Medical-surgical Nursing Quiz Questions And Answers

1. A nurse is caring for a client with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which of the following does the nurse teaches the client?

Glucose tablets and subcutaneous glucagon should be made available.

If the client is exercising, the evening dose of NPH insulin can be discontinued.

Urine should be monitored for the presence of acetone.

Assess for signs of coma and drowsiness.

The nurse teaches the client to have glucose tablets and subcutaneous glucagon available because these are the appropriate treatments for hypoglycemia. Glucose tablets can quickly raise blood sugar levels, while subcutaneous glucagon can be used if the client is unable to consume oral glucose. This is important for a client with type 1 diabetes mellitus who is at risk for hypoglycemia. The other options are not relevant to the management of hypoglycemia.

Explanation

The nurse teaches the client to have glucose tablets and subcutaneous glucagon available because these are the appropriate treatments for hypoglycemia. Glucose tablets can quickly raise blood sugar levels, while subcutaneous glucagon can be used if the client is unable to consume oral glucose. This is important for a client with type 1 diabetes mellitus who is at risk for hypoglycemia. The other options are not relevant to the management of hypoglycemia.

2. In an emergency situation like the occurrence of fire, which of the following should be done first by the nurse?

Extinguish the fire.

Call the fire department and report the situation.

Rescue the client and transfer them to a safe place.

Contain the fire.

It is important for nurses to be aware of the fire safety regulations and the fire prevention practices of the agency in which they work. When a fire occurs, the nurse follows four sequential priorities: protect and evacuate clients who are in immediate danger, report the fire, contain the fire, and extinguish the fire.

Explanation

It is important for nurses to be aware of the fire safety regulations and the fire prevention practices of the agency in which they work. When a fire occurs, the nurse follows four sequential priorities: protect and evacuate clients who are in immediate danger, report the fire, contain the fire, and extinguish the fire.

3. The primary use of the nasogastric tube is for feeding and for administering oral medications. A nurse teaches a postoperative client about the nasogastric tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed in the postoperative period when the client states that _________________.

They can swallow food without vomiting

They are comfortable eating solid food

Their GI system is completely healed

Their bowels begin to function again, and they begin to pass gas

The correct answer is "their bowels begin to function again, and they begin to pass gas". This is the correct statement because the nasogastric tube is used to decompress the stomach and prevent the accumulation of fluids and gas. Once the client's bowels begin to function again and they are passing gas, it indicates that their gastrointestinal system is functioning properly and there is no longer a need for the nasogastric tube.

Explanation

The correct answer is "their bowels begin to function again, and they begin to pass gas". This is the correct statement because the nasogastric tube is used to decompress the stomach and prevent the accumulation of fluids and gas. Once the client's bowels begin to function again and they are passing gas, it indicates that their gastrointestinal system is functioning properly and there is no longer a need for the nasogastric tube.

4. Hiatal hernia is a condition in which the upper portion of the stomach protrudes into the chest cavity through the opening of the diaphragm called the esophageal hiatus. A nurse is instructing a patient with a hiatal hernia about the fluids that the client can drink that will less likely produce irritation to the gastric mucosa. Which of the following juice is the correct response of the nurse?

Tomato juice

Pineapple juice

Apple juice

Grapefruit juice

Apple juice is the correct response because it is less likely to produce irritation to the gastric mucosa. Tomato juice and grapefruit juice are acidic and can aggravate the condition. Pineapple juice contains bromelain, which can cause irritation to the stomach lining. Apple juice, on the other hand, has a lower acidity level and is generally well-tolerated by individuals with hiatal hernia.

Explanation

Apple juice is the correct response because it is less likely to produce irritation to the gastric mucosa. Tomato juice and grapefruit juice are acidic and can aggravate the condition. Pineapple juice contains bromelain, which can cause irritation to the stomach lining. Apple juice, on the other hand, has a lower acidity level and is generally well-tolerated by individuals with hiatal hernia.

5. Dietary planning for a client with an ileostomy would include telling the client to:

Avoid high-fiber foods.

Restrict the amount of fluid intake.

Limit the calorie intake.

Encourage the patient to increase fluid intake.

The reason for telling a client with an ileostomy to avoid high-fiber foods is because high-fiber foods can be difficult to digest and may cause blockages or discomfort in the digestive system. Since the ileostomy bypasses a portion of the small intestine, it is important to avoid foods that could potentially cause complications. Instead, the client should focus on consuming low-fiber foods that are easier to digest.

Explanation

The reason for telling a client with an ileostomy to avoid high-fiber foods is because high-fiber foods can be difficult to digest and may cause blockages or discomfort in the digestive system. Since the ileostomy bypasses a portion of the small intestine, it is important to avoid foods that could potentially cause complications. Instead, the client should focus on consuming low-fiber foods that are easier to digest.

6. Addison’s disease is an endocrine disorder that develops when the adrenal glands are not able to produce enough cortisol. A client with Addison’s disease is receiving fludrocortisone acetate. The nurse knows that the therapeutic effect of this is to _________________.

