Medical Surgical Nursing Pre-test 1

30 ITEMS

1. If parents or legal guardians aren't available to give consent for treatment of a life-threatening
situation in a minor child, which of the following statements is most accurate?
a.)Consent may be obtained from a neighbor or close friend of the family.
b.)Consent may not be needed in a life-threatening situation.
c.)Consent must be in the form of a signed document; therefore, parents or guardians must be
contacted.
d.)Consent may be given by the family physician.

2. You're admitting a 15-month-old boy who has bilateral otitis media and bacterial meningitis. Which
room arrangements would be best for this client?
a.)In isolation off a side hallway
b.)A private room near the nurses' station
c.)A room with another child who also has meningitis
d.)A room with two toddlers who have croup

3. Which of the following points should a team leader consider when delegating work to team members
in order to conserve time?
a.)Assign unfinished work to other team members.
b.)Explain to each team member what needs to be done.
c.)Relinquish responsibility for the outcome of the work.
d.)Assign each team member the responsibility to obtain dietary trays.

4. The nurse is caring for a client admitted to the emergency department after a motor vehicle accident.
Under the law, the nurse must obtain informed consent before treatment unless:
a.)the client is mentally ill.
b.)the client refuses to give informed consent.
c.)the client is in an emergency situation.
d.)the client asks the nurse to give substituted consent.

5. The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb
out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break.
While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the
nurse should treat this occurrence as:
a.)a quality improvement issue.
b.)an ethical dilemma.
c.)an informed consent problem.
d.)a risk-management incident.

6. The nurse receives an assignment to provide care to 10 clients. Two of them have had kidney
transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of
clients. In addition, the nurse has never cared for a client who has undergone recent transplantation
surgery. What's the appropriate action for the nurse to take?
a.)Speak to the manager and document in writing all concerns related to the assignment.
b.)Refuse the assignment.
c.)Ignore the assignment and leave the unit.
d.)Trade assignments with another nurse.

7. The nurse works with a colleague who consistently fails to use standard precautions or wear gloves
when caring for clients. The nurse calls the colleague's attention to these oversights. The colleague tells
the nurse that standard precautions and gloves aren't necessary unless the client is known to have
tested positive for the human immunodeficiency virus. What's the most appropriate action for the nurse
to take?
a.)Ignore it because it isn't directly the nurse's problem
b.)Document the problem in writing for the manager.
c.)Talk to other staff members to ascertain their practices.
d.)Instruct the clients to remind this colleague to wear gloves.

8. An adult client is diagnosed with acquired immunodeficiency syndrome. The nurse who is caring for
the client is also his friend. The nurse tells the client's parents about the diagnosis; after all, they know
their son is the nurse's friend. Several weeks later, the nurse receives a letter from the client's attorney
stating that the nurse has committed an intentional tort. Which intentional tort has this nurse
committed?
a.)Fraud
b.)Defamation of character
c.)Assault and battery
d.)Breach of confidentiality

9. A nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although

10. The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the
assessment interview, the client reports that he's impotent and says that he's concerned about its effect
on his marriage. In planning this client's care, the most appropriate intervention would be to:
a.)encourage the client to ask questions about personal sexuality.
b.)provide time for privacy.
c.)provide support for the spouse or significant other.
d.)suggest referral to a sex counselor or other appropriate professional.

11. The nurse is assigned to care for eight clients. Two nonprofessionals are assigned to work with the
nurse. Which statement is valid in this situation?
a.)The nurse may assign the two nonprofessionals to work independently with a client assignment.
b.)The nurse is responsible to supervise assistive personnel.
c.)Nonprofessionals aren't responsible for their own actions.
d.)Nonprofessionals don't require training before they work with clients.

12. Each state has guidelines that regulate the different levels of nursing & licensed practical or
vocational nurse, registered nurse, or advanced practice nurse. Legal guidelines outlining the scope of
practice for nurses are known as:
a.)consent to treatment.
b.)client's bill of rights.
c.)nurse practice acts.
d.)licensure requirements.

13. A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses
to sign the paperwork. The nurse's next course of action is to:
a.)detain him until he signs the paperwork.
b.)detain him until his physician arrives.
c.)call security for assistance.
d.)let him leave.

14. A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client
to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself.
The nurse is at fault because she hasn't:
a.)properly educated this client about safety measures.
b.)restrained the client.
c.)documented that she left the client.
d.)arranged for continual care of the client.

