Med Surg 2 Final Exam Review 2025

A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? a. Unilateral swelling on the posterior of the vulva b. Extreme abdominal pain with intercourse c. Green, malodorous vaginal discharge d. Postmenopausal bleeding - d. Postmenopausal bleeding A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following? a. Overstimulation b. Necrotizing enterocolitis c. Need for placement of a gastrostomy tube d. Intraventricular hemorrhage - b. Necrotizing enterocolitis A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching? a. It prevents the formation of Rh antibodies in mothers who are Rh negative. b. It destroys Rh antibodies in mothers who are Rh negative. c. It destroys Rh antibodies in newborns who are Rh positive. d. It prevents the formation of Rh antibodies in newborns who are Rh positive. - a. It prevents the formation of Rh antibodies in mothers who are Rh negative. A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? a. 1+ pitting sacral edema b. 3+ protein in the urine c. Blood pressure 148/98 mm Hg d. Deep tendon reflexes of +1 - d. Deep tendon reflexes of +1 A nurse in a clinic is teaching information about cervical polyps with a client who has a new diagnosis. Which of the following information should the nurse include in the teaching? a. Avoid using tampons during menstruation. b. Cervical polyps are a precursor to the development of cervical cancer. c. Cervical polyps affect women before the age of 40. d. Postcoital bleeding may occur. - d. Postcoital bleeding may occur. A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? a. The client is exhibiting early indications of mastitis. b. Additional interventions are not indicated at this time. c. Application of a heating pad to the breasts is indicated. d. The client should be advised to remove her nursing bra. - b. Additional interventions are not indicated at this time. A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? a. Temperature b. Fetal heart rate (FHR) c. Bowel sounds d. Respiratory rate - d. Respiratory rate A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? a. Assist the family to identify prior use of positive coping skills in family crises. b. Ask the client if she has considered harming her newborn. c. Anticipate a prescription by the provider for an antidepressant. d. Reinforce postpartum and newborn care discharge teaching. - b. Ask the client if she has considered harming her newborn. A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings? a. Incomplete miscarriage b. Missed miscarriage c. Inevitable miscarriage d. Complete miscarriage - b. Missed miscarriage A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take? a. Apply an ice pack to the affected area. b. Offer a warm sitz bath. c. Provide a squeeze bottle of antiseptic solution. d. Place a hot pack to the perineum. - a. Apply an ice pack to the affected area. A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? a. "What part of the exam makes you most nervous?" b. "Don't worry, I will be with you during the exam." c. "All you need to do is relax." d. "A pelvic exam is required if you want birth control pills." - a. "What part of the exam makes you most nervous?" A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification? a. Methylergonovine 0.2 mg IM now. b. Insert an indwelling urinary catheter. c. Administer oxygen by nonrebreather mask at 5 L/min. d. Obtain laboratory study of prothrombin and partial thromboplastin time. - a. Methylergonovine 0.2 mg IM now. A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? a. These exercises help prevent constipation." b. "These exercises help pelvic muscles to stretch during birth." c. "They can help reduce back aches." d. "They can prevent further stretch marks." - b. "These exercises help pelvic muscles to stretch during birth." A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? a. Recheck the client's temperature in 4 hr. b. Administer glucocorticoids intramuscularly. c. Assess the odor of the amniotic fluid. d. Prepare the client for emergency cesarean section. - c. Assess the odor of the amniotic fluid. A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make? a. "Give your parents a chance; they'll understand." b. "If you want me to, I can tell your parents for you." c. "You seem scared to talk to your parents." d. "Your parents will have to be told why you are being admitted." - c. "You seem scared to talk to your parents." A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Blot the perineal area dry after cleansing. b. Clean the perineal area from front to back. c. Perform hand hygiene before and after voiding. d. Apply ice packs to the perineal area several times daily. e. Wash the perineal area using a squeeze bottle of warm water after each voiding. - a. Blot the perineal area dry after cleansing. b. Clean the perineal area from front to back. c. Perform hand hygiene before and after voiding. e. Wash