Stimulate thyroid gland production.

Activate parathyroid production.

Maintain electrolyte balance.

Activate the immune response.

Fludrocortisone acetate is a synthetic corticosteroid that mimics the effects of aldosterone, a hormone produced by the adrenal glands. Aldosterone is responsible for regulating electrolyte balance in the body, specifically sodium and potassium levels. By administering fludrocortisone acetate to a client with Addison's disease, the nurse is helping to maintain electrolyte balance by increasing sodium reabsorption and promoting potassium excretion. This helps to prevent imbalances that can occur due to the adrenal glands' inability to produce enough cortisol.

Explanation

Fludrocortisone acetate is a synthetic corticosteroid that mimics the effects of aldosterone, a hormone produced by the adrenal glands. Aldosterone is responsible for regulating electrolyte balance in the body, specifically sodium and potassium levels. By administering fludrocortisone acetate to a client with Addison's disease, the nurse is helping to maintain electrolyte balance by increasing sodium reabsorption and promoting potassium excretion. This helps to prevent imbalances that can occur due to the adrenal glands' inability to produce enough cortisol.

7. A colostomy is a surgical procedure that brings the end of the large intestine through the abdominal wall. A nurse is demonstrating colostomy care to a client with a newly-created colostomy. The nurse demonstrates correct cutting of the appliance by making the opening ______________ larger than that of the client's stoma?

½ inch

¼ inch

1/8 inch

1/16 inch

When demonstrating colostomy care, the nurse should make the opening of the appliance slightly larger than that of the client's stoma. This allows for a better fit and prevents any irritation or damage to the stoma. Making the opening 1/8 inch larger ensures that the appliance will fit comfortably and securely around the stoma without causing any discomfort or leakage.

Explanation

When demonstrating colostomy care, the nurse should make the opening of the appliance slightly larger than that of the client's stoma. This allows for a better fit and prevents any irritation or damage to the stoma. Making the opening 1/8 inch larger ensures that the appliance will fit comfortably and securely around the stoma without causing any discomfort or leakage.

8. Sepsis is a severe illness caused by an overwhelming infection of the bloodstream by toxin-producing bacteria. What is the most common portal of entry for microorganisms associated with sepsis?

Respiratory tract

GI tract skin

Skin

Urinary tract

The most common portal of entry for microorganisms associated with sepsis is the urinary tract. Sepsis can occur when bacteria from a urinary tract infection enter the bloodstream, leading to a severe infection throughout the body. This is a common route of entry for microorganisms because the urinary tract is in close proximity to the bloodstream, allowing bacteria to easily spread and cause systemic infection.

Explanation

The most common portal of entry for microorganisms associated with sepsis is the urinary tract. Sepsis can occur when bacteria from a urinary tract infection enter the bloodstream, leading to a severe infection throughout the body. This is a common route of entry for microorganisms because the urinary tract is in close proximity to the bloodstream, allowing bacteria to easily spread and cause systemic infection.

9. Personal protective equipment is used to reduce exposure to hazards. A nurse is preparing to change linens and clean a client who is incontinent of urine. Which of the following protective items should the nurse wear?

Gowns, shoe covers, gloves, and eyewear

Mask and gloves

Gowns and gloves

Mask, gown, and gloves

Personal protective equipment (PPE) is essential for minimizing exposure to hazards. When changing linens and caring for an incontinent client, a nurse should wear gloves and a gown. These protective items safeguard the nurse from contact with urine and ensure proper infection control practices in healthcare settings.

Explanation

Personal protective equipment (PPE) is essential for minimizing exposure to hazards. When changing linens and caring for an incontinent client, a nurse should wear gloves and a gown. These protective items safeguard the nurse from contact with urine and ensure proper infection control practices in healthcare settings.

10. Poisoning results from the ingestion, inhalation, or absorption of agents that cause chemical actions that injure the body. Your neighbor called asking what she should do after her 4-year-old daughter swallowed some meiotic acid. What advice should you give her?

Give her some Ipecac.

Feed her some burnt bread.

Give her some aspirin.

Make her drink lots of water.

Feeding the child some burnt bread is the correct advice to give in this situation. Burnt bread, specifically charcoal, is known to have adsorptive properties that can help absorb certain toxins in the stomach and prevent them from being absorbed into the bloodstream. This can be helpful in cases of poisoning, as it may reduce the toxicity of the ingested substance. However, it is important to note that this advice should be given in conjunction with seeking immediate medical attention, as professional medical assistance is crucial in cases of poisoning.

Explanation

Feeding the child some burnt bread is the correct advice to give in this situation. Burnt bread, specifically charcoal, is known to have adsorptive properties that can help absorb certain toxins in the stomach and prevent them from being absorbed into the bloodstream. This can be helpful in cases of poisoning, as it may reduce the toxicity of the ingested substance. However, it is important to note that this advice should be given in conjunction with seeking immediate medical attention, as professional medical assistance is crucial in cases of poisoning.