15. When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority
would be:
a.)allowing the family to see a newly admitted client.
b.)ambulating the client in the hallway.
c.)administering pain medication.
d.)placing wrist restraints on the client.

16. When developing a therapeutic relationship with a client, the nurse should begin preparing the client
for termination of the relationship:
a.)at discharge.
b.)during the first meeting.
c.)at the midpoint of the relationship.
d.)when the client demonstrates the ability to function independently.

17. To be effective, a clinical nurse-manager in a managed care environment must:

18. In community-based nursing, primary responsibility for decisions related to health care belongs to
the:
a.)nurse.
b.)client.
c.)health care team.
d.)physician.

19. A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files
a lawsuit. Who is most likely to be held liable?
a.)No one because it was an accident
b.)The hospital
c.)The nurse
d.)The nurse and the hospital

20. The nurse is providing care for a client who underwent mitral valve replacement. The best example
of a measurable client outcome goal is to:
a.)change his own dressing.
b.)walk in the hallway.
c.)walk from his room to the end of the hall and back before discharge.
d.)eat a special diet.

21. A client with end-stage liver cancer tells the nurse he doesn't want extraordinary measures used to
prolong his life. He asks what he must do to make these wishes known and legally binding. How should
the nurse respond to the client?
a.)Tell him that it's a legal question beyond the scope of nursing practice.
b.)Give him a copy of the client's bill of rights.
c.)Provide information on active euthanasia.
d.)Discuss documenting his wishes in an advance directive.

22. While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of
healing. The client has Alzheimer's disease and a history of multiple fractures. Legally, the most
important action for the nurse to take is to:
a.)document findings thoroughly.
b.)question the client about the bruising.
c.)inform appropriate local authorities.
d.)tell the client's physician.

23. The nurse is providing care for a client with multiple myeloma, a disorder characterized by episodes
of remissions and exacerbations. Which resource can best help the client adapt to the disease?
a.)The client's family
b.)Pastoral care
c.)Support group
.)Hospice care

24. A client with brain cancer is deteriorating and the prognosis is poor. The client meets brain-death
criteria. Which nursing intervention is most appropriate at this time?
a.)Approach the client's family about organ donation.
b.)Make the decision to withdraw life support.
c.)Sedate the client.
d.)Talk to the staff about their feelings.

25. A client is scheduled to have a descending colostomy. He's very anxious and has many questions
concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate
for the nurse to make a referral to which member of the health care team?
a.)Social worker
b.)Registered dietitian
c.)Occupational therapist
d.)Enterostomal nurse therapist

26. A 92-year-old client with prostate cancer and multiple metastases is in respiratory distress and is
admitted to a medical unit from a skilled nursing facility. His advance directive states that he doesn't
want to be placed on a ventilator or receive cardiopulmonary resuscitation. Based on the client's
advance directive, which intervention should the nursing care plan include?
a.)Check on the client once per shift.
b.)Provide mouth and skin care only if the family requests it.
c.)Turn the client only if he's uncomfortable.
d.)Provide emotional support and pain relief.

27. The registered nurse has an unlicensed assistant working with her for the shift. When delegating
tasks, the registered nurse understands that the unlicensed assistant:
a.)interprets clinical data.
b.)collects clinical data.
c.)is trained in the nursing process.
d.)can function independently.

28. A nurse on a medical-surgical floor is making assignments for an 8-hour shift. Which of the following
considerations has the highest priority?
a.)Complexity of care required
b.)Age of the clients
c.)Skills of the assigned personnel
d.)The number of clients

29. The nurse is caring for a homeless client with active tuberculosis. The client is almost ready for
discharge; however, the nurse is concerned about the client's ability to follow the medical regimen.
Which intervention will best ensure that the client complies with treatment?
a.)Referring the client to a social worker for discharge planning
b.)Providing individualized client education
c.)Having the client attend a formal education session
d.)Attempting to contact a member of the client's family to provide assistance

30. The nurse is following a critical pathway to help a client who underwent hip replacement surgery
meet specific objectives. What's a critical pathway?
a.)A nursing care plan that helps the nurse to decide which intervention to perform first
b.)A multidisciplinary care plan that helps the nurse to use a variety of critical interventions
c.)A standardized care plan that lists basic interventions for the nurse to use with every client
d.)A clinical management tool that organizes the major interventions for a multidisciplinary health care
team