MedSurg 4 Final Exam Questions with
Answers
A client with myocardial infarction suddenly becomes tachycardic, shows
signs of air hunger, and begins coughing frothy, pink-tinged sputum. The
nurse listens to breath sounds, expecting to hear which breath sounds
bilaterally?
A. Rhonchi
B. Crackles
C. Wheezes
D. Diminished breath sounds - ----ANS:ANS: B
Rationale: Pulmonary edema is characterized by extreme breathlessness,
dyspnea, air hunger, and production of frothy, pink-tinged sputum.
Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished
breath sounds are not associated with pulmonary edema.
The nurse is checking the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft.
The affected leg is warm, and the nurse notes redness and edema. The pedal
pulse is palpable and unchanged from admission. The nurse interprets that
the neurovascular status is which?
A. Moderately impaired, and the surgeon should be called
B. Normal, caused by increased blood flow through the leg
C. Slightly deteriorating, and should be monitored for another hour
D. Adequate from an arterial approach, but venous complications are arising -
----ANS:ANS: B
Rationale: An expected outcome of surgery is warmth, redness, and edema in
the surgical extremity caused by increased blood flow. Options A, C and D are
incorrect.
A client arrives at the emergency department with complaints of low
abdominal pain and hematuria. The client is afebrile. The nurse next assesses
the client to determine a history of which condition?
a. Pyelonephritis
,b. Glomerulonephritis
c. Trauma to the bladder or abdomen
d. Renal cancer in the client's family - ----ANS:ANS: C
Bladder trauma or injury should be considered or suspected in the client with
low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis
would be accompanied by fever and are thus not applicable to the client
described in this question. Renal cancer would not cause pain that is felt in the
low abdomen; rather, the pain would be in the flank area.
A client arriving at the emergency department has experienced frostbite to the
right hand. Which finding would the nurse note on assessment of the client's
hand?
a. A pink, edematous hand
b. Fiery red skin with edema in the nailbeds
c. Black fingertips surrounded by an erythematous rash
d. A white color to the skin, which is insensitive to touch - ----ANS:ANS: D
Rationale: Frostbite generally presents as extremely pale/white skin that is
cold and hard to the touch. Client will not be able to perceive the touch to this
part. Redness and pain comes during the thawing process, not during active
frostbite
A client calls the emergency department and tells the nurse that he came
directly into contact with poison ivy shrubs. The client tells the nurse that he
cannot see anything on the skin and asks the nurse what to do. The nurse
should make which response?
a. Come to the emergency department.
b. Apply calamine lotion immediately to the exposed skin areas.
c. Take a shower immediately, lathering and rinsing several times.
d. It is not necessary to do anything if you cannot see anything on your skin. -
----ANS:ANS: C
Rationale: The poison ivy should be washed off immediately in order to reduce
the risk of developing a rash. Since the client is currently not having a severe
reaction to the poison ivy, they do not need to be seen in the emergency room
at this time. Option 4 does not address the problem, so is incorrect. Option 2
(calamine lotion) could be helpful if dermatitis develops, but not useful at this
time while the poison ivy is still on the skin.
,A client is brought to the emergency department by emergency medical
services (EMS) after being hit by a car. The name of the client is unknown,
and the client has sustained a severe head injury and multiple fractures and is
unconscious. An emergency craniotomy is required. Regarding informed
consent for the surgical procedure, which is the best action?
a. Obtain a court order for the surgical procedure
b. Ask the EMS team to sign the informed consent
c. Transport the victim to the operating room for surgery
d. Call the police to identify the client and locate the family. - ----ANS:ANS: C
In general, there are two situations in which informed consent of an adult
client is not needed. One is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury
or death to the client. The second is when the client waives the right to give
informed consent. Option 1 will delay emergency treatment, and option 2 is
inappropriate. Although option 4 may be pursued, it is not the best action
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L
(7.0 mmol/L). The nurse should plan which actions as a priority? Select all that
apply.
a. Place the client on a cardiac monitor.
b. Notify the health care provider (HCP).
c. Put the client on NPO (nothing by mouth) status except for ice chips.
d. Review the client's medications to determine if any contain or retain
potassium]
e. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte
concentration. - ----ANS:ANS: A, B, D
The normal potassium level is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). A potassium
level of 7.0 is elevated. The client with hyperkalemia is at risk of developing
cardiac dysrhythmias and cardiac arrest. Because of this, the client should be
placed on a cardiac monitor. The nurse should notify the HCP and also review
medications to determine if any contain potassium or are potassium retaining.
