MedSurg 1 Final Exam Questions And
Answers With CompleteSolutions 100%
Correct Answers
1. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does
the nurse evaluate first? Irregular blue mole with white specks on the lower leg
2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take
to prevent infection by autocontamination?Change gloves between wound care on
different parts of the client's body.
3. Aclient has a leg wound that is in the second stage of the inflammatory response. For
what manifestation does the nurse assess?Purulent drainage
4. A nurse is caring for a client with systemic sclerosis. The client’s facial skin is very taut,
limiting the client’s ability to open the mouth. After consulting with a registered dietitian for
appropriate nutrition, what other consultation should the nurse facilitate? With limited
ability to open the mouth, dental hygiene may be lacking. The nurse should
encourage the client to see a dentist. The other referrals are not related to the
mouth.
5. Astudent nurse asks the nursing instructor what “apoptosis” means. What response by the
instructor is best? Apoptosis is programmed cell death. With this characteristic,
organs and tissues function with cells that are at their peak of performance.
Growth by cells enlarging is hyperplasia. Having the normal number of
chromosomes is euploidy. Inhibition of cell growth is contact inhibition.
6. Apreoperative nurse is assessing a client prior to surgery. Which information would
be most important for the nurse to relay to the surgical team? Use of multiple herbs and
supplements
7. Which statement about carcinogenesis is accurate? Tumor cells need to develop
their own blood supply.
8. A nurse is caring for a client who is receiving an epidural infusion for pain management.
Which assessment finding requires immediate intervention from the nurse? Report
of headache and stiff neck
9. The nurse caring for oncology clients knows that which form of metastasis is the
most common? Bloodborne
10. Anurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new
burn injury. The client asks, “Why am I taking this medication?” How should the nurse
respond? "It helps prevent stomach ulcers, which are common after burns."
11. Anurse is orienting a new client and family to the inpatient unit. What information
does the nurse provide to help the client promote his or her own safety? Encourage the
client and family to be active partners.
12. Anurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a
respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action
should the nurse take next? Place the client in an upright position.
13. Anurse is caring for a client who has a spinal cord injury at level T3. Which
, intervention should the nurse implement to assist with bladder dysfunction? Use the
Credé maneuver every 3 hours.
14. Anurse plans care for a client who is immobile. Which interventions should the nurse
include in this client’s plan of care to prevent pressure sores? (Select all that apply.)
Place a small pillow between bony surfaces. Use a lift sheet to assist with re-
positioning. Keep the client's heels off the bed surfaces.
15. Anurse assesses an older adult’s skin. Which findings require immediate referral?
(Select all that apply. Lesion with various colors Asymmetric 6-mm dark
lesion on forehead
16. Anurse reads on a hospitalized client’s chart that the client is receiving teletherapy.
What action by the nurse is best? Coordinate continuation of the therapy.
17. Anurse cares for a dying client. Which manifestation of dying should the nurse treat first?
Pain
18. Apostoperative client vomited.After cleaning and comforting the client, which action by the nurse
is most important? Auscultate lung sounds.
19. Anurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours
for a methicillin-resistantStaphylococcus aureus (MRSA) infection. Which action should the nurse
take? Assess the IV site at least every 2 hours for thrombophlebitis.
20. Anurse is caring for a client who has a pressure ulcer on the right ankle. Which action
should the nurse take first? Assess the right leg for pulses, skin color, and temperature
21. Anurse assesses a client who is prescribed a medication that inhibits angiotensin I from
converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which
expected therapeutic effect should the nurse assess? Blood pressure decrease from
180/72 mm Hg to 144/50 mm Hg
22. Aclient is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of
breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace
activities, allowing for adequate rest.
23. Anurse is assessing clients on a medical-surgical unit. Which adult client should the
nurse identify as being at greatest risk for insensible water loss? Anxious client who
has tachypnea
24. Anurse plans care for a client who has a wound that is not healing. Which focused
assessments should the nurse complete to develop the client’s plan of care? (Select all that
apply.) Height, Alcohol use, Prealbumin laboratory results
25. Aclient is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse
reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude
about this client’s cancer? There are no distant metastases noted in the report.
26. Anurse is working with a community group promoting healthy aging. What
recommendation is best to help prevent osteoarthritis (OA)? Lose weight if needed
27. The nurse working in the orthopedic clinic knows that a client with which factor has an
absolute contraindication for having a total joint replacement?Severe osteoporosis
28. After teaching a client about advance directives, a nurse assesses the client’s
understanding.Which statement indicates the client correctly understands the teaching?
, "An advance directive will specifywhat I want done when I can no longer make
decisions about health care."
