EXAM 2 MED SURG QUESTIONS AND
CORRECT VERIFIED ANSWERS
TheA2nurseA2assessesA2aA2surgicalA2patientA2theA2morningA2ofA2theA2firstA2postoperativeA2
dayA2andA2notesA2rednessA2andA2warmthA2aroundA2theA2incision.A2WhichA2actionA2byA2the
A2nurseA2isA2mostA2appropriate?
a.A2ObtainA2woundA2cultures.
b.A2DocumentA2theA2assessment.
c.A2NotifyA2theA2healthA2careA2provider.
d.A2AssessA2theA2woundA2everyA22A2hoursA2-A2Ans--Answer:A2BA2
Rationale:A2TheA2incisionalA2rednessA2andA2warmthA2areA2indicatorsA2ofA2theA2normalA2init
ialA2(inflammatory)A2stageA2ofA2woundA2healingA2byA2primaryA2intention.
AA224-year-
oldA2patientA2whoA2isA2receivingA2antibioticsA2forA2anA2infectedA2legA2woundA2hasA2aA2tem
peratureA2ofA2101.8°A2FA2(38.7°A2C).A2WhichA2actionA2byA2theA2nurseA2isA2mostA2appropria
te?
a.A2ApplyA2aA2coolingA2blanket.
b.A2NotifyA2theA2healthA2careA2provider.
c.A2GiveA2theA2prescribedA2PRNA2aspirinA2(Ascriptin)A2650A2mg.
d.A2CheckA2theA2patient'sA2oralA2temperatureA2againA2inA24A2hours.A2-A2Ans--Answer:A2DA2
Rationale:A2MildA2toA2moderateA2temperatureA2elevationsA2(lessA2thanA2103°A2F)A2doA2not
A2harmA2theA2youngA2adultA2patientA2andA2mayA2benefitA2hostA2defenseA2mechanisms.A2T
heA2nurseA2shouldA2continueA2toA2monitorA2theA2temperature.A2AntipyreticsA2areA2notA2indi
catedA2unlessA2theA2patientA2isA2complainingA2ofA2fever-
relatedA2symptoms.A2ThereA2isA2noA2needA2toA2notifyA2theA2patient'sA2healthA2careA2provid
erA2orA2toA2useA2aA2coolingA2blanketA2forA2aA2moderateA2temperatureA2elevation.
WhichA2nursingA2actionA2isA2mostA2likelyA2toA2detectA2earlyA2signsA2ofA2infectionA2inA2aA2pa
tientA2whoA2isA2takingA2immunosuppressiveA2medications?
a.A2MonitorA2whiteA2bloodA2cellA2count.
b.A2CheckA2theA2skinA2forA2areasA2ofA2redness.
c.A2CheckA2theA2temperatureA2everyA22A2hours.
d.A2AskA2aboutA2fatigueA2orA2feelingsA2ofA2malaise.A2-A2Ans--Answer:A2D
Rationale:A2CommonA2clinicalA2manifestationsA2ofA2inflammationA2andA2infectionA2areA2fre
quentlyA2notA2presentA2whenA2patientsA2receiveA2immunosuppressiveA2medications.A2Th
eA2earliestA2manifestationA2ofA2anA2infectionA2mayA2beA2"justA2notA2feelingA2well."
WhenA2evaluatingA2theA2responseA2toA2treatmentA2forA2aA2patientA2withA2aA2fluidA2imbalan
ce,A2theA2mostA2importantA2assessmentA2toA2includeA2is
a.A2skinA2turgor.
b.A2presenceA2ofA2edema.
, c.A2hourlyA2urineA2output.
d.A2dailyA2weight.A2-A2Ans--Answer:A2D
Rationale:A2DailyA2weightA2isA2theA2mostA2easilyA2obtainedA2andA2accurateA2meansA2ofA2a
ssessingA2volumeA2status.A2SkinA2turgorA2variesA2considerablyA2withA2age.A2Considerable
A2excessA2fluidA2volumeA2mayA2beA2presentA2beforeA2fluidA2movesA2intoA2theA2interstitialA2
spaceA2andA2causesA2edema.A2HourlyA2urineA2outputsA2doA2notA2takeA2accountA2ofA2fluidA
2intakeA2orA2ofA2fluidA2lossA2throughA2insensibleA2loss,A2sweating,A2orA2lossA2fromA2theA2ga
strointestinalA2tractA2orA2wounds.