The client does not need to be put on NPO status. Fluid intake is not
increased because it contributes to fluid overload and would not affect the
serum potassium level significantly.
A client with chronic kidney disease returns to the nursing unit following a
hemodialysis treatment. On assessment, the nurse notes that the client's
temperature is 38.5°C (101.2°F). Which nursing action is most appropriate?
, a. Encourage fluid intake.
b. Notify the health care provider.
c. Continue to monitor vital signs.
d. Monitor the site of the shunt for infection. - ----ANS:ANS: B
A temperature of 101.2°F (38.5°C) is significantly elevated and may indicate
infection. The nurse should notify the health care provider (HCP). Dialysis
clients cannot have fluid intake encouraged. Vital signs and the shunt site
should be monitored, but the HCP should be notified first.
A client with pneumonia caused by aspiration after alcohol intoxication has
just been admitted. The client is febrile and agitated. Which health care
provider order should the nurse implement first?
A) Administer levofloxacin (Levaquin) 500 mg IV.
B) Draw aerobic and anaerobic blood cultures.
C) Give lorazepam (Ativan) as needed for agitation.
D) Refer to social worker for alcohol counseling. - ----ANS:ANS: B) Draw
aerobic and anaerobic blood cultures.
A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The
nurse provides instructions regarding the side and adverse effects of this
medication and should tell the client that which undesirable effect is
associated with this medication?
a) Insomnia
b) Constipation
c) Hypotension
d) Bronchospasm - ----ANS:ANS: d)
Rationale: Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a
mast cell stabilizer. Undesirable effects associated with inhalation therapy of
cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation,
and wheezing. Clients receiving this medication orally may experience
pruritus, nausea, diarrhea, and myalgia.
A man whose BPH has been successfully managed through medical
treatment visits the provider's office and reports he has suddenly had a return
of symptoms including frequency, urgency, and a sensation of incomplete
emptying after voiding. The nurse collects a thorough history and suspects the
possible cause of the sudden exacerbation of the client's symptoms may be:
a. Increased sexual activity since his wife has retired.
Answers
A client with myocardial infarction suddenly becomes tachycardic, shows
signs of air hunger, and begins coughing frothy, pink-tinged sputum. The
nurse listens to breath sounds, expecting to hear which breath sounds
bilaterally?
A. Rhonchi
B. Crackles
C. Wheezes
D. Diminished breath sounds - ----ANS:ANS: B
Rationale: Pulmonary edema is characterized by extreme breathlessness,
dyspnea, air hunger, and production of frothy, pink-tinged sputum.
Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished
breath sounds are not associated with pulmonary edema.
The nurse is checking the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft.
The affected leg is warm, and the nurse notes redness and edema. The pedal
pulse is palpable and unchanged from admission. The nurse interprets that
the neurovascular status is which?
A. Moderately impaired, and the surgeon should be called
B. Normal, caused by increased blood flow through the leg
C. Slightly deteriorating, and should be monitored for another hour
D. Adequate from an arterial approach, but venous complications are arising -
----ANS:ANS: B
Rationale: An expected outcome of surgery is warmth, redness, and edema in
the surgical extremity caused by increased blood flow. Options A, C and D are
incorrect.
A client arrives at the emergency department with complaints of low
abdominal pain and hematuria. The client is afebrile. The nurse next assesses
the client to determine a history of which condition?
a. Pyelonephritis
,b. Glomerulonephritis
c. Trauma to the bladder or abdomen
d. Renal cancer in the client's family - ----ANS:ANS: C
Bladder trauma or injury should be considered or suspected in the client with
low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis
would be accompanied by fever and are thus not applicable to the client
described in this question. Renal cancer would not cause pain that is felt in the
low abdomen; rather, the pain would be in the flank area.
