MedSur 201/ Medical-Surgical Nursing/ Questions & Answer Keys Included 2025 Update

MedSur 201/ Medical-Surgical Nursing/ Questions & Answer Keys Included 2025 Update 1. Which ethics theory focuses on ends or consequences of actions? - ANSWER Utilitarian theory 2. An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The client is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse's action is an example of which therapeutic communication technique? - ANSWER Informing 3. A client had a total hip replacement earlier in the day. The nurse sits with the client to establish some goals. One goal they agree on is to ambulate 1 to 2 miles each day. This is an example of which type of goal? - ANSWER Long-term 4. Which intellectual skill is used by nurses when thinking critically? - ANSWER ccccc 5. Nurses in acute care settings must work with other health care team members to maintain quality care while facing pressures to care for clients who are hospitalized for shorter periods of time than in the past. To ensure positive health outcomes when clients return to their homes, what action should the nurse prioritize? - ANSWER Thorough and evidence-based discharge planning 6. While reviewing the chart of a client who was recently admitted, the nurse will use the nursing process to set up a plan of care. Order the activities the nurse will do in the most likely sequence from 1 to 5. Inquire about the reason for the admission. Confer with the client about the desire for pain control. Choose the nursing diagnosis of Acute Pain. Administer the prescribed 4 mg of IV push morphine. Re-assess the pain level. - ANSWER Inquire about the reason for the admission. Choose the nursing diagnosis of Acute Pain. Confer with the client about the desire for pain control. Administer the prescribed 4 mg of IV push morphine. Re-assess the pain level. 7. How is assessment defined as part of the nursing process? - ANSWER careful observation and evaluation of a client's health status 8. The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. What prescriptions for care that the nurse should anticipate for this client. -Place the left foot in a dependent position. -Perform neurovascular checks of lower extremities every 8 hours. -Administer IV antibiotic based on culture and sensitivity report. -Encourage ambulation with weight-bearing on the left leg. -Administer ibuprofen 400 mg orally three times daily, as needed for pain. -Make referral to dietitian to discuss nutrition for healing and blood glucose control. -Provide education on self-blood glucose monitoring and insulin administration. - ANSWER -Perform neurovascular checks of lower extremities every 8 hours. -Administer IV antibiotic based on culture and sensitivity report. -Administer ibuprofen 400 mg orally three times daily, as needed for pain. -Make referral to dietitian to discuss nutrition for healing and blood glucose control. -Provide education on self-blood glucose monitoring and insulin administration. 9. The community health nurse is preparing a teaching plan for a middle-aged client with hypertension, hypercholesterolemia, and obesity. Specify whether the information is focused on health promotion or health maintenance. - Exercise for 45 minutes at least three times per week. - Take medications as prescribed. - Avoid cigarette smoking and alcohol use. - Practice stress reduction techniques such as yoga or meditation. - Adhere to scheduled laboratory tests such as lipid profile, basic metabolic panel, and glucose tests. - ANSWER Health promotion - Exercise for 45 minutes at least three times per week. - Avoid cigarette smoking and alcohol use. - Practice stress reduction techniques such as yoga or meditation. Health maintenance - Take medications as prescribed. - Adhere to scheduled laboratory tests such as lipid profile, basic metabolic panel, and glucose tests. 10. A terminally ill client the nurse is caring for is reporting pain. The physician has prescribed a large dose of intravenous opioids by continuous infusion. When the nurse assesses the client's respiratory status, the rate has decreased from 16 to 10 breaths per minute. What action should the nurse take? - ANSWER Report the decreased respiratory rate to the physician. 11. The nurse working in the clinic has had several incidences of positive chlamydia cultures return in women with pelvic pain. The nurse understands that early diagnosis and treatment are essential measures in which to reduce contagion and limit the complications related to this infection. What type of prevention will the nurse use when these infections are treated? Secondary prevention Primary prevention Tertiary prevention Prevalence - ANSWER Secondary prevention 12. A nurse has been using the nursing process as a framework for planning and providing client care. What action would the nurse do during the evaluation phase of the nursing process? Remove a client's surgical staples on the scheduled postoperative day. Have a client provide input on the quality of care received. Provide information on a follow-up appointment for a postoperative client. Document a client's improved air entry with incentive spirometry use. - ANSWER Document a client's improved air entry with incentive spirometry use. 13. The nurse is preparing a client for a colonoscopy at the hospital. Who does the nurse understand is responsible for obtaining the informed