PN Medical-Surgical Nursing Final Exam
deWit 3rd edition
The home health nurse is caring for a patient with congestive heart failure (CHF). Which
assessment finding should the nurse report immediately to the physician?
A. Moderate shortness of breath after walking down the hall.
B. A 3 pound weight gain over the course of a week.
C. Heart rate of 104 beats/min after ambulating to the bathroom.
D. Increase urinary output to 50 mL in the last hour. - ANSWER-Answer:
A. Shortness of breath after walking down the hall.
The nurse is caring for a patient with C. difficile infection. Which action is most important
for the nurse to take?
A. Only use alcohol-based hand cleanser for hand hygiene.
B. Always wear an impervious mask.
C. Don proper eye protection before providing care.
D. Put the patient on contact plus isolation. - ANSWER-Answer:
D. Put the patient on contact plus isolation
The nurse is caring for a patient with general sepsis. Which finding should first alert the
nurse to a potential complication that warrants immediate attention?
A. Increased lethargy
B. Sudden coughing
C. Elevated blood pressure
D. Cloudy urine - ANSWER-Answer:
A. Increased lethargy
The nurse is teaching a patient about the purpose of his telemetry. Which statement
indicates the nurse's teaching has been successful?
A. "I will need to stay in bed when the monitor is reading my heart waves."
B. "This test will help determine if I have a blockage in my arteries."
C. "If there is a problem with my heart valves, it will show up with telemetry."
D. "The nurses will be able to monitor my heart rate and rhythm." - ANSWER-Answer:
,D. The nurses will be able to monitor my heart rate and rhythm.
The nurse is working in a trauma unit and is accidentally stuck with an IV needle
following venipuncture of the patient. What is the nurses first action?
A. Immediately begin taking the two- to three-drug regimen.
B. Report the stick to the charge nurse immediately so follow-up can be initiated.
C. Wash the punctured area with soap and water.
D. Complete an incident report so immediate testing of the patient and nurse can begin.
- ANSWER-Answer:
C. Wash the punctured area with soap and water.
The nurse is caring for a post-myocardial infarction (MI) patient who has been started
on daily simvastatin (Zocor) and a low-fat diet. Which statement best indicates the
nurse's teaching has been successful?
A. "I will need to have blood work every month while taking Zocor."
B. "I should take Zocor with grapefruit juice to help absorption."
C. " I should call my doctor if I experience unexplained muscle pain."
D. "I should take Zocor an hour before my biggest meal of the day." - ANSWER-
Answer:
C. "I should call my doctor if I experience unexplained muscle pain."
Which area is the major focus of Healthy People 2020 and the primary mechanism
through which to improve the health of Americans in the second decade of the century?
A. Research funding
B. Health information distribution
C. Healthy lifestyle encouragement
D. Health improvement program designs - ANSWER-Answer:
C. Healthy lifestyle encouragement
A 79-year-old patient with bacterial pneumonia becomes increasingly restless,
confused, and agitated. The patient's temperature is 100 F, and his pulse, blood
pressure, and respirations are elevated since the last assessment 6 hours ago. What
action should the nurse take first?
A. Auscultate the patient's lungs
B. Assess the patient's oxygen saturation
C. Administer the mild sedative as ordered
D. Administer an ordered analgesic for discomfort - ANSWER-Answer:
B. Assess the patient's oxygen saturation
, When caring for a 10-hour post-abdominal surgery patient, which finding should the
nurse report to the charge nurse?
A. 20mL of clear-green emesis
B. Pain level of 5/10
C. No urine output since surgery
D. A weak cough ability - ANSWER-Answer:
C. No urine output since surgery
The nurse is caring for a blind patient. Which action is most appropriate when entering
the patient's room?
A. Touch the patient before speaking to allow her to locate the nurse's position.
B. Speak to the patient by name when entering the room to avoid startling her.
C. Speak to the patient only when at the bedside to increase orientation.
D. Walk about the room, carrying on conversation. - ANSWER-Answer:
B. Speak to the patient by name when entering the room to avoid startling her.
An 86-year-old patient asks why her ankles have a brownish discoloration and the skin
looks thick. Which response best addresses the patient's concern?
A. "The valves in the vessels in your legs aren't working as well as they used to, which
causes the discoloration and thickening of your skin."
B. "You probably aren't getting enough iron in your diet. We should talk to your doctor
about adding an iron supplement."
C. "How many years have you smoked? Nicotine will cause these changes in your
skin."
D. "These are just normal changes seen in most older people." - ANSWER-Answer:
A. "The valves in the vessels in your legs aren't working as well as they used to, which
causes the discoloration and thickening of your skin."
The nurse is caring for a patient with anemia who has a medical history of diabetes,
hypertension, chronic kidney disease, and acid reflux. The nurse is aware the patient's
anemia is likely related to which condition?
