NUR 265 Advanced Concepts of
Medical–Surgical Nursing Exam 4
Questions & Answers
1. A nurse in the emergency department (ED) has attended an in-service on
maintaining client safety in the ED. Which statement by the nurse indicates a
correct understanding?
A. It is necessary to anticipate hostile or violent behavior by clients, family
members, or visitors
B. I should ask a client's family member to leave if the client appears confused
C. When searching through the belongings of a confused client, someone
from security should perform the search
D. Protection from skin injuries or breakdown is not necessary in the ED since
clients are only here a short time
Answer: A
2. Labs: Hct 30%, Hgb 9 g/dL, WBC 4,000 mm³, platelets 30,000 mm³. Which
assessment finding is a priority for follow-up?
A. Petechiae on the anterior abdomen
B. Ulcers on the mucous membrane
C. Reports of activity intolerance and fatigue
D. Reports of increased nausea and vomiting
Answer: A
3. The charge nurse observes a newly hired nurse caring for a client who had
a total laryngectomy 12 hours ago. Which intervention requires follow-up?
A. Providing preprinted flashcards for communication
B. Keeping the HOB elevated to enhance comfort
C. Applying humidified oxygen to the tracheostomy
D. Monitoring tissue flap integrity via Doppler every 2 hours
Answer: D
4. During a mass casualty event, the charge nurse must intervene if the new
nurse tags:
A. a client with a forehead laceration as nonurgent (green)
B. a client with a GCS of 3 as expectant (black)
, C. a client with extensive full-thickness burns to the entire body as urgent
(yellow)
D. a client with an open femur fracture as urgent (yellow)
Answer: C
5. During an external disaster, which action by a nurse requires the charge
nurse to intervene?
A. Leaving a penetrating object in place
B. Placing an IV line in the hand of a client with a suspected closed radial
fracture
C. Inserting an oropharyngeal airway in an unconscious client
D. Performing a jaw-thrust maneuver on a client with a suspected cervical
spine injury
Answer: B
6. Life-saving measures were unsuccessful on a victim of spousal abuse.
Which action should the nurse take initially?
A. Prepare the body for release to the morgue and report the case to the
police
B. Place an IV line in the hand of a client with a suspected closed radial
fracture
C. Notify the hospital's crisis team
D. Leave all IV lines and tubes in place
Answer: D
7. Which statement by a newly hired nurse about anaphylaxis indicates a
need for further education?
A. "The client may present with widespread hives and hypoxia."
B. "The client may present with swollen lips and tongue."
C. "The client may report new-onset abdominal cramping with hyperreflexia."
D. "The client may have audible wheezes and cyanosis."
Answer: C
8. A client with AIDS was just diagnosed with PJP. Which intervention should
the preceptor question?
A. Offering foods high in calories and protein
B. Instructing the client to drink 2-3 L of fluid throughout the day
C. Wearing a surgical mask when standing within 3 ft of the client
D. Auscultating breath sounds for crackles at least once per shift
Answer: C
Medical–Surgical Nursing Exam 4
Questions & Answers
1. A nurse in the emergency department (ED) has attended an in-service on
maintaining client safety in the ED. Which statement by the nurse indicates a
correct understanding?
A. It is necessary to anticipate hostile or violent behavior by clients, family
members, or visitors
B. I should ask a client's family member to leave if the client appears confused
C. When searching through the belongings of a confused client, someone
from security should perform the search
D. Protection from skin injuries or breakdown is not necessary in the ED since
clients are only here a short time
Answer: A
2. Labs: Hct 30%, Hgb 9 g/dL, WBC 4,000 mm³, platelets 30,000 mm³. Which
assessment finding is a priority for follow-up?
A. Petechiae on the anterior abdomen
B. Ulcers on the mucous membrane
C. Reports of activity intolerance and fatigue
D. Reports of increased nausea and vomiting
Answer: A
3. The charge nurse observes a newly hired nurse caring for a client who had
a total laryngectomy 12 hours ago. Which intervention requires follow-up?
A. Providing preprinted flashcards for communication
B. Keeping the HOB elevated to enhance comfort
C. Applying humidified oxygen to the tracheostomy
D. Monitoring tissue flap integrity via Doppler every 2 hours
Answer: D
4. During a mass casualty event, the charge nurse must intervene if the new
nurse tags:
A. a client with a forehead laceration as nonurgent (green)
B. a client with a GCS of 3 as expectant (black)
, C. a client with extensive full-thickness burns to the entire body as urgent
(yellow)
D. a client with an open femur fracture as urgent (yellow)
Answer: C
5. During an external disaster, which action by a nurse requires the charge
nurse to intervene?
A. Leaving a penetrating object in place
B. Placing an IV line in the hand of a client with a suspected closed radial
fracture
C. Inserting an oropharyngeal airway in an unconscious client
D. Performing a jaw-thrust maneuver on a client with a suspected cervical
spine injury
Answer: B
6. Life-saving measures were unsuccessful on a victim of spousal abuse.
Which action should the nurse take initially?
A. Prepare the body for release to the morgue and report the case to the
police
B. Place an IV line in the hand of a client with a suspected closed radial
fracture
C. Notify the hospital's crisis team
D. Leave all IV lines and tubes in place
Answer: D
7. Which statement by a newly hired nurse about anaphylaxis indicates a
need for further education?
A. "The client may present with widespread hives and hypoxia."
B. "The client may present with swollen lips and tongue."
C. "The client may report new-onset abdominal cramping with hyperreflexia."
D. "The client may have audible wheezes and cyanosis."
Answer: C
8. A client with AIDS was just diagnosed with PJP. Which intervention should
the preceptor question?
A. Offering foods high in calories and protein
B. Instructing the client to drink 2-3 L of fluid throughout the day
C. Wearing a surgical mask when standing within 3 ft of the client
D. Auscultating breath sounds for crackles at least once per shift
Answer: C