consent from this client? - ANSWER The primary care provider 14. A nurse using critical thinking interprets data and determines appropriate interventions. What factor will affect the nurse's ability to employ critical thinking with data interpretation? the nurse's personal biases the nurse's gender the date of the client's admission the client's admission diagnosis - ANSWER the nurse's personal biases 15. The definition of nursing has evolved over time since Florence Nightingale first attempted, in 1859, to explain nursing's scope of practice. In 2003, the American Nurses' Association, in its Social Policy Statement, included which of the following activities as a significant role of nursing? Diagnosing chronic illness in the elderly Diagnosing acute illnesses in children Identifying human responses to illness Modifying a medical plan of care to include nursing activities - ANSWER Identifying human responses to illness 16. Which set of nursing actions demonstrates that the nurse understands the nursing process? - Assessing for allergies, administering analgesic, obtaining baseline vital signs, and documenting the nursing diagnosis as acute pain - Prioritizing client goals, documenting all health records precisely, conducting the health history, and documenting the nursing diagnosis - Reviewing the health record, documenting client goals, identifying the etiology of the nursing problem, and evaluating treatment outcomes - Obtaining vital signs and pain scale rating, documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level - ANSWER Obtaining vital signs and pain scale rating, documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level A nurse is working in a rural nurse-managed agency that provides immunizations, health assessments, and screening services. The nurse is most likely working in which of the following? - ANSWER Community nursing center 17. Which is a primary task of nursing research? - ANSWER Contributing to the scientific base of nursing practice 18. A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The student tells the instructor that she is unwilling to care for this client. What key component of critical thinking is most likely missing from this student's practice? - ANSWER Withholding judgment 19. A nurse in a hospice facility cares for clients with terminal illnesses and witnesses a great deal of pain and emotional distress. Which factor that affects healthcare ethics determines how the nurse must respond when a client asks for help in ending his or her suffering? - ANSWER Legislative and judicial decisions 20. The nurse is caring for a client who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The client has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take? - ANSWER Obtain a physician's order to restrain the client. 21. Who should be involved in establishing specific and realistic outcomes, so the client does not become frustrated in trying to achieve them? - ANSWER The client and family 22. Which of the following patient age groups is currently one of the fastest growing age groups in the population? - ANSWER Adults 65 years of age and over 23. The nurse monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias. Specify if the finding indicates microcytic anemia or megaloblastic anemia. - decreased mean corpuscular volume (MCV) - decreased reticulocytes - increased mean corpuscular volume (MCV) - increased total iron-binding capacity (TIBC) - decreased vitamin B12 - decreased folate - ANSWER microcytic anemia - decreased mean corpuscular volume (MCV) - decreased reticulocytes - increased total iron-binding capacity (TIBC) megaloblastic anemia. - increased mean corpuscular volume (MCV) - decreased vitamin B12 - decreased folate 24. The nurse monitors a male client for symptoms of urethral strictures following a transurethral resection of the prostate (TURP) for the treatment of prostate cancer. Client symptoms indicative of this complication that the nurse monitors for following a TURP include _________, __________, and _______________. - ANSWER Client symptoms indicative of this complication that the nurse monitors for following a TURP include straining, dysuria, and a weak urinary stream. 25. The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease. Specify if the intervention is indicated or contraindicated for this client. -Take blood pressure readings in the left arm. -Auscultate for a bruit over AV fistula every 8 hours. -Assess for redness, swelling, and drainage at AV fistula site. -Use AV fistula site to draw blood. -Palpate for a thrill over the AV fistula every 8 hours. -Wrap the AV fistula site in the left arm with a compression dressing. - ANSWER Indicated -Auscultate for a bruit over AV fistula every 8 hours. -Assess for redness, swelling, and drainage at AV fistula site. -Palpate for a thrill over the AV fistula every 8 hours. Contraindicated -Take blood pressure readings in the left arm. -Use AV fistula site to draw blood. -Wrap the AV fistula site in the left arm with a compression dressing. The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. 