MED-SURG EXAM
1. A nurse is collecting data from a client who has emphysema. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
2. A nurse is caring for a client who sustained a basal skull fracture. When performing
morning hygiene care, the nurse notices a thin stream of clear drainage coming from
out of the client's right nostril. Which of the following actions should the nurse take
first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.
3. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should
recognize that the client is at risk for autonomic dysreflexia. Which of the following
interventions should the nurse take to prevent autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.
4. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of
the following findings should the nurse expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding
5. A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
6. A nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the
following is the priority finding the nurse should report to the provider?
,1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
7. A nurse is reinforcing discharge teaching with a client about how to care for a newly
created ileal conduit. Which of the following instructions should the nurse include in
the teaching?
1) Change the ostomy pouch daily.
2) Empty the ostomy pouch when it is 2/3 full.
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
4) Apply lotion to the peristomal skin when changing the ostomy pouch.
8. A nurse is assisting in the plan of care for a client who had a removal of the pituitary
gland. Which of the following actions should the nurse include in the plan?
1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
4) Encourage the client to cough every 2 hr following surgery.
9. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg
daily following a myocardial infarction. The nurse should instruct the client that
aspirin is prescribed for clients who have coronary artery disease for which of the
following effects?
1) To provide analgesia
2) To reduce inflammation
3) To prevent blood clotting
4) To prevent fever
10. A nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
1) Loss of peripheral vision
2) Headache
3) Halos around lights
4) Discomfort in the eyes
11. A nurse is collecting data from a client who has acute gastroenteritis. Which of the
following data collection findings should the nurse identify as the priority?
1) Weight loss of 3% of total body weight.
2) Blood glucose 150 mg/dL.
3) Potassium 2.5 mEq/L
4) Urine specific gravity 1.035
A nurse is reinforcing teaching with a client who has HIV and is being discharged to
home. Which of the following instructions should the nurse include in the teaching?
, 1) Take temperature once a day.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water.
12. A nurse is caring for a client who is postoperative following a tracheostomy, and has
copious and tenacious secretions. Which of the following is an acceptable method for
the nurse to use to thin this client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning the
airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway..
13. Following admission, a client with a vascular occlusion of the right lower extremity
calls the nurse and reports difficulty sleeping because of cold feet. Which of the
following nursing actions should the nurse take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
14. A nurse is caring for a client is who is 4 hr postoperative following a transurethral
resection of the prostate (TURP). Which of the following is the priority finding for the
nurse report to the provider?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale
15. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which
of the following adverse effects of the hypothermia blanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia
16. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes
mellitus. Which of the following statements by the client indicates an understanding
of the teaching?
1) "I will carry a complex carbohydrate snack with me when I exercise."
2) "I should exercise first thing in the morning before eating breakfast."
3) "I should avoid injecting insulin into my thigh if I am going to go running."
4) "I will not exercise if my urine is positive for ketones."
1. A nurse is collecting data from a client who has emphysema. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
2. A nurse is caring for a client who sustained a basal skull fracture. When performing
morning hygiene care, the nurse notices a thin stream of clear drainage coming from
out of the client's right nostril. Which of the following actions should the nurse take
first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.
3. A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should
recognize that the client is at risk for autonomic dysreflexia. Which of the following
interventions should the nurse take to prevent autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.
4. A nurse is caring for a client who is being evaluated for endometrial cancer. Which of
the following findings should the nurse expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding
5. A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
6. A nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the
following is the priority finding the nurse should report to the provider?
,1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
7. A nurse is reinforcing discharge teaching with a client about how to care for a newly
created ileal conduit. Which of the following instructions should the nurse include in
the teaching?
1) Change the ostomy pouch daily.
2) Empty the ostomy pouch when it is 2/3 full.
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
4) Apply lotion to the peristomal skin when changing the ostomy pouch.
8. A nurse is assisting in the plan of care for a client who had a removal of the pituitary
gland. Which of the following actions should the nurse include in the plan?
1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
4) Encourage the client to cough every 2 hr following surgery.
9. A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg
daily following a myocardial infarction. The nurse should instruct the client that
aspirin is prescribed for clients who have coronary artery disease for which of the
following effects?
1) To provide analgesia
2) To reduce inflammation
3) To prevent blood clotting
4) To prevent fever
10. A nurse is collecting data from a client who has open-angle glaucoma. Which of the
following findings should the nurse expect?
1) Loss of peripheral vision
2) Headache
3) Halos around lights
4) Discomfort in the eyes
11. A nurse is collecting data from a client who has acute gastroenteritis. Which of the
following data collection findings should the nurse identify as the priority?
1) Weight loss of 3% of total body weight.
2) Blood glucose 150 mg/dL.
3) Potassium 2.5 mEq/L
4) Urine specific gravity 1.035
A nurse is reinforcing teaching with a client who has HIV and is being discharged to
home. Which of the following instructions should the nurse include in the teaching?
, 1) Take temperature once a day.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water.
12. A nurse is caring for a client who is postoperative following a tracheostomy, and has
copious and tenacious secretions. Which of the following is an acceptable method for
the nurse to use to thin this client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning the
airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway..
13. Following admission, a client with a vascular occlusion of the right lower extremity
calls the nurse and reports difficulty sleeping because of cold feet. Which of the
following nursing actions should the nurse take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
14. A nurse is caring for a client is who is 4 hr postoperative following a transurethral
resection of the prostate (TURP). Which of the following is the priority finding for the
nurse report to the provider?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale
15. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which
of the following adverse effects of the hypothermia blanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia
16. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes
mellitus. Which of the following statements by the client indicates an understanding
of the teaching?
1) "I will carry a complex carbohydrate snack with me when I exercise."
2) "I should exercise first thing in the morning before eating breakfast."
3) "I should avoid injecting insulin into my thigh if I am going to go running."
4) "I will not exercise if my urine is positive for ketones."