WhenA2caringA2forA2anA2alertA2andA2orientedA2elderlyA2patientA2withA2aA2historyA2ofA2dehyd
ration,A2theA2homeA2healthA2nurseA2willA2teachA2theA2patientA2toA2increaseA2fluidA2intake
a.A2whenA2theA2patientA2feelsA2thirsty.
b.A2inA2theA2lateA2eveningA2hours.
c.A2asA2soonA2asA2changesA2inA2LOCA2occur.
d.A2ifA2theA2oralA2mucosaA2feelsA2dry.A2-A2Ans--Answer:A2DA2
Rationale:A2AnA2alert,A2elderlyA2patientA2willA2beA2ableA2toA2self-
assessA2forA2signsA2ofA2oralA2drynessA2suchA2asA2thickA2oralA2secretionsA2orA2dry-
appearingA2mucosa.A2TheA2thirstA2mechanismA2decreasesA2withA2ageA2andA2isA2notA2anA2
accurateA2indicatorA2ofA2volumeA2depletion.A2ManyA2olderA2patientsA2preferA2toA2restrictA2fl
uidsA2slightlyA2inA2theA2eveningA2toA2improveA2sleepA2quality.A2TheA2patientA2willA2notA2beA
2likelyA2toA2noticeA2andA2actA2appropriatelyA2whenA2changesA2inA2LOCA2occur.
AA2patientA2isA2takingA2hydrochlorothiazide,A2aA2potassium-
wastingA2diuretic,A2forA2treatmentA2ofA2hypertension.A2TheA2nurseA2willA2teachA2theA2patie
ntA2toA2reportA2symptomsA2ofA2adverseA2effectsA2suchA2as
a.A2generalizedA2weakness.
b.A2facialA2muscleA2spasms.
c.A2frequentA2looseA2stools.
d.A2personalityA2changes.A2-A2Ans--Answer:A2AA2
Rationale:A2GeneralizedA2weaknessA2progressingA2toA2flaccidityA2isA2aA2manifestationA2of
A2hypokalemia.A2FacialA2muscleA2spasmsA2mightA2occurA2withA2hypocalcemia.A2LooseA2st
oolsA2areA2associatedA2withA2hyperkalemia.A2PersonalityA2changesA2areA2notA2associated
A2withA2electrolyteA2disturbances,A2althoughA2changesA2inA2mentalA2statusA2areA2common
A2manifestationsA2withA2sodiumA2excessA2orA2deficit.
TheA2long-term-
careA2nurseA2isA2evaluatingA2theA2effectivenessA2ofA2proteinA2supplementsA2onA2aA2patien
tA2whoA2hasA2lowA2serumA2totalA2proteinA2level.A2WhichA2ofA2theseA2dataA2indicateA2thatA2t
heA2patient'sA2conditionA2hasA2improved?
a.A2AbsenceA2ofA2peripheralA2edema
b.A2GoodA2skinA2turgor
c.A2HematocritA228%
d.A2BloodA2pressureA2110/72A2mmA2HgA2-A2Ans--Answer:A2AA2
CORRECT VERIFIED ANSWERS
TheA2nurseA2assessesA2aA2surgicalA2patientA2theA2morningA2ofA2theA2firstA2postoperativeA2
dayA2andA2notesA2rednessA2andA2warmthA2aroundA2theA2incision.A2WhichA2actionA2byA2the
A2nurseA2isA2mostA2appropriate?
a.A2ObtainA2woundA2cultures.
b.A2DocumentA2theA2assessment.
c.A2NotifyA2theA2healthA2careA2provider.
d.A2AssessA2theA2woundA2everyA22A2hoursA2-A2Ans--Answer:A2BA2
Rationale:A2TheA2incisionalA2rednessA2andA2warmthA2areA2indicatorsA2ofA2theA2normalA2init
ialA2(inflammatory)A2stageA2ofA2woundA2healingA2byA2primaryA2intention.
AA224-year-
oldA2patientA2whoA2isA2receivingA2antibioticsA2forA2anA2infectedA2legA2woundA2hasA2aA2tem
peratureA2ofA2101.8°A2FA2(38.7°A2C).A2WhichA2actionA2byA2theA2nurseA2isA2mostA2appropria
te?
a.A2ApplyA2aA2coolingA2blanket.
b.A2NotifyA2theA2healthA2careA2provider.
c.A2GiveA2theA2prescribedA2PRNA2aspirinA2(Ascriptin)A2650A2mg.
d.A2CheckA2theA2patient'sA2oralA2temperatureA2againA2inA24A2hours.A2-A2Ans--Answer:A2DA2
Rationale:A2MildA2toA2moderateA2temperatureA2elevationsA2(lessA2thanA2103°A2F)A2doA2not
A2harmA2theA2youngA2adultA2patientA2andA2mayA2benefitA2hostA2defenseA2mechanisms.A2T
heA2nurseA2shouldA2continueA2toA2monitorA2theA2temperature.A2AntipyreticsA2areA2notA2indi
catedA2unlessA2theA2patientA2isA2complainingA2ofA2fever-
relatedA2symptoms.A2ThereA2isA2noA2needA2toA2notifyA2theA2patient'sA2healthA2careA2provid
erA2orA2toA2useA2aA2coolingA2blanketA2forA2aA2moderateA2temperatureA2elevation.
