RN Med Surg 4 Exam 1 LATEST 2024/2025 EXAM WITH
ANSWERS GRADED A+ 100%
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action? - ANSWER: Observe the color,
consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen
per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold,
and diaphoretic. Which assessment is most important for the nurse to obtain? -
ANSWER: Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH),
a client develops pontine myselinolysis. Which intervention should the nurse
implement first? - ANSWER: Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the nurse
obtain? - ANSWER: Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She
is anxious and is complaining of a dry mouth. Which intervention should the nurse
implement? - ANSWER: Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath, productive cough with thickened tenacious mucous, and the inability to walk
up a flight of stairs without experiencing breathlessness. Which action is most
important for the nurse to instruct the client about self-care? - ANSWER: Increase
the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex,
and ? % proximal right coronary artery (RCA). The client later asks the nurse "what
does all this mean for me?" What information should the nurse provide? - ANSWER:
Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg.
The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should
the nurse administer?
(Enter numeric value only. If rounding is required, round to the nearest tenth.) -
ANSWER: 0.6 ml
,What information should the nurse include in the teaching plan of a client diagnosed
with gastroesophageal reflux disease (GERD)? - ANSWER: Minimize symptoms by
wearing loose, comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which
position should the nurse instruct the client to maintain? - ANSWER: left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is
unable to eat or drink without becoming nauseated and vomiting. Which finding
should the nurse report to the healthcare provider. - ANSWER: Yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs
a neurological assessment every four hours. Which assessment finding warrants
immediate intervention by the nurse? - ANSWER: Weakened cough effort
The nurse is providing preoperative education for a Jewish client scheduled to
receive a xenograft graft to promote burn healing. Which information should the
nurse provide this client? - ANSWER: The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requesting assistance
to reposition. While the nurse is turning him, the wound dehiscences and
eviscerates. The nurse moistens an available sterile dressing and places it over the
wound. What intervention should the nurse implement next? - ANSWER: Prepare
the client to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a serum
sodium level of 117 mEq/L. Which nursing problem should the nurse include in this
client's plan of care? - ANSWER: Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and
reports a racing heart beat and recent weight loss of 15 pounds. After ruling out
substance withdrawal, the healthcare provider suspects hyperthyroidism and admits
her for further testing. Which action should the nurse implement? - ANSWER: Space
the client's care to provide periods of rest
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary
recommendations should the nurse encourage the client to follow? - ANSWER:
Restrict protein intake by limiting meats and other high-protein foods
An overweight, young adult made who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak
and jittery. Which actions should the nurse implement? (Select all that apply.) -
ANSWER: Check his fingerstick glucose level.
Assess his skin temperature and moisture.
Measure his pulse and blood pressure.
, A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrants immediate intervention by the
nurse? - ANSWER: Irregular apical pulse
An adult woman with primary Raynaud phenomenon develops pallor and then
cyanosis of her fingers. After warming her hands, the fingers turn red and the client
reports a burning sensation. What action should the nurse take? - ANSWER:
Continue to monitor the fingers until color returns to normal
A male client with muscular dystrophy fell in his home and is admitted with a right
hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with
diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128
beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which
intervention is most important for the nurse to implement first? - ANSWER:
Administer PRN oral antipyretic
The nurse is completing the preoperative assessment of a client who is scheduled for
a laparoscopic cholecystectomy under general anesthesia. Which finding warrants
notification of the healthcare provider prior to proceeding with the scheduled
procedure? - ANSWER: The client's blood pressure reading is 184/88 mm Hg
Following surgical repair of the bladder, a female client is being discharged from the
hospital to home with an indwelling urinary catheter. Which instruction is most
important for the nurse to provide to this client? - ANSWER: Keep the drainage bag
lower than the level of the bladder
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the
nurse? - ANSWER: Further decline in level of consciousness
Which client has the highest risk for developing skin cancer? - ANSWER: A 65 year-
old fair-skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most
important for the nurse to obtain? - ANSWER: Daily weight
A female client who was involved in a motor vehicle collision is admitted with a
fractured left femur which is immobilized using a fracture traction splint in
preparation for an open reduction internal fixation (ORIF). The nurse determines
that her distal pulses are diminished in the left foot. Which interventions should the
nurse implement? (Select all that apply.) - ANSWER: Verify pedal pulses using a
doppler pulse device.
Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
Evaluate the application of the splint to the left leg.