26. Specify if the finding indicates understanding or the need for reinforcement of the teaching. -"I will take the antibiotics until the secretions clear up." -"I should get the PPSV23 this year because I got the PCV13 last year." -"I will drink 1 liter of fluid each day." -"Sleeping with a humidifier can help loosen secretions." -"I will seek medical attention if my cough worsens." -"I will rest and avoid overexertion." -"A persistent or recurring fever is normal after starting antibiotics." -"I will perform deep-breathing exercises once per day." - ANSWER Understanding -"I should get the PPSV23 this year because I got the PCV13 last year." -"Sleeping with a humidifier can help loosen secretions." -"I will seek medical attention if my cough worsens." -"I will rest and avoid overexertion." 27. Requires reinforcement of teaching -"I will take the antibiotics until the secretions clear up." -"I will drink 1 liter of fluid each day." -"A persistent or recurring fever is normal after starting antibiotics." -"I will perform deep-breathing exercises once per day." The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. Specify if the finding is a risk factor for osteoporosis or is not a risk factor for osteoporosis. -66 years of age -large frame -Asian heritage -postmenopausal status -Nonsmoker -alcohol intake of 3 drinks/week -takes fluticasone inhaler for asthma -walks 2 miles, 3 days/week - ANSWER Risk factor -66 years of age -Asian heritage -postmenopausal status -takes fluticasone inhaler for asthma Not a risk factor -large frame -Nonsmoker -alcohol intake of 3 drinks/week -walks 2 miles, 3 days/week 28. The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS). Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of __________ as evidenced by ____________. - ANSWER Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of acute lung injury (ALI) as evidenced by shortness of breath(SOB). 29. Nursing continues to recognize and participate in collaboration with other health care disciplines to meet the complex needs of the client. Which of the following is the best example of a collaborative practice model? - ANSWER The nurse and the physician jointly making clinical decisions. 30. The nurse is caring for a terminally ill client in the intensive care unit that is on life support measures. The family members are opposed in their decision to take the client off of life support. What option does the nurse discuss with the nurse manager? - ANSWER Contact the ethics committee for their input. 32. The use of patient restraints limits which ethical principle? - ANSWER Autonomy 33. A nurse is a member of which entity within the larger health care environment? - ANSWER health care team 34. A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this as a reflection of which need? - ANSWER Physiologic needs 35. A group of nursing students are reviewing the various types of advanced practice nurses. The students demonstrate the need for additional review when they identify which of the following as an advanced practice nurse? - ANSWER Nurse manager 36.Many skills are needed in critical thinking. The nurse knows that the following skills are involved with critical thinking. Choose all that apply. -Self-regulation -Inference -Analysis -Interpretation -Independence - ANSWER -Self-regulation -Inference -Analysis -Interpretation 37. The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read: "The client will have clear lungs by the third postoperative day." On the third postoperative day, the client has left lower lobe crackles and infiltrates on the chest x-ray. What conclusion does the nurse reach for this client? - ANSWER The outcome is not achieved, and the plan requires critical reevaluation and revision. 38. Which is not an important reason that nurses utilize research in nursing practice? -financial obligation -validation -replication -dissemination -evaluation of research findings - ANSWER Financial obligation 39. Which of the following is a cognitive or mental activity that nurses use in critical thinking? - ANSWER Drawing on past clinical experiences and knowledge to explain what is happening 40. The nurse provides care for a client who is diagnosed with bladder retention following urinary catheterization. The nurse should first ask the client to ________ then perform the prescribed _________. - ANSWER The nurse should first ask the client to urinate then perform the prescribed bladder scan. 41. A nurse is caring for a client who was admitted with pain, tenderness, and rigidity of the upper right abdomen, suggesting a gall bladder issue. The client has also been experiencing nausea and vomiting for the past 3 days. The admitting service is planning for tests to be conducted in the morning. What is the implication for the following testing: Laboratory Assessments Ultrasonography Cholescintigraphy - ANSWER Laboratory Assessments -Cholesterol is elevated in biliary obstruction. Ultrasonography -It is used to visualize calculi in the gallbladder. Cholescintigraphy -A series of x ray images from different angles will create images of the soft tissues of the gallbladder. 42. The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin. The client is at the highest risk for developing _________ as evidenced by ______. - ANSWER The client is at the highest risk for developing septic shock as evidenced by altered mentation. 43. The nurse assesses a client who is diagnosed with bulimia nervosa and at risk for alterations in both fluid and electrolyte balance. 44. During the assessment, the nurse focuses on monitoring the client for _________ as evidenced by ________________. - ANSWER During the assessment, t