MED SURG REAL EXAM WITH QUESTIONS AND ANSWERS, RATIONALES, TEST-TAKING STRATEGIES AND REFERENCES

MED SURG REAL
EXAM WITH
QUESTIONS AND
ANSWERS,
RATIONALES,
TEST-TAKING
STRATEGIES AND
REFERENCES


A nurse is watching as a nursing student suctions a client through a
tracheostomy tube. Which actions on the part of the student would prompt
the nurse to intervene and demonstrate correct procedure? Select all that
apply.

Setting the suction pressure to 60 mm Hg Correct
Applying suction throughout the procedure Correct
Assessing breath sounds before suctioning
Placing the client in a supine position before the procedure Correct
Hyperoxygenating the client with 100% oxygen before suctioning
Rationale: The client with a tracheostomy tube should be positioned with
the head of the bed elevated. Correct suction pressure for the adult client is
80 to 120 mm Hg. Suction is applied intermittently during catheter
withdrawal. Breath sounds should be assessed before the procedure to
help determine the need for suctioning. The client should be
hyperoxygenated with 100% oxygen before suctioning.

Test-Taking Strategy: Use the process of elimination, noting the words “to
intervene,” which should tell you that the correct answer is an incorrect
nursing action. Visualizing the procedure and recalling the principles of
suctioning will direct you to the correct options. Review the procedure for
suctioning if you had difficulty with this question.

Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Leadership and Management
References: Monahan, F., Sands, J., Marek, J., Neighbors, M., & Green, C.
(2007). Phipps' medical-surgical nursing: Health and illness perspectives
(8th ed., pp. 618, 703). St. Louis: Mosby.
Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p.
670). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
42.ID: 383739346
A client who has undergone an esophagogastroduodenoscopy (EGD)
returns from the endoscopy department. After checking the client’s gag
reflex, which action should the nurse take?

Taking the client’s vital signs Correct
Giving the client a drink of water
Monitoring the client for a sore throat
Being alert to complaints of heartburn
Rationale: The nurse would first assess the client for the return of the gag
reflex, which is part of managing the client’s airway. The client’s vital signs
should be checked next; a sudden sharp increase in temperature could
indicate perforation of the gastrointestinal tract (this would be
accompanied by other signs, such as pain, as well). Monitoring the client
for sore throat and heartburn is also important but is of lesser priority than
ensuring a patent airway. Water or any other fluid would not be given to
the client until the gag reflex had returned and the client was stable.

Test-Taking Strategy: Use your knowledge of the ABCs (airway, breathing,
and circulation) to identify the correct option. Review care of the client
after EGD if you had difficulty with this question.

Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Gastrointestinal
Reference: Pagana, K., & Pagana, T. (2009). Mosby’s diagnostic and
laboratory test reference (9th ed., p. 407). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
59.ID: 383738723
A client has just been scheduled for endoscopic retrograde
cholangiopancreatography (ERCP). What should the nurse tell the client
about the procedure? Select all that apply.

That informed consent is required Correct
That the test takes about 4 hours to complete
That no premedication for sedation will be necessary

That food and fluids will be withheld before the procedure Correct
That multiple position changes may be necessary to pass the tube Correct

Rationale: The client must sign informed consent before the procedure,
which takes about an hour to perform. Intravenous sedation is given to
relax the client, and an anesthetic spray is used to help keep the client from
gagging as the endoscope is passed. Food and fluids are withheld before
the procedure to prevent aspiration. Multiple position changes may be
necessary to facilitate the passage of the tube.
Test-Taking Strategy: Specific knowledge about the procedure is needed to
answer the question. Think about the procedure and how it is done. This
will assist in eliminating the option that states that no premedication for
sedation will be necessary and selecting the option that states multiple
position changes may be necessary to pass the tube. Knowing that it is
invasive will assist in selecting the option related to informed consent being
required. Eliminate the option that states that test takes about 4 hours to
complete because of the words "4 hours." Recalling that aspiration is a
concern will assist in selecting the option that says to withhold food and
fluids before the procedure. Review this procedure if you had difficulty with
this question.

Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Gastrointestinal
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques
(7th ed., p. 1187). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
60.ID: 383737776
• A client who just returned from the recovery room after a tonsillectomy
and adenoidectomy is restless and her pulse rate is increased. As the nurse
continues the assessment, the client begins to vomit a copious amount of
bright- red blood. The immediate nursing action is to:

Notify the surgeon
Continue the assessment
Check the client’s blood pressure

Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy and
adenoidectomy. If the client vomits a large amount of bright-red blood or
the pulse rate increases and the patient is restless, the nurse must notify the
surgeon immediately. The nurse should obtain a light, mirror, gauze,
curved hemostat, and waste basin to facilitate examination of the surgical
site. The nurse should also gather additional assessment data, but the
surgeon must be contacted immediately.

Test-Taking Strategy: Focus on the data in the question. Noting the words
“bright- red blood” will assist in directing you to the correct option.
Remember that the presence of bright-red blood indicates active bleeding.
Review the nursing actions to be taken immediately when bleeding occurs
after a tonsillectomy and adenoidectomy if you had difficulty with this
question.

Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medicalsurgical
nursing: Patient-centered collaborative care (6th ed., p.
657). St. Louis: Saunders.