29. The nurse working in the rheumatology clinic is seeing clients with rheumatoid
arthritis (RA). What assessment would be most important for the client whose chart
contains the diagnosis of Sjögren’s syndrome? Visual acuity
30. The nurse is presenting information to a community group on safer sex practices. The nurse
should teach that which sexual practice is the riskiest?Anal intercourse
31. Anurse assesses a client who has a lesion on the skin that is suspicious for skin
cancer, as shown below Punch skin biopsy
32. After educating a caregiver of a home care client, a nurse assesses the caregiver’s
understanding. Which statement indicates that the caregiver needs additional education?" If his
tailbone is red and tender in the morning, I will massage it with baby oil "
33. Anurse is talking with a client about a negative enzyme-linked immunosorbent assay
(ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and
the client states “Whew! I was really worried about that result.” What action by the nurse is
most important?Assess the client's sexual activity and patterns.
34. Anurse assesses a young female client who is prescribed isotretinoin (Accutane). Which
question should the nurse ask prior to starting this therapy?"Which method of
contraception are you using?"
35. Anurse on the medical-surgical unit has received a hand-off report. Which client
should the nurse see first? Client with new-onset abdominal pain, rated as an 8 on a
0-to-10 scale
36. Anurse identifies clinical practice problems on a cardiac unit. Which question is a
background question? "How are a client's vital signs affected by anxiety?
37. After teaching a client who expressed concern about a rash located beneath her breast, a
nurse assesses the client’s understanding. Which statement indicates the client has a
good understanding of this condition? "I can use powder to keep this area dry."
38. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client’s
understanding. Which statement indicates the client correctly understands the teaching?" I'll
cleanse the are prior to applying antibiotic cream "
39. Aclient is in the preoperative holding area prior to surgery. The nurse notes that the client
has allergies to avocados and strawberries. What action by the nurse is best? Ensure the
information is relayed to the surgical team.
40. Anurse is assessing a client for acute rejection of a kidney transplant. What
assessment finding requires the most rapid communication with the provider?
Creatinine of 3.9 mg/dL
41. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base
imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
Kussmaul respirations
42. What action by the perioperative nursing staff is most important to prevent surgical wound
infection in a client having a total joint replacement? Administer preoperative antibiotic
as ordered.
43. Anurse assesses a client and identifies that the client has pallor conjunctivae. Which
Answers With CompleteSolutions 100%
Correct Answers
1. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does
the nurse evaluate first? Irregular blue mole with white specks on the lower leg
2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take
to prevent infection by autocontamination?Change gloves between wound care on
different parts of the client's body.
3. Aclient has a leg wound that is in the second stage of the inflammatory response. For
what manifestation does the nurse assess?Purulent drainage
4. A nurse is caring for a client with systemic sclerosis. The client’s facial skin is very taut,
limiting the client’s ability to open the mouth. After consulting with a registered dietitian for
appropriate nutrition, what other consultation should the nurse facilitate? With limited
ability to open the mouth, dental hygiene may be lacking. The nurse should
encourage the client to see a dentist. The other referrals are not related to the
mouth.
5. Astudent nurse asks the nursing instructor what “apoptosis” means. What response by the
instructor is best? Apoptosis is programmed cell death. With this characteristic,
organs and tissues function with cells that are at their peak of performance.
Growth by cells enlarging is hyperplasia. Having the normal number of
chromosomes is euploidy. Inhibition of cell growth is contact inhibition.
6. Apreoperative nurse is assessing a client prior to surgery. Which information would
be most important for the nurse to relay to the surgical team? Use of multiple herbs and
supplements
7. Which statement about carcinogenesis is accurate? Tumor cells need to develop
their own blood supply.
8. A nurse is caring for a client who is receiving an epidural infusion for pain management.
Which assessment finding requires immediate intervention from the nurse? Report
of headache and stiff neck
9. The nurse caring for oncology clients knows that which form of metastasis is the
most common? Bloodborne
10. Anurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new
burn injury. The client asks, “Why am I taking this medication?” How should the nurse
respond? "It helps prevent stomach ulcers, which are common after burns."
11. Anurse is orienting a new client and family to the inpatient unit. What information
does the nurse provide to help the client promote his or her own safety? Encourage the
client and family to be active partners.
12. Anurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a
respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action
should the nurse take next? Place the client in an upright position.
13. Anurse is caring for a client who has a spinal cord injury at level T3. Which
, intervention should the nurse implement to assist with bladder dysfunction? Use the
Credé maneuver every 3 hours.
14. Anurse plans care for a client who is immobile. Which interventions should the nurse
include in this client’s plan of care to prevent pressure sores? (Select all that apply.)