A client arriving at the emergency department has experienced frostbite to the
right hand. Which finding would the nurse note on assessment of the client's
hand?
a. A pink, edematous hand
b. Fiery red skin with edema in the nailbeds
c. Black fingertips surrounded by an erythematous rash
d. A white color to the skin, which is insensitive to touch - ----ANS:ANS: D
Rationale: Frostbite generally presents as extremely pale/white skin that is
cold and hard to the touch. Client will not be able to perceive the touch to this
part. Redness and pain comes during the thawing process, not during active
frostbite
A client calls the emergency department and tells the nurse that he came
directly into contact with poison ivy shrubs. The client tells the nurse that he
cannot see anything on the skin and asks the nurse what to do. The nurse
should make which response?
a. Come to the emergency department.
b. Apply calamine lotion immediately to the exposed skin areas.
c. Take a shower immediately, lathering and rinsing several times.
d. It is not necessary to do anything if you cannot see anything on your skin. -
----ANS:ANS: C
Rationale: The poison ivy should be washed off immediately in order to reduce
the risk of developing a rash. Since the client is currently not having a severe
reaction to the poison ivy, they do not need to be seen in the emergency room
at this time. Option 4 does not address the problem, so is incorrect. Option 2
(calamine lotion) could be helpful if dermatitis develops, but not useful at this
time while the poison ivy is still on the skin.
,A client is brought to the emergency department by emergency medical
services (EMS) after being hit by a car. The name of the client is unknown,
and the client has sustained a severe head injury and multiple fractures and is
unconscious. An emergency craniotomy is required. Regarding informed
consent for the surgical procedure, which is the best action?
a. Obtain a court order for the surgical procedure
b. Ask the EMS team to sign the informed consent
c. Transport the victim to the operating room for surgery
d. Call the police to identify the client and locate the family. - ----ANS:ANS: C
In general, there are two situations in which informed consent of an adult
client is not needed. One is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury
or death to the client. The second is when the client waives the right to give
informed consent. Option 1 will delay emergency treatment, and option 2 is
inappropriate. Although option 4 may be pursued, it is not the best action
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L
(7.0 mmol/L). The nurse should plan which actions as a priority? Select all that
apply.
a. Place the client on a cardiac monitor.
b. Notify the health care provider (HCP).
c. Put the client on NPO (nothing by mouth) status except for ice chips.
d. Review the client's medications to determine if any contain or retain
potassium]
e. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte
concentration. - ----ANS:ANS: A, B, D
The normal potassium level is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). A potassium
level of 7.0 is elevated. The client with hyperkalemia is at risk of developing
cardiac dysrhythmias and cardiac arrest. Because of this, the client should be
placed on a cardiac monitor. The nurse should notify the HCP and also review
medications to determine if any contain potassium or are potassium retaining.
The client does not need to be put on NPO status. Fluid intake is not
increased because it contributes to fluid overload and would not affect the
serum potassium level significantly.
A client with chronic kidney disease returns to the nursing unit following a
hemodialysis treatment. On assessment, the nurse notes that the client's
temperature is 38.5°C (101.2°F). Which nursing action is most appropriate?
, a. Encourage fluid intake.
b. Notify the health care provider.
c. Continue to monitor vital signs.
d. Monitor the site of the shunt for infection. - ----ANS:ANS: B
A temperature of 101.2°F (38.5°C) is significantly elevated and may indicate
infection. The nurse should notify the health care provider (HCP). Dialysis
clients cannot have fluid intake encouraged. Vital signs and the shunt site
should be monitored, but the HCP should be notified first.
A client with pneumonia caused by aspiration after alcohol intoxication has
just been admitted. The client is febrile and agitated. Which health care
provider order should the nurse implement first?
A) Administer levofloxacin (Levaquin) 500 mg IV.
B) Draw aerobic and anaerobic blood cultures.
C) Give lorazepam (Ativan) as needed for agitation.
D) Refer to social worker for alcohol counseling. - ----ANS:ANS: B) Draw
aerobic and anaerobic blood cultures.
A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The
nurse provides instructions regarding the side and adverse effects of this
medication and should tell the client that which undesirable effect is
associated with this medication?
a) Insomnia
b) Constipation
c) Hypotension
d) Bronchospasm - ----ANS:ANS: d)
Rationale: Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a
mast cell stabilizer. Undesirable effects associated with inhalation therapy of
cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation,
and wheezing. Clients receiving this medication orally may experience
pruritus, nausea, diarrhea, and myalgia.
A man whose BPH has been successfully managed through medical
treatment visits the provider's office and reports he has suddenly had a return
of symptoms including frequency, urgency, and a sensation of incomplete
emptying after voiding. The nurse collects a thorough history and suspects the
possible cause of the sudden exacerbation of the client's symptoms may be:
a. Increased sexual activity since his wife has retired.