A. Diabetes
B. Hypertension
C. Chronic kidney disease
D. Acid reflux - ANSWER-Answer:
C. Chronic kidney disease
deWit 3rd edition
The home health nurse is caring for a patient with congestive heart failure (CHF). Which
assessment finding should the nurse report immediately to the physician?
A. Moderate shortness of breath after walking down the hall.
B. A 3 pound weight gain over the course of a week.
C. Heart rate of 104 beats/min after ambulating to the bathroom.
D. Increase urinary output to 50 mL in the last hour. - ANSWER-Answer:
A. Shortness of breath after walking down the hall.
The nurse is caring for a patient with C. difficile infection. Which action is most important
for the nurse to take?
A. Only use alcohol-based hand cleanser for hand hygiene.
B. Always wear an impervious mask.
C. Don proper eye protection before providing care.
D. Put the patient on contact plus isolation. - ANSWER-Answer:
D. Put the patient on contact plus isolation
The nurse is caring for a patient with general sepsis. Which finding should first alert the
nurse to a potential complication that warrants immediate attention?
A. Increased lethargy
B. Sudden coughing
C. Elevated blood pressure
D. Cloudy urine - ANSWER-Answer:
A. Increased lethargy
The nurse is teaching a patient about the purpose of his telemetry. Which statement
indicates the nurse's teaching has been successful?
A. "I will need to stay in bed when the monitor is reading my heart waves."
B. "This test will help determine if I have a blockage in my arteries."
C. "If there is a problem with my heart valves, it will show up with telemetry."
D. "The nurses will be able to monitor my heart rate and rhythm." - ANSWER-Answer:
,D. The nurses will be able to monitor my heart rate and rhythm.
The nurse is working in a trauma unit and is accidentally stuck with an IV needle
following venipuncture of the patient. What is the nurses first action?
A. Immediately begin taking the two- to three-drug regimen.
B. Report the stick to the charge nurse immediately so follow-up can be initiated.
C. Wash the punctured area with soap and water.
D. Complete an incident report so immediate testing of the patient and nurse can begin.
- ANSWER-Answer:
C. Wash the punctured area with soap and water.
The nurse is caring for a post-myocardial infarction (MI) patient who has been started
on daily simvastatin (Zocor) and a low-fat diet. Which statement best indicates the
nurse's teaching has been successful?
A. "I will need to have blood work every month while taking Zocor."
B. "I should take Zocor with grapefruit juice to help absorption."
C. " I should call my doctor if I experience unexplained muscle pain."
D. "I should take Zocor an hour before my biggest meal of the day." - ANSWER-
Answer:
C. "I should call my doctor if I experience unexplained muscle pain."
Which area is the major focus of Healthy People 2020 and the primary mechanism
through which to improve the health of Americans in the second decade of the century?
A. Research funding
B. Health information distribution
C. Healthy lifestyle encouragement
D. Health improvement program designs - ANSWER-Answer:
C. Healthy lifestyle encouragement
A 79-year-old patient with bacterial pneumonia becomes increasingly restless,
confused, and agitated. The patient's temperature is 100 F, and his pulse, blood
pressure, and respirations are elevated since the last assessment 6 hours ago. What
action should the nurse take first?
A. Auscultate the patient's lungs
B. Assess the patient's oxygen saturation
C. Administer the mild sedative as ordered
D. Administer an ordered analgesic for discomfort - ANSWER-Answer:
B. Assess the patient's oxygen saturation
, When caring for a 10-hour post-abdominal surgery patient, which finding should the
nurse report to the charge nurse?
A. 20mL of clear-green emesis
B. Pain level of 5/10
C. No urine output since surgery
D. A weak cough ability - ANSWER-Answer:
C. No urine output since surgery
The nurse is caring for a blind patient. Which action is most appropriate when entering
the patient's room?
A. Touch the patient before speaking to allow her to locate the nurse's position.
B. Speak to the patient by name when entering the room to avoid startling her.
C. Speak to the patient only when at the bedside to increase orientation.
D. Walk about the room, carrying on conversation. - ANSWER-Answer:
B. Speak to the patient by name when entering the room to avoid startling her.
An 86-year-old patient asks why her ankles have a brownish discoloration and the skin
looks thick. Which response best addresses the patient's concern?
A. "The valves in the vessels in your legs aren't working as well as they used to, which
causes the discoloration and thickening of your skin."
B. "You probably aren't getting enough iron in your diet. We should talk to your doctor
about adding an iron supplement."
C. "How many years have you smoked? Nicotine will cause these changes in your
skin."
D. "These are just normal changes seen in most older people." - ANSWER-Answer:
A. "The valves in the vessels in your legs aren't working as well as they used to, which
causes the discoloration and thickening of your skin."
The nurse is caring for a patient with anemia who has a medical history of diabetes,
hypertension, chronic kidney disease, and acid reflux. The nurse is aware the patient's
anemia is likely related to which condition?
A. Diabetes
B. Hypertension
C. Chronic kidney disease
D. Acid reflux - ANSWER-Answer:
C. Chronic kidney disease
