Medical-SurgicalvnNursingvnExamvn1
Thevnnursevnisvncaringvnforvnavnclientvnwhovnhasvnasvnavnsonvnwithvnavnstreptococcusvnthro
atvninfection.vnWhichvnnursevnrecommendationvnwouldvnbevnbestvntovnadvisevnthevnclient
vntovndovninvnordervntovnpreventvnacquiringvnthevninfection?vn-vncorrectvnanswer✔ ✔
Frequentlyvnwashvnhervnhandsvnandvnsurfacesvnofvnthevnhome.
ThevnnursevnisvncaringvnforvnavnclientvninfectedvnwithvnRockyvnMountainvnspottedvnfever.
vnThevnnursevnshouldvnaskvnifvnthevnclientvnhasvnexperiencedvnwhichvnofvnthevnfollowing?
vn-vncorrectvnanswer✔ ✔ Wasvnbittenvnbyvnavntick
Thevnnursevnisvncaringvnforvnavnclientvnwithvnavnprotozoavninfection.vnWhichvnisvnthevnmo
stvnlikelyvnmodevnofvntransmission?vn-vncorrectvnanswer✔ ✔
Ingestionvnofvncontaminatedvnfoodvnorvnwater
Thevnnursevnisvncaringvnforvnavnclientvnwhovnisvnrecoveringvnfromvnanvnallergicvnreaction.
vnWhichvnleukocytevnlevelvnwouldvnthevnnursevnexpectvntovnbevnthevnmostvnelevated?vn-
vncorrectvnanswer✔ ✔ Eosinophils
Thevnnursevnisvncaringvnforvnavnclientvnwhovnhasvnanvninfectedvnwoundvnonvnthevngreatvnto
evnthatvnisvnredvnwithvnavnpurulentvnexudate.vnThevnnursevnexpectsvnthatvnthisvnclientvnhasv
nwhichvntypevnofvninfection? vn-vncorrectvnanswer✔ ✔ Localized
Thevnclientvnexperiencedvnavnfall.vnNursingvnassessmentvnrevealsvnthatvnthevnclientvnisvne
xperiencingvntachycardia,vnhypotension,vnconfusion,vntachypnea,vnandvnflatvnjugularvnv
eins.vnWhatvnshouldvnbevnthevnnurse'svnfirstvnresponse?vn-vncorrectvnanswer✔ ✔
Administervnoxygen.
,Thevnfamilyvnwantsvntovnknowvnwhyvnthevnnursevnisvnputtingvnavnurinaryvncathetervninvnavn
clientvnexperiencingvnshock.vnWhatvnisvnthevnnurse'svnbestvnresponse?vn-
vncorrectvnanswer✔ ✔
"Itvnwillvnhelpvnmonitorvnhowvnmuchvnurinevnthevnkidneysvnarevnablevntovnproduce."
Avnclientvnexperiencingvnshockvnhasvnhadvnavnurinaryvnoutputvnofvn250vnmLvninvnthevnlast
vn10vnhours.vnWhatvnisvnthevnnurse'svnmostvnappropriatevnresponse?vn-vncorrectvnanswer
✔ ✔ Notifyvnthevnphysician.
Whichvnclientvnisvnmostvnlikelyvntovnbevnexperiencingvnhypovolemicvnshock?vn-
vncorrectvnanswer✔ ✔
Avnclientvnwhovnhadvnsurgeryvn24vnhoursvnagovnandvnwhovnalsovnhasvnavnnasogastricvntu
be
Thevnphysicianvnhasvnorderedvnarterialvnbloodvngasesvnforvnavnclientvnexperiencingvnshoc
k.vnThevnnursevnknowsvnthatvnwhichvnvaluevnindicatesvnshock?vn-vncorrectvnanswer✔
✔ pHvn7.32
Avn63-year-
oldvnArabvnAmericanvnmalevnstatesvnhisvnleftvnlegvnisvn"hot."vnWhatvnisvnthevnnurse'svnbes
tvnfirstvnresponse?vn-vncorrectvnanswer✔ ✔ Assessvnforvnpain
Thevnclientvnisvncomplainingvnofvnexcruciatingvnpainvninvnavnfootvnthatvnhasvnbeenvnampu
tated.vnThevnfamilyvntellsvnthevnnursevnthatvnthevnclientvnisvnjustvnaddictedvntovnpainvnmedi
cations.vnWhatvnisvnthevnnurse'svnbestvnresponse?vn-vncorrectvnanswer✔ ✔
"Hevnisvnexperiencingvnphantomvnlimbvnpain."
