Medsurg 2 Final Exam
The client reports that a previously sensitive area of skin no longer
responds to changes or painful stimuli. This finding indicates a functional
temperature
for which skin
abnormality
layer?
A. Stratum
corneum
B. Adipose
C.
layer
Epidermis
D. Dermis correct answersD.
Dermis
During skin inspection the nurse observes three lesions on the client's
right knee.
lesions are round,
The have a raised border, and are grouped in a "smiley
face" pattern.
Which descriptors does the nurse use to document these
observations?
A. Annular, circinate,
B. Linear, confluent,
clustered
vesicular
C. Circumscribed, universal,
D. Serpiginous, coalesced, wheal-like correct answersA. Annular, circinate,
pustular
clustered
Which technique for obtaining a specimen for bacterial culture is most
correcttofor
nurse use thewith a client who has crusted skin lesions on the
upper back?
A. Remove several crusts, and swab the underlying
B. Dampen the culture swab with sterile water, and then roll the swab over
exudate.
the central
crusts
.C. Apply a gauze bandage to the area, remove it after 1 hour, and send
the entire
gauze to the
D. Clean the area with an antibacterial solution, remove a crust from the
laboratory.
center of
cluster of the
lesions, and send it to the laboratory. correct answersA.
Removeand
crusts, several
swab the underlying
exudate.
An 88-year-old man is admitted to the ED from home with weakness
and acute
confusion.What is the nurse's priority for his care to maintain
client safety?
A. Assess his mental status every
B. Ensure that siderails are raised on his
30minutes
stretcher
C. Check his bowel sounds for intestinal
obstruction
D. Teach him to move slowly when walking correct answersB. Ensure that
siderails
raised onare
his
stretcher
A client is admitted to the ED with multiple stab wounds to his chest,
abdomen
arms. What andis the nurse's priority upon admission to
the ED?
,A. Check for bleeding from the stab
wounds
B. Assess and maintain the client's
C. Start 2 large-bore IV
airway
lines
D. Assess the level of consciousness correct answersB. Assess and
maintain the
client's
airway
An older client with heat stroke is being cooled with a cooling blanket
and iceher
under packs
arms and behind her neck. What assessment indicates to the
nurse that
cooling process
the is
effective?
A. The client is alert and
oriented
B. The client states that she feels
C. The client's temperature is 100
cooler
degrees
D. F
The client's urinary output is 30 mL/hr correct answersC. The client's
temperature
100 degrees is
F
An older client is preparing for a trip to a cold-weather area and asks the
nurse
can how hehypothermia while visiting there. Which preventative actions
prevent
will the in
include nurse
the health teaching? Select all that
apply.
A. Wear cotton clothing to help absorb
moisture
B. Layer clothing to keep heat near the
C. Avoid skiing if it is snowing
body
heavily
D. Be sure to wear gloves and
a hat
E. Do not wear too many pairs of socks correct answersB. Layer clothing to
keep the
near heat
C. Avoid skiing if it is snowing
body
heavily
D. Be sure to wear gloves and
a hat
E. Do not wear too many pairs of
socks
A client experiences altitude-related illness after visiting a ski resort in
Colorado.
the nurse'sWhat is action when the client is admitted to the emergency
priority
department?
A. Provide supplemental
B. Place the client on a
oxygen
ventilator
C. Perform an
electrocardiogram
D. Insert a nasogastric tube correct answersA. Provide
supplemental oxygen
The nurse is preparing to triage clients at the scene of an airplane crash.
Which of
clients these
will the nurse identify as
emergent?
A. Young woman with closed fractures of her right leg
B.
andOlder
arm woman with abdominal bleeding who is dzed and
confused
C. Middle-aged man with third-degree burns over 90% of
his body
, D. Young man with numerous bruises and superficial lacerations correct
Middle-aged man with third-degree burns over 90% of
answersC.
his body
A nurse needs to discharge two medical-surgical clients to make room for
two
a victimsWhich
tornado. of of these clients could be discharged from the unit now?
