JERSEY COLLEGE MEDSURG 1 RN FINAL TEST 1 EXAM WITH COMPLETE SOLUTIONS.
1. Which information does the post-anesthesia care unit (PACU) nurse include in the hand-off that to the nurse who will
assume care on the medical-surgical unit? Select all that apply(ANSWER) A. Fluid intake and blood loss
B. Placement of intravenous (IV) lines %
$
D. Information regarding the surgical procedure #
2. The nurse monitors for which clinical manifestations in the patient diag- nosed with malignant hyperthermia?
Select all that apply(ANSWER) PH.7.32
B. PaCO2
D. Dark brown urine
3. Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that
apply(ANSWER) Obtaining informed consent
Assisting the certified RN anesthetist with patient monitoring Labeling patient sam- ples and sending for analysis
Documenting information pertinent to the surgical procedure
4. 4. The nurse correlates increased risk of deep vein thrombosis formation in patients placed in which position during a
surgical procedure? Select all that apply.(ANSWER) A. Fowler's
B. Jackknife
C. Lateral
E. Reverse Trendelenburg
5. The perioperative nurse educator is preparing an inservice for new staff. In describing settings where postanesthesia
care is provided, the nurse includes which of the following? Select all that apply.(ANSWER) A. Inpatient post-anesthesia
care units
B. Intensive care units
D. Outpatient post-anesthesia care units
E. Procedure areas
6. During preoperative teaching, the nurse explains to the patient and family that which of the following staff will take
part in providing care during the intraoperative period of the surgical process? Select all that apply.(ANSWER) a,c,d
A. Surgeon
C. Circulating nurse
D. Anesthesiologist
7. The nurse monitors for which potential complications in the patient who is receiving spinal anesthesia? Select all the
apply.(ANSWER) headache
,hypotension
8. Before advancing to phase II of postanesthesia care, the patient must achieve which outcomes? Select all that
apply.(ANSWER) Stable vital signs
, Oxygenation saturation Stable
airway
9. Which statements are most true about the concept of acculturation? Select all that apply.(ANSWER) A. An acculturated
person accepts both their own culture and a new culture, adopting elements of each.
B. It may take years and even generations for an immigrant group to acculturate.
D. Acculturation results from a minority group's need to survive and flourish in a new culture.
10. The nurse is caring for a school-age child with tinea capitis. The child has open lesions from the disease and has lost
hair in the areas affected. Which nursing diagnoses would be a part of this client's care plan? Select all that
apply.(ANSWER) Disturbed body image
D. Impaired skin integrity
E. Risk for infection
11. A nurse demonstrates an understanding of multiculturalism when they can demonstrate which of the following? Select
all that apply. A. Accommodates diversity B. Identifies cultural archetypes C. Incorporates inclusion D. Identi- fies
cultural stereotypes E. Embraces ethnocentrism(ANSWER) a,c
12. The nurse working on the medical-surgical unit has received a patient from the post-anesthesia care unit (PACU). Which
clinical manifestations are indica- tive of pain in the postoperative patient? Select all that applyA. Restlessness
B. Diaphoresis C. Hypotension D. Constricted pupils E. . Piloerection(ANSWER)
13. The nurse working on the medical-surgical unit has received a patient from the post-anesthesia care unit (PACU). Which
clinical manifestations are indica- tive of pain in the postoperative patient? Select all that applyA. Restlessness
B. Diaphoresis C. Hypotension D. Constricted pupils E. . Piloerection(ANSWER) a,b,e
14. The home-health nurse learns that an elderly client isn't able to get to the grocery store. They don't have much food in
their home, and they eat and drink little. Most of their time is spent sitting in their chair watching television, often not
realizing that they have had bladder leakage. Which nursing actions would be implemented to reduce the risk of this client
developing a pressure injury? Select all that apply. A. Help the client to get out of the chair every 2 hours.