,Avnclientvnhasvnhadvnabdominalvnsurgeryvnandvnhasvnordersvntovnbevnambulatedvnthreevnti
mesvnavnday.vnOralvnpainvnmedicationvnhasvnbeenvnorderedvnforvnthevnclient.vnWhatvnshou
ldvnthevnnursevndovntovnfacilitatevnambulation?vn-vncorrectvnanswer✔ ✔
Mediatevn1vnhourvnpriorvntovnambulatingvnthevnclient.
Thevnclientvnreportsvnfrequentvnusevnofvnacetaminophen.vnHowvnshouldvnthevnnursevnbes
tvnrespond?vn-vncorrectvnanswer✔ ✔ "Dovnyouvndrinkvnalcohol?"
Avnclientvnwithvnchronicvnpainvnhasvnbeenvnadmittedvnwithvnavnfever.vnThevnnursingvnasse
ssmentvnrevealsvnthatvnthevnclientvnhasvnavndecreasedvnlevelvnofvnconsciousness.vnWhatvn
shouldvnthevnnursevnaskvnthevnfamilyvnabout?vn-vncorrectvnanswer✔ ✔
Whatvnmedicationsvnthevnclientvnhasvntaken
Thevnpracticalvnnursevnisvnreviewingvnthevnsocialvnhistoryvnfromvnavnclientvndiagnosedvn
withvnsmallvncellvncarcinomavnofvnthevnlung.vnWhichvninformationvnisvnsignificantvnforvnt
hisvndisease?vn-vncorrectvnanswer✔ ✔
Thevnclientvnhasvnsmokedvntwovn(2)vnpacksvnofvncigarettesvnavndayvnforvn20vnyears
Thevnpracticalvnnursevnandvnanvnunlicensedvnassistivevnpersonnelvn(UAP)vnarevncaringvnf
orvnavngroupvnofvnclientsvnonvnavnmedicalvnunit.vnWhichvninformationvnprovidedvnbyvnthev
nUAPvnwarrantsvnimmediatevninterventionvnbyvnthevnpracticalvnnurse?vn-
vncorrectvnanswer✔ ✔
ThevnclientvnreceivingvnProcritvn(epoetinvnalfa)vnhasvnavnTvn99.2˚F,vnPvn68,vnRvn24,vnan
dvnBPvnofvn198/102
, Thevnclientvndiagnosedvnwithvnlungvncancervnhasvnbeenvntoldvnthevncancervnhasvnmetastas
izedvntovnthevnbrain.vnWhichvninterventionvnshouldvnthevnpracticalvnnursevnexpectvntovnim
plement?vn-vncorrectvnanswer✔ ✔ Discussvnimplementingvnanvnadvancevndirective
Thevnclientvndiagnosedvnwithvnlungvncancervnisvnbeingvndischarged.vnWhichvnstatementv
nmadevnbyvnthevnclientvnindicatesvnavnreiterationvnofvninformationvnisvnrequired?vn-
vncorrectvnanswer✔ ✔
"Itvndoesn'tvnmattervnifvnIvnsmokevnnow.vnIvnalreadyvnhavevncancer."
Thevnpracticalvnnursevnisvninterviewingvnclientsvnatvnthevnclinic.vnWhichvninformationvnp
rovidedvnbyvnavnclientvnwarrantsvnfurthervninvestigation?vn-vncorrectvnanswer✔ ✔
Thevnclientvnhasvnbeenvncoughingvnupvnbloodvninvnthevnmornings
Thevnmalevnclientvnhadvnabdominalvnsurgeryvnandvnthevnpracticalvnnursevnsuspectsvnthevn
clientvnhasvnperitonitis.vnWhichvninformationvnsupportvnthevndiagnosisvnofvnperitonitis?v
n-vncorrectvnanswer✔ ✔
Hard,vnrigidvnabdomenvnandvnwhitevnbloodvncellvncountvn22,000/mm3
Thevnclientvnwhovnhadvnabdominalvnsurgeryvntellsvnthevnpracticalvnnurse,vn"Ivnfeltvnsomet
hingvngivevnwayvninvnmyvnstomach."vnWhichvninterventionvnshouldvnthevnpracticalvnnurs
evnimplementvnfirst?vn-vncorrectvnanswer✔ ✔
Inspectvnthevnabdominalvnwoundvnincision
Thevnclientvnisvnonevn(1)vndayvnpostoperativevnmajorvnabdominalvnsurgery.vnWhichvnclie
ntvnproblemvnisvnavnpriority?vn-vncorrectvnanswer✔ ✔
Fluidvnandvnelectrolytevnimbalance
Thevnnursevnisvncaringvnforvnavnclientvnwhovnhasvnasvnavnsonvnwithvnavnstreptococcusvnthro
atvninfection.vnWhichvnnursevnrecommendationvnwouldvnbevnbestvntovnadvisevnthevnclient
vntovndovninvnordervntovnpreventvnacquiringvnthevninfection?vn-vncorrectvnanswer✔ ✔
Frequentlyvnwashvnhervnhandsvnandvnsurfacesvnofvnthevnhome.