Select all that
apply
.
A. 78-year-old with telemetry monitoring for chest pain
last57-year-old
B. night who had a bowel resection for cancer 2
days
C. 44-year-old
ago who has received 3 days of IV antibiotics for
pneumonia
D. 61-year-old who had a thyroidectomy this
E. 72-year-old who had a total hip replacement 2 days ago correct
morning
answersB.
old who had 57-year-
a bowel resection for cancer 2
days
C. 44-year-old
ago who has received 3 days of IV antibiotics for
pneumonia
A female business woman has extremely dry skin on her legs. In
addition to using
lotions after bathing, she asks the nurse about other measures to help
dryness.
reduce the What is the nurse's best
response?
A. "Wear long-legged pajamas to sleep in rather than
nightgowns."
B. "Avoid wearing pantyhose or nylon stockings for more than 2 hours
at a
C. "Leave
time."the fat-containing soap on your skin when bathing rather than
rinsing
D. it off."
"Bathe in water that is as warm as you can stand to stimulate the release
of body
from your
oilssebaceous glands." correct answersB. "Avoid wearing
pantyhosefor
stockings or more
nylon than 2 hours at a
time."
The newly admitted client has all of the following laboratory test values.
Which value
suggests to the nurse that the client may be at an increased risk for
pressure ulcer
formation
?
A. International normalized ratio (INR)
of 1.5
B. White blood cell (WBC) count of
5200/mm3
C. Serum sodium concentrationof 134
D. Serum prealbumin concentration of 15.2mg/dL correct answersD. Serum
mEq/L
prealbumin
concentration of
15.2mg/dL
Which intervention does the nurse use to promote "take" of a graft placed on
the client's
right
heel?
A. Elevate the client's right foot by placing pillows under the leg from the
ankle
knees to the
s
B. Position the client on the abdomen with the right foot hyperextended
for at least 4
hours
C. Ensure that the grafted area is pressed tightly to the bed to promote
daily
adherence
the wound to
bed
The client reports that a previously sensitive area of skin no longer
responds to changes or painful stimuli. This finding indicates a functional
temperature
for which skin
abnormality
layer?
A. Stratum
corneum
B. Adipose
C.
layer
Epidermis
D. Dermis correct answersD.
Dermis
During skin inspection the nurse observes three lesions on the client's
right knee.
lesions are round,
The have a raised border, and are grouped in a "smiley
face" pattern.
Which descriptors does the nurse use to document these
observations?
A. Annular, circinate,
B. Linear, confluent,
clustered
vesicular
C. Circumscribed, universal,
D. Serpiginous, coalesced, wheal-like correct answersA. Annular, circinate,
pustular
clustered
Which technique for obtaining a specimen for bacterial culture is most
correcttofor
nurse use thewith a client who has crusted skin lesions on the
upper back?
A. Remove several crusts, and swab the underlying
B. Dampen the culture swab with sterile water, and then roll the swab over
exudate.
the central
crusts
.C. Apply a gauze bandage to the area, remove it after 1 hour, and send
the entire
gauze to the
D. Clean the area with an antibacterial solution, remove a crust from the
laboratory.
center of
cluster of the
lesions, and send it to the laboratory. correct answersA.
Removeand
crusts, several
swab the underlying
exudate.
An 88-year-old man is admitted to the ED from home with weakness
and acute
confusion.What is the nurse's priority for his care to maintain
client safety?
A. Assess his mental status every
B. Ensure that siderails are raised on his
30minutes
stretcher
C. Check his bowel sounds for intestinal
obstruction
D. Teach him to move slowly when walking correct answersB. Ensure that
siderails
raised onare
his
stretcher
A client is admitted to the ED with multiple stab wounds to his chest,
abdomen
arms. What andis the nurse's priority upon admission to
the ED?
