MEDICAL-SURGICAL NURSING: CONCEPTS FOR
CLINICAL JUDGMENT AND COLLABORATIVE
CARE (EVOLVE) 11TH EDITION 2025
_____________________________________________________________________________________
A nurse evaluates the following arterial blood gas values in a patient: pH 7.48, PaO2 98 mm
Hg, PaCO2 28 mm Hg, and HCO3
- 22 mEq/L (22 mmol/L). Which patient condition does the nurse correlate with these results?
Anxiety-induced hyperventilation
After providing discharge teaching, a nurse assesses the patient's understanding regarding increased
risk for metabolic alkalosis. Which statement indicates that the patient needs
additional teaching?
"I take sodium bicarbonate after every meal to prevent heartburn."
A diabetic patient becomes septic after a bowel resection and is having problems with
respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50; PaCO2
30; HCO3: 24; and PaO2 68. What does the nurse recognize as the primary factor causing this the
acid-base imbalance?
Hyperventilation due to poor oxygenation
An 80-year-old resident prefers to lie in bed on her left side. The nurse will take extra care
in assessing the left ______ for evidence of skin breakdown.
trochanter
To decrease the threat of a pressure ulcer, the nurse instructs a person who is in a wheelchair for long
periods to:
lift weight on the arms of the chair every 15 minutes.
A patient with dark skin has been admitted to the hospital with acute decompensated heart
failure. How would the nurse assess this patient for cyanosis?
Check the lips and oral mucous membranes.
What is the most effective method to prevent the spread of infection to others when the
nurse is changing the dressing over a wound infected with Staphylococcus aureus?
Wash hands and properly dispose of soiled dressings.
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is
most important for the nurse to report to the health care provider?
, Separation of proximal wound edges
A patient who has diabetes and acute abdominal pain is admitted for an exploratory
laparotomy. When planning postoperative interventions to promote wound healing, what is the
nurse's highest priority?
Maintaining the patient's blood glucose within a normal range
Which finding is most important for the nurse to communicate to the health care provider when
caring for a patient who is receiving negative-pressure wound therapy?
Low serum albumin level
The nurse working in an organ transplantation program knows that which individual is typically the
best donor of an organ?
identical twin
A patient has just received a kidney transplant. Nursing care includes teaching on which of the
following potential signs of an acute rejection?
The patient takes garlic capsules every day.
The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will
be able to eat a normal diet. The nurse's best response is:
It will depend on how well you tolerate advancing from a clear liquid diet.”
Which information should the nurse include when teaching patients about decreasing the risk for sun
damage to the skin?
Try to stay out of the direct sun between the hours of 10 AM and 2 PM
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment
finding will the nurse expect next?
Rising body temperature
A patient with an open abdominal wound has a complete blood cell (CBC) count and differential,
which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates
that the next action will be to
Obtain wound cultures
The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision
deficits. His wife answers most questions that are directed to the patient. Which action should the
nurse take when doing the teaching?
. Provide additional time for the patient to understand preoperative instructions and carry out
procedures.
A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight
before having a knee replacement surgery. Which action should the nurse take?
CLINICAL JUDGMENT AND COLLABORATIVE
CARE (EVOLVE) 11TH EDITION 2025
_____________________________________________________________________________________
A nurse evaluates the following arterial blood gas values in a patient: pH 7.48, PaO2 98 mm
Hg, PaCO2 28 mm Hg, and HCO3
- 22 mEq/L (22 mmol/L). Which patient condition does the nurse correlate with these results?
Anxiety-induced hyperventilation
After providing discharge teaching, a nurse assesses the patient's understanding regarding increased
risk for metabolic alkalosis. Which statement indicates that the patient needs
additional teaching?
"I take sodium bicarbonate after every meal to prevent heartburn."
A diabetic patient becomes septic after a bowel resection and is having problems with
respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50; PaCO2
30; HCO3: 24; and PaO2 68. What does the nurse recognize as the primary factor causing this the
acid-base imbalance?
Hyperventilation due to poor oxygenation
An 80-year-old resident prefers to lie in bed on her left side. The nurse will take extra care
in assessing the left ______ for evidence of skin breakdown.
trochanter
To decrease the threat of a pressure ulcer, the nurse instructs a person who is in a wheelchair for long
periods to:
lift weight on the arms of the chair every 15 minutes.
A patient with dark skin has been admitted to the hospital with acute decompensated heart
failure. How would the nurse assess this patient for cyanosis?
Check the lips and oral mucous membranes.
What is the most effective method to prevent the spread of infection to others when the
nurse is changing the dressing over a wound infected with Staphylococcus aureus?
Wash hands and properly dispose of soiled dressings.
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is
most important for the nurse to report to the health care provider?
, Separation of proximal wound edges
A patient who has diabetes and acute abdominal pain is admitted for an exploratory
laparotomy. When planning postoperative interventions to promote wound healing, what is the
nurse's highest priority?
Maintaining the patient's blood glucose within a normal range
Which finding is most important for the nurse to communicate to the health care provider when
caring for a patient who is receiving negative-pressure wound therapy?
Low serum albumin level
The nurse working in an organ transplantation program knows that which individual is typically the
best donor of an organ?
identical twin
A patient has just received a kidney transplant. Nursing care includes teaching on which of the
following potential signs of an acute rejection?
The patient takes garlic capsules every day.
The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will
be able to eat a normal diet. The nurse's best response is:
It will depend on how well you tolerate advancing from a clear liquid diet.”
Which information should the nurse include when teaching patients about decreasing the risk for sun
damage to the skin?
Try to stay out of the direct sun between the hours of 10 AM and 2 PM
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment
finding will the nurse expect next?
Rising body temperature
A patient with an open abdominal wound has a complete blood cell (CBC) count and differential,
which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates
that the next action will be to
Obtain wound cultures
The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision
deficits. His wife answers most questions that are directed to the patient. Which action should the
nurse take when doing the teaching?
. Provide additional time for the patient to understand preoperative instructions and carry out
procedures.
A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight
before having a knee replacement surgery. Which action should the nurse take?