ThevnnursevnisvncaringvnforvnavnclientvninfectedvnwithvnRockyvnMountainvnspottedvnfever.
vnThevnnursevnshouldvnaskvnifvnthevnclientvnhasvnexperiencedvnwhichvnofvnthevnfollowing?
vn-vncorrectvnanswer✔ ✔ Wasvnbittenvnbyvnavntick
Thevnnursevnisvncaringvnforvnavnclientvnwithvnavnprotozoavninfection.vnWhichvnisvnthevnmo
stvnlikelyvnmodevnofvntransmission?vn-vncorrectvnanswer✔ ✔
Ingestionvnofvncontaminatedvnfoodvnorvnwater
Thevnnursevnisvncaringvnforvnavnclientvnwhovnisvnrecoveringvnfromvnanvnallergicvnreaction.
vnWhichvnleukocytevnlevelvnwouldvnthevnnursevnexpectvntovnbevnthevnmostvnelevated?vn-
vncorrectvnanswer✔ ✔ Eosinophils
Thevnnursevnisvncaringvnforvnavnclientvnwhovnhasvnanvninfectedvnwoundvnonvnthevngreatvnto
evnthatvnisvnredvnwithvnavnpurulentvnexudate.vnThevnnursevnexpectsvnthatvnthisvnclientvnhasv
nwhichvntypevnofvninfection? vn-vncorrectvnanswer✔ ✔ Localized
Thevnclientvnexperiencedvnavnfall.vnNursingvnassessmentvnrevealsvnthatvnthevnclientvnisvne
xperiencingvntachycardia,vnhypotension,vnconfusion,vntachypnea,vnandvnflatvnjugularvnv
eins.vnWhatvnshouldvnbevnthevnnurse'svnfirstvnresponse?vn-vncorrectvnanswer✔ ✔
Administervnoxygen.
,Thevnfamilyvnwantsvntovnknowvnwhyvnthevnnursevnisvnputtingvnavnurinaryvncathetervninvnavn
clientvnexperiencingvnshock.vnWhatvnisvnthevnnurse'svnbestvnresponse?vn-
vncorrectvnanswer✔ ✔
"Itvnwillvnhelpvnmonitorvnhowvnmuchvnurinevnthevnkidneysvnarevnablevntovnproduce."
Avnclientvnexperiencingvnshockvnhasvnhadvnavnurinaryvnoutputvnofvn250vnmLvninvnthevnlast
vn10vnhours.vnWhatvnisvnthevnnurse'svnmostvnappropriatevnresponse?vn-vncorrectvnanswer
✔ ✔ Notifyvnthevnphysician.
Whichvnclientvnisvnmostvnlikelyvntovnbevnexperiencingvnhypovolemicvnshock?vn-
vncorrectvnanswer✔ ✔
Avnclientvnwhovnhadvnsurgeryvn24vnhoursvnagovnandvnwhovnalsovnhasvnavnnasogastricvntu
be
Thevnphysicianvnhasvnorderedvnarterialvnbloodvngasesvnforvnavnclientvnexperiencingvnshoc
k.vnThevnnursevnknowsvnthatvnwhichvnvaluevnindicatesvnshock?vn-vncorrectvnanswer✔
✔ pHvn7.32
Avn63-year-
oldvnArabvnAmericanvnmalevnstatesvnhisvnleftvnlegvnisvn"hot."vnWhatvnisvnthevnnurse'svnbes
tvnfirstvnresponse?vn-vncorrectvnanswer✔ ✔ Assessvnforvnpain
Thevnclientvnisvncomplainingvnofvnexcruciatingvnpainvninvnavnfootvnthatvnhasvnbeenvnampu
tated.vnThevnfamilyvntellsvnthevnnursevnthatvnthevnclientvnisvnjustvnaddictedvntovnpainvnmedi
cations.vnWhatvnisvnthevnnurse'svnbestvnresponse?vn-vncorrectvnanswer✔ ✔
"Hevnisvnexperiencingvnphantomvnlimbvnpain."