the perineal area using a squeeze bottle of warm water after each voiding. A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care? a. Administer oxygen via nasal cannula. b. Offer option to view products of conception. c. Instruct the client to increase potassium-rich foods in the diet. d. Maintain the client on bed rest. - b. Offer option to view products of conception. A nurse is caring for a male client who has a new diagnosis of genital herpes (HSV 2). Which of the following findings should the nurse expect? a. Anuria b. Influenza-like symptoms c. White- or flesh-colored papillary growths in the genital area d. Green penile discharge - b. Influenza-like symptoms 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? a. Instruct the client about preventing reinfection by using a diaphragm. b. Tell the client to expect some joint pain. c. Obtain information about the client's recent sexual experiences. d. Collect a urine specimen from the client. - c. Obtain information about the client's recent sexual experiences. A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times? a. Every morning before arising b. On days 13 to 17 of her menstrual cycle c. 1 hour following intercourse d. Before going to bed every night - a. Every morning before arising A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? a. A male condom b. An intrauterine device (IUD) c. An oral contraceptive d. A diaphragm with spermicide. - b. An intrauterine device (IUD) A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? a. Assess client's blood pressure. b. Assess the bladder for distention. c. Massage the client's fundus. d. Prepare to administer a prescribed oxytocic preparation. - c. Massage the client's fundus. A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis? a. Severe nausea and vomiting b. Large amount of vaginal bleeding c. Unilateral, cramp-like abdominal pain d. Uterine enlargement greater than expected for gestational age - c. Unilateral, cramplike abdominal pain A nurse is preparing to administer an injection of Rho (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications? a. Hydrops fetalis b. Hypobilirubinemia c. Biliary atresia d. Transient clotting difficulties - a. Hydrops fetalis A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching? a. "I should limit my carbohydrates to 50% of caloric intake." b. "I will reduce my exercise schedule to 3 days a week." c. "I will take my glyburide daily with breakfast." d. "I know I am at increased risk to develop type 2 diabetes." - b. "I will reduce my exercise schedule to 3 days a week." A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? a. Orthostatic hypotension b. Fundus palpable at the umbilicus c. Urine output of 3,000 mL in 12 hr d. Heart rate 110/min - d. Heart rate 110/min A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.) a. History of migraines b. Nulliparous c. Twin gestations d. History of gestational hypertension e. Oligohydramnios - a. History of migraines b. Nulliparous c. Twin gestations A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? a. Painless red vaginal bleeding b. Increasing abdominal pain with a nonrelaxed uterus c. Abdominal pain with scant red vaginal bleeding d. Intermittent abdominal pain following passage of bloody mucus - a. Painless red vaginal bleeding A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? a. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months b. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth d. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days - c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next? a. Insert an indwelling urinary catheter. b. Administer oxytocin by continuous IV infusion. c. Tilt the client onto her right side with her legs elevated to at least 30°. d. Massage the client's fundus to promote contractions. - d. Massage the client's fundus to promote contractions. A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations? a. "It is used to stop preterm labor contractions." b. "It halts cervical dilation." c. "It promotes fetal lung maturity." d. "It increases the fetal heart rate." - c. "It promotes fetal lung maturity." A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following? a. Hyperinsulinemia b. Increased deposits of fat in the chest and shoulder area c. Brachial plexus injury d. Increased blood viscosity - a. Hyperinsulinemia A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? a. Abruptio placentae b. Placenta previa c. Precipitous labor d. Threatened abortion - b. Placenta previa A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? a. "Mongolian spots can be found on the skin of many newborns." b. "A caput succedaneum occurs due to compression of blood vessels." c. "This is a cephalhematoma, which can occur spontaneously." d. "This is erythema toxicum, which is a transient condition." - b. "A caput succedaneum occurs due to compression of blood