A nurse is caring for a client who is to undergo a liver biopsy. Which of the following
instructions should the nurse provide to the client following the procedure?
a. “Lie on your left side.”
b. “Lie on your right side.”
c. “Increase your fluid intake.”
d. “Decrease your fluid intake.”
Answer: b
Question 48 of 50
A nurse is reviewing the medial record of a client who has unstable angima. Which of the
following findings should the nurse report to the provider? (Click on the “Exhibit” button for
additional information about the client. There are three tabs that contain separate categories of
data)
a. Breath sounds
b. Temperature
c. Blood pressure
d. Creatine kinase
Answer: a
Question 49 of 50
A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the
following interventions should the nurse implement?
a. Place sever pillows behind the client’s head.
b. Place the client in a Sins position.
c. Keep the client’s neck in a midline position
d. Maintain flexion of the client’s hip at the 90 degree angle.
Answer: c
Question 50 of 50
A nurse is administering a blood transfusion to a client and suspects that the client is having
an adverse reaction to the blood. Which of the following actions should the nurse take first?
a. Maintain IV access
b. Obtain the client’s vital signs
c. Contact the provider.
d. Stop the transfusion
Answer: d