,A. Check for bleeding from the stab
wounds
B. Assess and maintain the client's
C. Start 2 large-bore IV
airway
lines
D. Assess the level of consciousness correct answersB. Assess and
maintain the
client's
airway
An older client with heat stroke is being cooled with a cooling blanket
and iceher
under packs
arms and behind her neck. What assessment indicates to the
nurse that
cooling process
the is
effective?
A. The client is alert and
oriented
B. The client states that she feels
C. The client's temperature is 100
cooler
degrees
D. F
The client's urinary output is 30 mL/hr correct answersC. The client's
temperature
100 degrees is
F
An older client is preparing for a trip to a cold-weather area and asks the
nurse
can how hehypothermia while visiting there. Which preventative actions
prevent
will the in
include nurse
the health teaching? Select all that
apply.
A. Wear cotton clothing to help absorb
moisture
B. Layer clothing to keep heat near the
C. Avoid skiing if it is snowing
body
heavily
D. Be sure to wear gloves and
a hat
E. Do not wear too many pairs of socks correct answersB. Layer clothing to
keep the
near heat
C. Avoid skiing if it is snowing
body
heavily
D. Be sure to wear gloves and
a hat
E. Do not wear too many pairs of
socks
A client experiences altitude-related illness after visiting a ski resort in
Colorado.
the nurse'sWhat is action when the client is admitted to the emergency
priority
department?
A. Provide supplemental
B. Place the client on a
oxygen
ventilator
C. Perform an
electrocardiogram
D. Insert a nasogastric tube correct answersA. Provide
supplemental oxygen
The nurse is preparing to triage clients at the scene of an airplane crash.
Which of
clients these
will the nurse identify as
emergent?
A. Young woman with closed fractures of her right leg
B.
andOlder
arm woman with abdominal bleeding who is dzed and
confused
C. Middle-aged man with third-degree burns over 90% of
his body
, D. Young man with numerous bruises and superficial lacerations correct
Middle-aged man with third-degree burns over 90% of
answersC.
his body
A nurse needs to discharge two medical-surgical clients to make room for
two
a victimsWhich
tornado. of of these clients could be discharged from the unit now?
Select all that
apply
.
A. 78-year-old with telemetry monitoring for chest pain
last57-year-old
B. night who had a bowel resection for cancer 2
days
C. 44-year-old
ago who has received 3 days of IV antibiotics for
pneumonia
D. 61-year-old who had a thyroidectomy this
E. 72-year-old who had a total hip replacement 2 days ago correct
morning
answersB.
old who had 57-year-
a bowel resection for cancer 2
days
C. 44-year-old
ago who has received 3 days of IV antibiotics for
pneumonia
A female business woman has extremely dry skin on her legs. In
addition to using
lotions after bathing, she asks the nurse about other measures to help
dryness.
reduce the What is the nurse's best
response?
A. "Wear long-legged pajamas to sleep in rather than
nightgowns."
B. "Avoid wearing pantyhose or nylon stockings for more than 2 hours
at a
C. "Leave
time."the fat-containing soap on your skin when bathing rather than
rinsing
D. it off."
"Bathe in water that is as warm as you can stand to stimulate the release
of body
from your
oilssebaceous glands." correct answersB. "Avoid wearing
pantyhosefor
stockings or more
nylon than 2 hours at a
time."
The newly admitted client has all of the following laboratory test values.
Which value
suggests to the nurse that the client may be at an increased risk for
pressure ulcer
formation
?
A. International normalized ratio (INR)
of 1.5
B. White blood cell (WBC) count of
5200/mm3
C. Serum sodium concentrationof 134
D. Serum prealbumin concentration of 15.2mg/dL correct answersD. Serum
mEq/L
prealbumin
concentration of
15.2mg/dL
Which intervention does the nurse use to promote "take" of a graft placed on
the client's
right
heel?
A. Elevate the client's right foot by placing pillows under the leg from the
ankle
knees to the
s
B. Position the client on the abdomen with the right foot hyperextended
for at least 4
hours
C. Ensure that the grafted area is pressed tightly to the bed to promote
daily
adherence
the wound to
bed