vessels." A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? a. "It determines if kernicterus will occur in the newborn." b. "It detects Rh-negative antibodies in the newborn's blood." c. "It detects Rh-positive antibodies in the mother's blood." d. "It determines the presence of maternal antibodies in the newborn's blood." - c. "It detects Rh-positive antibodies in the mother's blood." A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching? a. A Papanicolaou (Pap) test should be performed every 6 months. b. Artificial lubrication can be used to treat vaginal itching and dryness. c. Increased vaginal drainage typically occurs 5 days following surgery. d. Resume sexual intercourse in 2 to 3 weeks. - b. Artificial lubrication can be used to treat vaginal itching and dryness. A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? a. Examination to determine cervical status b. A magnesium sulfate infusion c. Initiation of pushing d. Preparation for cesarean birth - d. Preparation for cesarean birth A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alphafetoprotein (MSAFP) screening for which of the following clients? a. A client who has mitral valve prolapse b. A client who has been exposed to AIDS c. All of the clients d. A client who has a history of preterm labor - c. All of the clients A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? a. Discontinue the medication infusion. b. Prepare for an emergency cesarean birth. c. Assess maternal blood glucose. d. Place the client in Trendelenburg position. - a. Discontinue the medication infusion. A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching? a. Consume 40 to 50 g of protein daily. b. Avoid salting of foods during cooking. c. Drink 48 to 64 ounces of water daily. d. Limit intake of whole grains, raw fruits, and vegetables. - c. Drink 48 to 64 ounces of water daily. A nurse in a provider's office is planning care for a client who has a new diagnosis of polycystic ovarian syndrome. The nurse should plan to monitor which of the following laboratory values? a. BUN b. Glucose c. Liver function d. Thyroid-stimulating hormone - b. Glucose A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use? a. The client is 42 years old. b. The client smokes cigarettes. c. The client has pelvic relaxation. d. The client has a 3-month-old infant. - c. The client has pelvic relaxation. A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include? a. Expect some breast dimpling or discharge with age. b. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation. c. Using the palm of the hand, feel for lumps using a circular motion. d. Breasts can be examined in the shower with soapy hands. - d. Breasts can be examined in the shower with soapy hands. A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? a. Cervical dilation b. Report of pain above the umbilicus c. Brownish vaginal discharge d. Amniotic fluid in the vaginal vault - a. Cervical dilation A nurse is caring for a client who asks to be screened for cervical cancer because a relative has been diagnosed with it. Which of the following tests should the nurse expect the provider to use? a. A serum prolactin level b. A Papanicolaou test c. A vaginal ultrasound d. An endometrial biopsy - b. A Papanicolaou test A nurse is speaking with a 35-year-old client who has fibrocystic disease of the breasts. At which of the following times should the nurse inform the client that manifestations are most evident? a. Before menstruation begins b. After menstruation ends c. During cold weather d. During hot weather - a. Before menstruation begins A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? a. Anaphylactoid syndrome of pregnancy b. Disseminated intravascular coagulation c. Preeclampsia d. Puerperal infection - b. Disseminated intravascular coagulation A nurse is caring for a client who is 16 -hr postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide? a. "Most new mothers feel somewhat anxious about things like this." b. "There's nothing for you to worry about. Newborns often breathe this way." c. "Why do you think there is something wrong with that?" d. "Let's sit here together and observe your baby while you feed him." - d. "Let's sit here together and observe your baby while you feed him." A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? a. "You must be feeling scared and powerless." b. "Everyone worries about her baby when she's in labor." c. "Your pregnancy is advanced so your baby should be fine." d. "We have a neonatal unit here that's equipped to handle emergencies." - a. "You must be feeling scared and powerless." A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? a. "This infection is treated with one dose of azithromycin." b. "If your sexual partner has no symptoms, no medication is needed." c. "You have to avoid sexual relations for 3 days." d. "You need to return in 6 months for retesting." - a. "This infection is treated with one dose of azithromycin."