B. Change the client's clothing frequently. C. Bath the client using soap and water. D. Promote intake of green tea througho
the day. E. Encourage the client to wear incontinence products.(ANSWER) a,b,e
15. The nurse must verify a patient's identity during the first time-out process. Which actions by the nurse are
appropriate? Select all that apply. A. Asking the patient to state his or her name B. Asking the patient to state his or her
date of birth C. Asking the patient to state his or her Social Security number
1. Which information does the post-anesthesia care unit (PACU) nurse include in the hand-off that to the nurse who will
assume care on the medical-surgical unit? Select all that apply(ANSWER) A. Fluid intake and blood loss
B. Placement of intravenous (IV) lines %
$
D. Information regarding the surgical procedure #
2. The nurse monitors for which clinical manifestations in the patient diag- nosed with malignant hyperthermia?
Select all that apply(ANSWER) PH.7.32
B. PaCO2
D. Dark brown urine
3. Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that
apply(ANSWER) Obtaining informed consent
Assisting the certified RN anesthetist with patient monitoring Labeling patient sam- ples and sending for analysis
Documenting information pertinent to the surgical procedure
4. 4. The nurse correlates increased risk of deep vein thrombosis formation in patients placed in which position during a
surgical procedure? Select all that apply.(ANSWER) A. Fowler's
B. Jackknife
C. Lateral
E. Reverse Trendelenburg
5. The perioperative nurse educator is preparing an inservice for new staff. In describing settings where postanesthesia
care is provided, the nurse includes which of the following? Select all that apply.(ANSWER) A. Inpatient post-anesthesia
care units
B. Intensive care units
D. Outpatient post-anesthesia care units
E. Procedure areas
6. During preoperative teaching, the nurse explains to the patient and family that which of the following staff will take
part in providing care during the intraoperative period of the surgical process? Select all that apply.(ANSWER) a,c,d
A. Surgeon
C. Circulating nurse
D. Anesthesiologist
7. The nurse monitors for which potential complications in the patient who is receiving spinal anesthesia? Select all the
apply.(ANSWER) headache
,hypotension
8. Before advancing to phase II of postanesthesia care, the patient must achieve which outcomes? Select all that
apply.(ANSWER) Stable vital signs
, Oxygenation saturation Stable
airway
9. Which statements are most true about the concept of acculturation? Select all that apply.(ANSWER) A. An acculturated
person accepts both their own culture and a new culture, adopting elements of each.
B. It may take years and even generations for an immigrant group to acculturate.
D. Acculturation results from a minority group's need to survive and flourish in a new culture.
10. The nurse is caring for a school-age child with tinea capitis. The child has open lesions from the disease and has lost
hair in the areas affected. Which nursing diagnoses would be a part of this client's care plan? Select all that
apply.(ANSWER) Disturbed body image
D. Impaired skin integrity
E. Risk for infection
11. A nurse demonstrates an understanding of multiculturalism when they can demonstrate which of the following? Select
all that apply. A. Accommodates diversity B. Identifies cultural archetypes C. Incorporates inclusion D. Identi- fies
cultural stereotypes E. Embraces ethnocentrism(ANSWER) a,c
12. The nurse working on the medical-surgical unit has received a patient from the post-anesthesia care unit (PACU). Which
clinical manifestations are indica- tive of pain in the postoperative patient? Select all that applyA. Restlessness
B. Diaphoresis C. Hypotension D. Constricted pupils E. . Piloerection(ANSWER)
13. The nurse working on the medical-surgical unit has received a patient from the post-anesthesia care unit (PACU). Which
clinical manifestations are indica- tive of pain in the postoperative patient? Select all that applyA. Restlessness
B. Diaphoresis C. Hypotension D. Constricted pupils E. . Piloerection(ANSWER) a,b,e
14. The home-health nurse learns that an elderly client isn't able to get to the grocery store. They don't have much food in
their home, and they eat and drink little. Most of their time is spent sitting in their chair watching television, often not
realizing that they have had bladder leakage. Which nursing actions would be implemented to reduce the risk of this client
developing a pressure injury? Select all that apply. A. Help the client to get out of the chair every 2 hours.
B. Change the client's clothing frequently. C. Bath the client using soap and water. D. Promote intake of green tea througho
the day. E. Encourage the client to wear incontinence products.(ANSWER) a,b,e
15. The nurse must verify a patient's identity during the first time-out process. Which actions by the nurse are
appropriate? Select all that apply. A. Asking the patient to state his or her name B. Asking the patient to state his or her
date of birth C. Asking the patient to state his or her Social Security number
