MED SURG EXAM 1 PRACTICE TEST
100% CORRECT!!!!!
, A nurse is caring for a client receiving IV therapy in the left forearm and notices that the
site is red, swollen, and warm. Which of the following actions should the nurse perform
first? - ANSWER Discontinue the existing IV infusion.
-The greatest risk to this client is further injury from the IV infusion or catheter; therefore,
the first action the nurse should take is to discontinue the infusion by stopping the fluid
flow and removing the catheter. Redness, swelling, and warmth indicate phlebitis.
Incentive spirometer can help to prevent... - ANSWER Atelectasis
A nurse is reviewing the laboratory values for a client who takes spironolactone and
notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the
provider and anticipates that the provider will provide which of the following
instructions? - ANSWER Obtain a 12-lead ECG.
-This client's potassium level is above the expected reference range. Because
hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac
arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes.
A nurse is contributing to the plan of care for a client who has a pressure ulcer on his
heel. Which of the following information should the nurse include in the plan? -
ANSWER Provide the client a diet high in vitamin C.
-Vitamin C is essential for wound healing to promote formation of new capillaries,
synthesis of new tissue and development of collagen.
A client arrives for initial evaluation following a diagnosis of systemic lupus
erythematosus (SLE). The nurse understands that which of the following is a classic
cutaneous manifestation of SLE? - ANSWER Butterfly rash on face
-The nurse should identify a butterfly rash as a common cutaneous manifestation for the
client who has SLE. Other common findings include hair loss, weakness, and sun
sensitivity resulting in a widespread rash.
A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the
following actions should the nurse take? - ANSWER Cover the wound with a moist
sterile dressing.
-A deep wound open to air is at serious risk for contamination, and exposed organ
tissue could become dry and ischemic. The nurse should cover the wound with a moist
sterile dressing to prevent further injury.
100% CORRECT!!!!!
, A nurse is caring for a client receiving IV therapy in the left forearm and notices that the
site is red, swollen, and warm. Which of the following actions should the nurse perform
first? - ANSWER Discontinue the existing IV infusion.
-The greatest risk to this client is further injury from the IV infusion or catheter; therefore,
the first action the nurse should take is to discontinue the infusion by stopping the fluid
flow and removing the catheter. Redness, swelling, and warmth indicate phlebitis.
Incentive spirometer can help to prevent... - ANSWER Atelectasis
A nurse is reviewing the laboratory values for a client who takes spironolactone and
notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the
provider and anticipates that the provider will provide which of the following
instructions? - ANSWER Obtain a 12-lead ECG.
-This client's potassium level is above the expected reference range. Because
hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac
arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes.
A nurse is contributing to the plan of care for a client who has a pressure ulcer on his
heel. Which of the following information should the nurse include in the plan? -
ANSWER Provide the client a diet high in vitamin C.
-Vitamin C is essential for wound healing to promote formation of new capillaries,
synthesis of new tissue and development of collagen.
A client arrives for initial evaluation following a diagnosis of systemic lupus
erythematosus (SLE). The nurse understands that which of the following is a classic
cutaneous manifestation of SLE? - ANSWER Butterfly rash on face
-The nurse should identify a butterfly rash as a common cutaneous manifestation for the
client who has SLE. Other common findings include hair loss, weakness, and sun
sensitivity resulting in a widespread rash.
A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the
following actions should the nurse take? - ANSWER Cover the wound with a moist
sterile dressing.
-A deep wound open to air is at serious risk for contamination, and exposed organ
tissue could become dry and ischemic. The nurse should cover the wound with a moist
sterile dressing to prevent further injury.
