Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
Exam Review
1. A nurse is planning care for a client who is 2 hr. postoperative following a
transurethral resection of the prostate. The client is receiving continuous bladder
irrigation (CBI). Which of the following interventions should the nurse include?
Remind the client he might feel a constant urge to void.
Rationale: the client receiving continuous bladder irrigation will experience a
continuous urge to void due to pressure on the internal sphincter from the catheter
balloon.
2. A nurse is monitoring the urinary output of an adult client who had a colon
resection. Which of the following 24 hr. output totals indicate oliguria?
380mL
This urinary output indicates oliguria, which is defined as less than 400ml of total
output in 24 hr. or less than 30ml per hour.
3. A nurse is reviewing the BUN and creatinine levels of an older adult client who has
chronic kidney disease. The nurse should expect which of the following findings?
BUN 45 mg/dL and creatinine 8 mg/dL
Rationale: An elevation of both BUN and creatinine is an expected finding of chronic
kidney disease.
4. A nurse is teaching a group of newly licensed nurses on effective techniques for
counseling clients about sexually transmitted infections (STIs). Which of the
following statements should the nurse include in the teaching?
"Ask about the client's exposure to any past or present STIs."
Rationale: The nurse should assess the client exposure to any past or present STIs
and any treatment taken.
5. A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery
for an open reduction and internal fixation. The nurse should understand that the JP
drain was placed for which of the following purposes?
To prevent fluid from accumulating in the wound
Rationale: The purpose of a JP drain is to promote healing by draining fluid from a
wound. This prevents pooling of blood and fluid, which can contribute to discomfort,
delay healing, and provide a medium for infection. The JP drainage tube is threaded
Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
,Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
through the skin into the wound near the surgical incision and is held in place by
sutures.
6. A client is starting celecoxib to treat osteoarthritis. The nurse should instruct the
client to watch for and report which of the following adverse effects?
Black, tarry stools
Rationale: Celecoxib can cause gastrointestinal bleeding. The client should watch for
and report black, dark-colored, or bloody stools, abdominal pain, or coffee-ground
emesis. The nurse also should instruct the client to take celecoxib with food to reduce
gastric irritation.
7. A nurse is caring for a client immediately following a hemodialysis treatment. For
which of the following manifestations will the nurse administer a PRN dose of
phenytoin?
Headache, restlessness
Rationale: Headache and restlessness are manifestations of disequilibrium
syndrome, which occurs during or after hemodialysis due to the rapid shift of fluids,
pH, and osmolarity between fluid and blood that occurs.. This condition can cause
cerebral edema leading to seizures and coma, and a PRN dose of the anticonvulsant
phenytoin should be administered.
8. A nurse is providing discharge teaching for a client who is postoperative following a
simple mastectomy. The client is to begin outpatient radiation therapy the next day.
Which of the following instructions about maintaining skin integrity should the
nurse include?
Do not apply heat to the area of irradiation.
Rationale: This instruction will help the client avoid tissue damage. Radiated tissue
becomes thinner and might lack tissue receptors that would otherwise alert the client
to a potential burn injury. When outdoors in sunlight, the client should wear protective
clothing over the area of irradiation.
9. A nurse is caring for a client whose Papanicolaou (Pap) test cytology results are
abnormal. Which of the following procedures should the nurse anticipate for this
client?
Colposcopy
Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
, Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
Rationale: The nurse should anticipate follow-up visit for a client who has an
abnormal Pap test to include a colposcopy and directed biopsy. The specimen
obtained from endocervical testing is examined for abnormal cells.
10. A nurse is assessing a client who is 48 hr postoperative following abdominal
surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
Rationale: Thick yellow-green drainage is indicative of an infection and should be
reported immediately.
11. A nurse is caring for a client who has undergone a transurethral prostatectomy.
Following catheter removal, the nurse should inform the client that he should
expect which of the following variations in the color of his urine?
Pale pink
Rationale: The client should expect to pass some small clots and tissue in his urine
for few a days, which may give the urine a pale pink color. By 2 to 3 days after surgery,
around the time of discharge, his urine should be clear yellow
12. A nurse in a clinic is caring for a female client who was exposed to gonorrhea.
Which of the following actions should the nurse take?
Obtain information about the client's recent sexual experiences.
Rationale: The nurse should get information from the client about the types of sexual
exposure they may have had to thoroughly assess them.
13. A nurse is caring for a client who is 2 hr postoperative following a transurethral
resection of the prostate (TURP) gland. Which of the following assessments should
the nurse view to be an indication of a postoperative complication?
Output of burgundy colored urine
Rationale: Output of burgundy colored urine may indicate venous bleeding, a
potential complication following a TURP. Should this occur, the nurse should inform
the provider and anticipate an order for increased CBI rate or manual irrigation of the
catheter.
14. A nurse is caring for a client who is experiencing hypovolemic shock. Which of the
following blood products should the nurse anticipate administering to this client?
Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
Exam Review
1. A nurse is planning care for a client who is 2 hr. postoperative following a
transurethral resection of the prostate. The client is receiving continuous bladder
irrigation (CBI). Which of the following interventions should the nurse include?
Remind the client he might feel a constant urge to void.
Rationale: the client receiving continuous bladder irrigation will experience a
continuous urge to void due to pressure on the internal sphincter from the catheter
balloon.
2. A nurse is monitoring the urinary output of an adult client who had a colon
resection. Which of the following 24 hr. output totals indicate oliguria?
380mL
This urinary output indicates oliguria, which is defined as less than 400ml of total
output in 24 hr. or less than 30ml per hour.
3. A nurse is reviewing the BUN and creatinine levels of an older adult client who has
chronic kidney disease. The nurse should expect which of the following findings?
BUN 45 mg/dL and creatinine 8 mg/dL
Rationale: An elevation of both BUN and creatinine is an expected finding of chronic
kidney disease.
4. A nurse is teaching a group of newly licensed nurses on effective techniques for
counseling clients about sexually transmitted infections (STIs). Which of the
following statements should the nurse include in the teaching?
"Ask about the client's exposure to any past or present STIs."
Rationale: The nurse should assess the client exposure to any past or present STIs
and any treatment taken.
5. A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery
for an open reduction and internal fixation. The nurse should understand that the JP
drain was placed for which of the following purposes?
To prevent fluid from accumulating in the wound
Rationale: The purpose of a JP drain is to promote healing by draining fluid from a
wound. This prevents pooling of blood and fluid, which can contribute to discomfort,
delay healing, and provide a medium for infection. The JP drainage tube is threaded
Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
,Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
through the skin into the wound near the surgical incision and is held in place by
sutures.
6. A client is starting celecoxib to treat osteoarthritis. The nurse should instruct the
client to watch for and report which of the following adverse effects?
Black, tarry stools
Rationale: Celecoxib can cause gastrointestinal bleeding. The client should watch for
and report black, dark-colored, or bloody stools, abdominal pain, or coffee-ground
emesis. The nurse also should instruct the client to take celecoxib with food to reduce
gastric irritation.
7. A nurse is caring for a client immediately following a hemodialysis treatment. For
which of the following manifestations will the nurse administer a PRN dose of
phenytoin?
Headache, restlessness
Rationale: Headache and restlessness are manifestations of disequilibrium
syndrome, which occurs during or after hemodialysis due to the rapid shift of fluids,
pH, and osmolarity between fluid and blood that occurs.. This condition can cause
cerebral edema leading to seizures and coma, and a PRN dose of the anticonvulsant
phenytoin should be administered.
8. A nurse is providing discharge teaching for a client who is postoperative following a
simple mastectomy. The client is to begin outpatient radiation therapy the next day.
Which of the following instructions about maintaining skin integrity should the
nurse include?
Do not apply heat to the area of irradiation.
Rationale: This instruction will help the client avoid tissue damage. Radiated tissue
becomes thinner and might lack tissue receptors that would otherwise alert the client
to a potential burn injury. When outdoors in sunlight, the client should wear protective
clothing over the area of irradiation.
9. A nurse is caring for a client whose Papanicolaou (Pap) test cytology results are
abnormal. Which of the following procedures should the nurse anticipate for this
client?
Colposcopy
Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
, Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
Rationale: The nurse should anticipate follow-up visit for a client who has an
abnormal Pap test to include a colposcopy and directed biopsy. The specimen
obtained from endocervical testing is examined for abnormal cells.
10. A nurse is assessing a client who is 48 hr postoperative following abdominal
surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
Rationale: Thick yellow-green drainage is indicative of an infection and should be
reported immediately.
11. A nurse is caring for a client who has undergone a transurethral prostatectomy.
Following catheter removal, the nurse should inform the client that he should
expect which of the following variations in the color of his urine?
Pale pink
Rationale: The client should expect to pass some small clots and tissue in his urine
for few a days, which may give the urine a pale pink color. By 2 to 3 days after surgery,
around the time of discharge, his urine should be clear yellow
12. A nurse in a clinic is caring for a female client who was exposed to gonorrhea.
Which of the following actions should the nurse take?
Obtain information about the client's recent sexual experiences.
Rationale: The nurse should get information from the client about the types of sexual
exposure they may have had to thoroughly assess them.
13. A nurse is caring for a client who is 2 hr postoperative following a transurethral
resection of the prostate (TURP) gland. Which of the following assessments should
the nurse view to be an indication of a postoperative complication?
Output of burgundy colored urine
Rationale: Output of burgundy colored urine may indicate venous bleeding, a
potential complication following a TURP. Should this occur, the nurse should inform
the provider and anticipate an order for increased CBI rate or manual irrigation of the
catheter.
14. A nurse is caring for a client who is experiencing hypovolemic shock. Which of the
following blood products should the nurse anticipate administering to this client?
Medsurg 2 Exam 3 Review Notes - Client Care & Interventions