WhichA2nursingA2actionA2isA2mostA2likelyA2toA2detectA2earlyA2signsA2ofA2infectionA2inA2aA2pa
tientA2whoA2isA2takingA2immunosuppressiveA2medications?
a.A2MonitorA2whiteA2bloodA2cellA2count.
b.A2CheckA2theA2skinA2forA2areasA2ofA2redness.
c.A2CheckA2theA2temperatureA2everyA22A2hours.
d.A2AskA2aboutA2fatigueA2orA2feelingsA2ofA2malaise.A2-A2Ans--Answer:A2D
Rationale:A2CommonA2clinicalA2manifestationsA2ofA2inflammationA2andA2infectionA2areA2fre
quentlyA2notA2presentA2whenA2patientsA2receiveA2immunosuppressiveA2medications.A2Th
eA2earliestA2manifestationA2ofA2anA2infectionA2mayA2beA2"justA2notA2feelingA2well."
WhenA2evaluatingA2theA2responseA2toA2treatmentA2forA2aA2patientA2withA2aA2fluidA2imbalan
ce,A2theA2mostA2importantA2assessmentA2toA2includeA2is
a.A2skinA2turgor.
b.A2presenceA2ofA2edema.
, c.A2hourlyA2urineA2output.
d.A2dailyA2weight.A2-A2Ans--Answer:A2D
Rationale:A2DailyA2weightA2isA2theA2mostA2easilyA2obtainedA2andA2accurateA2meansA2ofA2a
ssessingA2volumeA2status.A2SkinA2turgorA2variesA2considerablyA2withA2age.A2Considerable
A2excessA2fluidA2volumeA2mayA2beA2presentA2beforeA2fluidA2movesA2intoA2theA2interstitialA2
spaceA2andA2causesA2edema.A2HourlyA2urineA2outputsA2doA2notA2takeA2accountA2ofA2fluidA
2intakeA2orA2ofA2fluidA2lossA2throughA2insensibleA2loss,A2sweating,A2orA2lossA2fromA2theA2ga
strointestinalA2tractA2orA2wounds.
WhenA2caringA2forA2anA2alertA2andA2orientedA2elderlyA2patientA2withA2aA2historyA2ofA2dehyd
ration,A2theA2homeA2healthA2nurseA2willA2teachA2theA2patientA2toA2increaseA2fluidA2intake
a.A2whenA2theA2patientA2feelsA2thirsty.
b.A2inA2theA2lateA2eveningA2hours.
c.A2asA2soonA2asA2changesA2inA2LOCA2occur.
d.A2ifA2theA2oralA2mucosaA2feelsA2dry.A2-A2Ans--Answer:A2DA2
Rationale:A2AnA2alert,A2elderlyA2patientA2willA2beA2ableA2toA2self-
assessA2forA2signsA2ofA2oralA2drynessA2suchA2asA2thickA2oralA2secretionsA2orA2dry-
appearingA2mucosa.A2TheA2thirstA2mechanismA2decreasesA2withA2ageA2andA2isA2notA2anA2
accurateA2indicatorA2ofA2volumeA2depletion.A2ManyA2olderA2patientsA2preferA2toA2restrictA2fl
uidsA2slightlyA2inA2theA2eveningA2toA2improveA2sleepA2quality.A2TheA2patientA2willA2notA2beA
2likelyA2toA2noticeA2andA2actA2appropriatelyA2whenA2changesA2inA2LOCA2occur.
AA2patientA2isA2takingA2hydrochlorothiazide,A2aA2potassium-
wastingA2diuretic,A2forA2treatmentA2ofA2hypertension.A2TheA2nurseA2willA2teachA2theA2patie
ntA2toA2reportA2symptomsA2ofA2adverseA2effectsA2suchA2as
a.A2generalizedA2weakness.
b.A2facialA2muscleA2spasms.
c.A2frequentA2looseA2stools.
d.A2personalityA2changes.A2-A2Ans--Answer:A2AA2
Rationale:A2GeneralizedA2weaknessA2progressingA2toA2flaccidityA2isA2aA2manifestationA2of
A2hypokalemia.A2FacialA2muscleA2spasmsA2mightA2occurA2withA2hypocalcemia.A2LooseA2st
oolsA2areA2associatedA2withA2hyperkalemia.A2PersonalityA2changesA2areA2notA2associated
A2withA2electrolyteA2disturbances,A2althoughA2changesA2inA2mentalA2statusA2areA2common
A2manifestationsA2withA2sodiumA2excessA2orA2deficit.
TheA2long-term-
careA2nurseA2isA2evaluatingA2theA2effectivenessA2ofA2proteinA2supplementsA2onA2aA2patien
tA2whoA2hasA2lowA2serumA2totalA2proteinA2level.A2WhichA2ofA2theseA2dataA2indicateA2thatA2t
heA2patient'sA2conditionA2hasA2improved?
a.A2AbsenceA2ofA2peripheralA2edema
b.A2GoodA2skinA2turgor
c.A2HematocritA228%
d.A2BloodA2pressureA2110/72A2mmA2HgA2-A2Ans--Answer:A2AA2