,Avnclientvnhasvnhadvnabdominalvnsurgeryvnandvnhasvnordersvntovnbevnambulatedvnthreevnti
mesvnavnday.vnOralvnpainvnmedicationvnhasvnbeenvnorderedvnforvnthevnclient.vnWhatvnshou
ldvnthevnnursevndovntovnfacilitatevnambulation?vn-vncorrectvnanswer✔ ✔
Mediatevn1vnhourvnpriorvntovnambulatingvnthevnclient.
Thevnclientvnreportsvnfrequentvnusevnofvnacetaminophen.vnHowvnshouldvnthevnnursevnbes
tvnrespond?vn-vncorrectvnanswer✔ ✔ "Dovnyouvndrinkvnalcohol?"
Avnclientvnwithvnchronicvnpainvnhasvnbeenvnadmittedvnwithvnavnfever.vnThevnnursingvnasse
ssmentvnrevealsvnthatvnthevnclientvnhasvnavndecreasedvnlevelvnofvnconsciousness.vnWhatvn
shouldvnthevnnursevnaskvnthevnfamilyvnabout?vn-vncorrectvnanswer✔ ✔
Whatvnmedicationsvnthevnclientvnhasvntaken
Thevnpracticalvnnursevnisvnreviewingvnthevnsocialvnhistoryvnfromvnavnclientvndiagnosedvn
withvnsmallvncellvncarcinomavnofvnthevnlung.vnWhichvninformationvnisvnsignificantvnforvnt
hisvndisease?vn-vncorrectvnanswer✔ ✔
Thevnclientvnhasvnsmokedvntwovn(2)vnpacksvnofvncigarettesvnavndayvnforvn20vnyears
Thevnpracticalvnnursevnandvnanvnunlicensedvnassistivevnpersonnelvn(UAP)vnarevncaringvnf
orvnavngroupvnofvnclientsvnonvnavnmedicalvnunit.vnWhichvninformationvnprovidedvnbyvnthev
nUAPvnwarrantsvnimmediatevninterventionvnbyvnthevnpracticalvnnurse?vn-
vncorrectvnanswer✔ ✔
ThevnclientvnreceivingvnProcritvn(epoetinvnalfa)vnhasvnavnTvn99.2˚F,vnPvn68,vnRvn24,vnan
dvnBPvnofvn198/102
, Thevnclientvndiagnosedvnwithvnlungvncancervnhasvnbeenvntoldvnthevncancervnhasvnmetastas
izedvntovnthevnbrain.vnWhichvninterventionvnshouldvnthevnpracticalvnnursevnexpectvntovnim
plement?vn-vncorrectvnanswer✔ ✔ Discussvnimplementingvnanvnadvancevndirective
Thevnclientvndiagnosedvnwithvnlungvncancervnisvnbeingvndischarged.vnWhichvnstatementv
nmadevnbyvnthevnclientvnindicatesvnavnreiterationvnofvninformationvnisvnrequired?vn-
vncorrectvnanswer✔ ✔
"Itvndoesn'tvnmattervnifvnIvnsmokevnnow.vnIvnalreadyvnhavevncancer."
Thevnpracticalvnnursevnisvninterviewingvnclientsvnatvnthevnclinic.vnWhichvninformationvnp
rovidedvnbyvnavnclientvnwarrantsvnfurthervninvestigation?vn-vncorrectvnanswer✔ ✔
Thevnclientvnhasvnbeenvncoughingvnupvnbloodvninvnthevnmornings
Thevnmalevnclientvnhadvnabdominalvnsurgeryvnandvnthevnpracticalvnnursevnsuspectsvnthevn
clientvnhasvnperitonitis.vnWhichvninformationvnsupportvnthevndiagnosisvnofvnperitonitis?v
n-vncorrectvnanswer✔ ✔
Hard,vnrigidvnabdomenvnandvnwhitevnbloodvncellvncountvn22,000/mm3
Thevnclientvnwhovnhadvnabdominalvnsurgeryvntellsvnthevnpracticalvnnurse,vn"Ivnfeltvnsomet
hingvngivevnwayvninvnmyvnstomach."vnWhichvninterventionvnshouldvnthevnpracticalvnnurs
evnimplementvnfirst?vn-vncorrectvnanswer✔ ✔
Inspectvnthevnabdominalvnwoundvnincision
Thevnclientvnisvnonevn(1)vndayvnpostoperativevnmajorvnabdominalvnsurgery.vnWhichvnclie
ntvnproblemvnisvnavnpriority?vn-vncorrectvnanswer✔ ✔
Fluidvnandvnelectrolytevnimbalance