ANSWERS GRADED A+ 100%
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action? - ANSWER: Observe the color,
consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen
per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold,
and diaphoretic. Which assessment is most important for the nurse to obtain? -
ANSWER: Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH),
a client develops pontine myselinolysis. Which intervention should the nurse
implement first? - ANSWER: Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the nurse
obtain? - ANSWER: Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She
is anxious and is complaining of a dry mouth. Which intervention should the nurse
implement? - ANSWER: Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath, productive cough with thickened tenacious mucous, and the inability to walk
up a flight of stairs without experiencing breathlessness. Which action is most
important for the nurse to instruct the client about self-care? - ANSWER: Increase
the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex,
and ? % proximal right coronary artery (RCA). The client later asks the nurse "what
does all this mean for me?" What information should the nurse provide? - ANSWER:
Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg.
The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should
the nurse administer?
(Enter numeric value only. If rounding is required, round to the nearest tenth.) -
ANSWER: 0.6 ml
,What information should the nurse include in the teaching plan of a client diagnosed
with gastroesophageal reflux disease (GERD)? - ANSWER: Minimize symptoms by
wearing loose, comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which
position should the nurse instruct the client to maintain? - ANSWER: left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is
unable to eat or drink without becoming nauseated and vomiting. Which finding
should the nurse report to the healthcare provider. - ANSWER: Yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs
a neurological assessment every four hours. Which assessment finding warrants
immediate intervention by the nurse? - ANSWER: Weakened cough effort
The nurse is providing preoperative education for a Jewish client scheduled to
receive a xenograft graft to promote burn healing. Which information should the
nurse provide this client? - ANSWER: The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requesting assistance
to reposition. While the nurse is turning him, the wound dehiscences and
eviscerates. The nurse moistens an available sterile dressing and places it over the
wound. What intervention should the nurse implement next? - ANSWER: Prepare
the client to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a serum
sodium level of 117 mEq/L. Which nursing problem should the nurse include in this
client's plan of care? - ANSWER: Fluid volume excess
A female client enters the clinic and insists on being seen. She is weak, nervous, and
reports a racing heart beat and recent weight loss of 15 pounds. After ruling out
substance withdrawal, the healthcare provider suspects hyperthyroidism and admits
her for further testing. Which action should the nurse implement? - ANSWER: Space
the client's care to provide periods of rest
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary
recommendations should the nurse encourage the client to follow? - ANSWER:
Restrict protein intake by limiting meats and other high-protein foods
An overweight, young adult made who was recently diagnosed with type 2 diabetes
mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak
and jittery. Which actions should the nurse implement? (Select all that apply.) -
ANSWER: Check his fingerstick glucose level.
Assess his skin temperature and moisture.
Measure his pulse and blood pressure.
, A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrants immediate intervention by the
nurse? - ANSWER: Irregular apical pulse
An adult woman with primary Raynaud phenomenon develops pallor and then
cyanosis of her fingers. After warming her hands, the fingers turn red and the client
reports a burning sensation. What action should the nurse take? - ANSWER:
Continue to monitor the fingers until color returns to normal
A male client with muscular dystrophy fell in his home and is admitted with a right
hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with
diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128
beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which
intervention is most important for the nurse to implement first? - ANSWER:
Administer PRN oral antipyretic
The nurse is completing the preoperative assessment of a client who is scheduled for
a laparoscopic cholecystectomy under general anesthesia. Which finding warrants
notification of the healthcare provider prior to proceeding with the scheduled
procedure? - ANSWER: The client's blood pressure reading is 184/88 mm Hg
Following surgical repair of the bladder, a female client is being discharged from the
hospital to home with an indwelling urinary catheter. Which instruction is most
important for the nurse to provide to this client? - ANSWER: Keep the drainage bag
lower than the level of the bladder
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the
nurse? - ANSWER: Further decline in level of consciousness
Which client has the highest risk for developing skin cancer? - ANSWER: A 65 year-
old fair-skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assessment is most
important for the nurse to obtain? - ANSWER: Daily weight
A female client who was involved in a motor vehicle collision is admitted with a
fractured left femur which is immobilized using a fracture traction splint in
preparation for an open reduction internal fixation (ORIF). The nurse determines
that her distal pulses are diminished in the left foot. Which interventions should the
nurse implement? (Select all that apply.) - ANSWER: Verify pedal pulses using a
doppler pulse device.
Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
Evaluate the application of the splint to the left leg.
