Medical-Surgical Nursing I Test 2
Questions with Correct Answers
A 30-year-old African American had surgery 6 months ago and the incision site is now
raised, indurated, and shiny. This is most likely which type of tissue growth? -
ANSWERSKeloid
A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which
is most appropriate? - ANSWERS"Because of the incidence of shingles in your age
group, you should consider taking the vaccination.
After a medicated bath, the patient is assisted from the tub. Which statement about
lotion application is correct? - ANSWERSApply lotion immediately after drying the
patient
An 84-year-old patient has had a low-grade fever for 2 days. This morning, the patient
complains about burning, tingling hip pain that shoots down the leg. The nurse observes
a small group of vesicles on the leg. These findings are consistent with which disorder?
- ANSWERSHerpes zoster
An older patient is admitted for treatment of fluid volume excess. For which serious
respiratory complication of fluid volume excess should the nurse assist this patient? -
ANSWERSPulmonary edema
A patient admitted in a state of extreme anxiety has vital signs of: T 96.6 F, P 81, BP
130/86, R 32. What will result if this hyperventilation continues? -
ANSWERSRespiratory alkalosis
A patient began vomiting and continued to do so for several hours. What is the result of
this loss of stomach contents? - ANSWERSmetabolic alkalosis
A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a
thyroidectomy. Which emergency medication should the nurse anticipate being
prescribed for this patient? - ANSWERScalcium gluconate
A patient has been admitted to the hospital with burns to the upper chest. The nurse
notes singed nasal hairs. The nurse needs to assess this patient frequently for which
condition? - ANSWERSrespiratory complications
A patient has the following risk factors for melanoma. Which risk factor should the nurse
assign as the priority focus of patient teaching? - ANSWERSThe patient uses tanning
booth weekly.
, A patient is admitted to the emergency department with severe fatigue and confusion.
Laboratory studies are done. Which laboratory value will require the most immediate
action by the nurse? - ANSWERSSerum calcium is 18 mg/dL.
A patient is having a surgical procedure done to promote peripheral tissue perfusion in
an extremity with full-thickness circumferential burns. What term should the nurse use to
document this procedure? - ANSWERSEscharotomy
A patient is in the intensive care unit with acute renal failure secondary to septic shock
and is receiving IV fluids of 0.9% NaCI at 125 mL/hr. The patient develops crackles in
the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain
from the previous day. What nursing diagnosis is most appropriate for this situation? -
ANSWERSExcess fluid volume
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial
blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16
mEq/L. How should the nurse interpret these results? - ANSWERSMetabolic acidosis
A patient with acute abdominal pain has a serum potassium level of 2 mEq/L. What
should the nurse do first? - ANSWERSCall the physician STAT
A patient with a history of renal failure is admitted to the hospital because of decreasing
urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the
patient to avoid? - ANSWERSpotatoes
A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that
further teaching is necessary if the patient chooses which menu? - ANSWERSTomato
soup, grilled cheese sandwich, salad, and chocolate chip cookie
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment
would be the most accurate way for the nurse to evaluate fluid balance? -
ANSWERSDaily weight
The home health nurse gives instructions to a patient in avoiding recurrence of athlete's
foot. Which information should the nurse include? *(Select all that apply)* - ANSWERS-
wash and dry feet daily.
-wear shoes that allow ventilation.
-use only clean towels.
-wear clean cotton socks.
The home health nurse is educating the family of a child with head lice. Which
instructions are most important for the nurse to include? - ANSWERSWash and dry all
linens on the hottest setting.
Questions with Correct Answers
A 30-year-old African American had surgery 6 months ago and the incision site is now
raised, indurated, and shiny. This is most likely which type of tissue growth? -
ANSWERSKeloid
A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which
is most appropriate? - ANSWERS"Because of the incidence of shingles in your age
group, you should consider taking the vaccination.
After a medicated bath, the patient is assisted from the tub. Which statement about
lotion application is correct? - ANSWERSApply lotion immediately after drying the
patient
An 84-year-old patient has had a low-grade fever for 2 days. This morning, the patient
complains about burning, tingling hip pain that shoots down the leg. The nurse observes
a small group of vesicles on the leg. These findings are consistent with which disorder?
- ANSWERSHerpes zoster
An older patient is admitted for treatment of fluid volume excess. For which serious
respiratory complication of fluid volume excess should the nurse assist this patient? -
ANSWERSPulmonary edema
A patient admitted in a state of extreme anxiety has vital signs of: T 96.6 F, P 81, BP
130/86, R 32. What will result if this hyperventilation continues? -
ANSWERSRespiratory alkalosis
A patient began vomiting and continued to do so for several hours. What is the result of
this loss of stomach contents? - ANSWERSmetabolic alkalosis
A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a
thyroidectomy. Which emergency medication should the nurse anticipate being
prescribed for this patient? - ANSWERScalcium gluconate
A patient has been admitted to the hospital with burns to the upper chest. The nurse
notes singed nasal hairs. The nurse needs to assess this patient frequently for which
condition? - ANSWERSrespiratory complications
A patient has the following risk factors for melanoma. Which risk factor should the nurse
assign as the priority focus of patient teaching? - ANSWERSThe patient uses tanning
booth weekly.
, A patient is admitted to the emergency department with severe fatigue and confusion.
Laboratory studies are done. Which laboratory value will require the most immediate
action by the nurse? - ANSWERSSerum calcium is 18 mg/dL.
A patient is having a surgical procedure done to promote peripheral tissue perfusion in
an extremity with full-thickness circumferential burns. What term should the nurse use to
document this procedure? - ANSWERSEscharotomy
A patient is in the intensive care unit with acute renal failure secondary to septic shock
and is receiving IV fluids of 0.9% NaCI at 125 mL/hr. The patient develops crackles in
the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain
from the previous day. What nursing diagnosis is most appropriate for this situation? -
ANSWERSExcess fluid volume
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial
blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16
mEq/L. How should the nurse interpret these results? - ANSWERSMetabolic acidosis
A patient with acute abdominal pain has a serum potassium level of 2 mEq/L. What
should the nurse do first? - ANSWERSCall the physician STAT
A patient with a history of renal failure is admitted to the hospital because of decreasing
urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the
patient to avoid? - ANSWERSpotatoes
A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that
further teaching is necessary if the patient chooses which menu? - ANSWERSTomato
soup, grilled cheese sandwich, salad, and chocolate chip cookie
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment
would be the most accurate way for the nurse to evaluate fluid balance? -
ANSWERSDaily weight
The home health nurse gives instructions to a patient in avoiding recurrence of athlete's
foot. Which information should the nurse include? *(Select all that apply)* - ANSWERS-
wash and dry feet daily.
-wear shoes that allow ventilation.
-use only clean towels.
-wear clean cotton socks.
The home health nurse is educating the family of a child with head lice. Which
instructions are most important for the nurse to include? - ANSWERSWash and dry all
linens on the hottest setting.