Place a small pillow between bony surfaces. Use a lift sheet to assist with re-
positioning. Keep the client's heels off the bed surfaces.
15. Anurse assesses an older adult’s skin. Which findings require immediate referral?
(Select all that apply. Lesion with various colors Asymmetric 6-mm dark
lesion on forehead
16. Anurse reads on a hospitalized client’s chart that the client is receiving teletherapy.
What action by the nurse is best? Coordinate continuation of the therapy.
17. Anurse cares for a dying client. Which manifestation of dying should the nurse treat first?
Pain
18. Apostoperative client vomited.After cleaning and comforting the client, which action by the nurse
is most important? Auscultate lung sounds.
19. Anurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours
for a methicillin-resistantStaphylococcus aureus (MRSA) infection. Which action should the nurse
take? Assess the IV site at least every 2 hours for thrombophlebitis.
20. Anurse is caring for a client who has a pressure ulcer on the right ankle. Which action
should the nurse take first? Assess the right leg for pulses, skin color, and temperature
21. Anurse assesses a client who is prescribed a medication that inhibits angiotensin I from
converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which
expected therapeutic effect should the nurse assess? Blood pressure decrease from
180/72 mm Hg to 144/50 mm Hg
22. Aclient is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of
breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace
activities, allowing for adequate rest.
23. Anurse is assessing clients on a medical-surgical unit. Which adult client should the
nurse identify as being at greatest risk for insensible water loss? Anxious client who
has tachypnea
24. Anurse plans care for a client who has a wound that is not healing. Which focused
assessments should the nurse complete to develop the client’s plan of care? (Select all that
apply.) Height, Alcohol use, Prealbumin laboratory results
25. Aclient is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse
reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude
about this client’s cancer? There are no distant metastases noted in the report.
26. Anurse is working with a community group promoting healthy aging. What
recommendation is best to help prevent osteoarthritis (OA)? Lose weight if needed
27. The nurse working in the orthopedic clinic knows that a client with which factor has an
absolute contraindication for having a total joint replacement?Severe osteoporosis
28. After teaching a client about advance directives, a nurse assesses the client’s
understanding.Which statement indicates the client correctly understands the teaching?
, "An advance directive will specifywhat I want done when I can no longer make
decisions about health care."
29. The nurse working in the rheumatology clinic is seeing clients with rheumatoid
arthritis (RA). What assessment would be most important for the client whose chart
contains the diagnosis of Sjögren’s syndrome? Visual acuity
30. The nurse is presenting information to a community group on safer sex practices. The nurse
should teach that which sexual practice is the riskiest?Anal intercourse
31. Anurse assesses a client who has a lesion on the skin that is suspicious for skin
cancer, as shown below Punch skin biopsy
32. After educating a caregiver of a home care client, a nurse assesses the caregiver’s
understanding. Which statement indicates that the caregiver needs additional education?" If his
tailbone is red and tender in the morning, I will massage it with baby oil "
33. Anurse is talking with a client about a negative enzyme-linked immunosorbent assay
(ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and
the client states “Whew! I was really worried about that result.” What action by the nurse is
most important?Assess the client's sexual activity and patterns.
34. Anurse assesses a young female client who is prescribed isotretinoin (Accutane). Which
question should the nurse ask prior to starting this therapy?"Which method of
contraception are you using?"
35. Anurse on the medical-surgical unit has received a hand-off report. Which client
should the nurse see first? Client with new-onset abdominal pain, rated as an 8 on a
0-to-10 scale
36. Anurse identifies clinical practice problems on a cardiac unit. Which question is a
background question? "How are a client's vital signs affected by anxiety?
37. After teaching a client who expressed concern about a rash located beneath her breast, a
nurse assesses the client’s understanding. Which statement indicates the client has a
good understanding of this condition? "I can use powder to keep this area dry."
38. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client’s
understanding. Which statement indicates the client correctly understands the teaching?" I'll
cleanse the are prior to applying antibiotic cream "
39. Aclient is in the preoperative holding area prior to surgery. The nurse notes that the client
has allergies to avocados and strawberries. What action by the nurse is best? Ensure the
information is relayed to the surgical team.
40. Anurse is assessing a client for acute rejection of a kidney transplant. What
assessment finding requires the most rapid communication with the provider?
Creatinine of 3.9 mg/dL
41. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base
imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
Kussmaul respirations
42. What action by the perioperative nursing staff is most important to prevent surgical wound
infection in a client having a total joint replacement? Administer preoperative antibiotic
as ordered.
43. Anurse assesses a client and identifies that the client has pallor conjunctivae. Which
