Adult Medical-Surgical Nursing Practice A – Comprehensive Exam Questions & Verified
Answers Updated Version
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect? Facial butterfly rash.
R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks
and nose and can disappear during times of remission. CORRECT ANSWER A nurse is caring
for a client who is receiving plasmapheresis through a venous access site. Which of the following
actions should the nurse take?Check electrolyte levels before and after therapy.
R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor
the clients electrolyte levels before and after therapy. CORRECT ANSWER A nurse is
assessing a client who has Graves disease. Which of the following images should indicate to the
nurse that the client has exophthalmos? The nurse should identify an outward protrusion of
the eyes is exophthalmos a common finding of graves disease. An overproduction of the thyroid
hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye which
results in the eyes protruding outward. Exophthalmos can cause the client to experience
problems with vision including focusing on objects as well as pressure on the optic nerve.
CORRECT ANSWER A nurse is performing a cardiac assessment for a client who had a
myocardial infarction 2 days ago. Which of the following actions should the nurse take first after
hearing the following sound? Listen with the client on his left side. When providing nursing care
the nurse should first use the least invasive intervention. Therefore after auscultating a murmur
the first action the nurse should take is to place the client on his left side and listen to his heart
again. CORRECT ANSWER A nurse is providing teaching to an older adult female client who
has stress incontinence and a BMI of 32. Which of the following statements by the client
indicates an understanding of the teaching question mark I am dieting to lose weight. Excess
weight cut creates increased abdominal pressure that can result in stress incontinence.
CORRECT ANSWER A nurse is reviewing the ABG results of a client who has advanced
, COPD. Which of the following results should the nurse expect? Paco2 of 56. A client who
has COPD retains paco2 due to the weakening and the collapse of the alveolar sacs which
decreases the area and lungs for gas exchange and causes the paco2 to increase above the
expected reference range. CORRECT ANSWER A nurse is providing teaching to a client who
is perimenopausal and has a prescription for hormone replacement therapy. For which of the
following adverse effects should the nurse instruct the client to notify the provider? Select all
that apply. Calf pain, numbness in the arms and intense headache. Calf pain is an indication
of DVT and the client should report this finding to the provider immediately. Numbness in the
arms can indicate cerebrovascular accident which is an adverse effect of hormone replacement
therapy and an intense headache can indicate a cerebrovascular accident. CORRECT ANSWER
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding of
the teaching? I am taking this medication to increase my energy level. The goal of
erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When
the medication is effective the client should have a decreasing fatigue and an improvement and
activity tolerance. CORRECT ANSWER A nurse is teaching a client who has venous
insufficiency about self-care. Which of the following statements should the nurse identify as an
indication that the client understands teaching? I will wear clean graduated compression
stockings everyday. The client should apply a clean pair of graduated compression stockings
each day and clean soiled stockings with mild detergent and warm water by hand. CORRECT
ANSWER A nurse is preparing to present a program about atherosclerosis at a health fair.
Which of the following recommendations should the nurse plan to include? Select all that apply.
Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet
and increase fluid intake. Smoking cessation is an important lifestyle modification to prevent
Arthur sclerosis and preventing obesity through diet and exercise can help prevent
atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.
CORRECT ANSWER A nurse is caring for a client who is 12 hours post-operative following a
total hip arthroplasty. Which of the following actions should the nurse take? Place a pillow
between the clients legs. The nurse should place a pillow between the clients legs to prevent hip
dislocation. CORRECT ANSWER A nurse is reviewing the medication history of a client who
is to undergo allergy testing. The nurse should instruct the client to discontinue which of the
Answers Updated Version
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus.
Which of the following findings should the nurse expect? Facial butterfly rash.
R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks
and nose and can disappear during times of remission. CORRECT ANSWER A nurse is caring
for a client who is receiving plasmapheresis through a venous access site. Which of the following
actions should the nurse take?Check electrolyte levels before and after therapy.
R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor
the clients electrolyte levels before and after therapy. CORRECT ANSWER A nurse is
assessing a client who has Graves disease. Which of the following images should indicate to the
nurse that the client has exophthalmos? The nurse should identify an outward protrusion of
the eyes is exophthalmos a common finding of graves disease. An overproduction of the thyroid
hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye which
results in the eyes protruding outward. Exophthalmos can cause the client to experience
problems with vision including focusing on objects as well as pressure on the optic nerve.
CORRECT ANSWER A nurse is performing a cardiac assessment for a client who had a
myocardial infarction 2 days ago. Which of the following actions should the nurse take first after
hearing the following sound? Listen with the client on his left side. When providing nursing care
the nurse should first use the least invasive intervention. Therefore after auscultating a murmur
the first action the nurse should take is to place the client on his left side and listen to his heart
again. CORRECT ANSWER A nurse is providing teaching to an older adult female client who
has stress incontinence and a BMI of 32. Which of the following statements by the client
indicates an understanding of the teaching question mark I am dieting to lose weight. Excess
weight cut creates increased abdominal pressure that can result in stress incontinence.
CORRECT ANSWER A nurse is reviewing the ABG results of a client who has advanced
, COPD. Which of the following results should the nurse expect? Paco2 of 56. A client who
has COPD retains paco2 due to the weakening and the collapse of the alveolar sacs which
decreases the area and lungs for gas exchange and causes the paco2 to increase above the
expected reference range. CORRECT ANSWER A nurse is providing teaching to a client who
is perimenopausal and has a prescription for hormone replacement therapy. For which of the
following adverse effects should the nurse instruct the client to notify the provider? Select all
that apply. Calf pain, numbness in the arms and intense headache. Calf pain is an indication
of DVT and the client should report this finding to the provider immediately. Numbness in the
arms can indicate cerebrovascular accident which is an adverse effect of hormone replacement
therapy and an intense headache can indicate a cerebrovascular accident. CORRECT ANSWER
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription
for erythropoietin. Which of the following statements by the client indicates an understanding of
the teaching? I am taking this medication to increase my energy level. The goal of
erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When
the medication is effective the client should have a decreasing fatigue and an improvement and
activity tolerance. CORRECT ANSWER A nurse is teaching a client who has venous
insufficiency about self-care. Which of the following statements should the nurse identify as an
indication that the client understands teaching? I will wear clean graduated compression
stockings everyday. The client should apply a clean pair of graduated compression stockings
each day and clean soiled stockings with mild detergent and warm water by hand. CORRECT
ANSWER A nurse is preparing to present a program about atherosclerosis at a health fair.
Which of the following recommendations should the nurse plan to include? Select all that apply.
Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet
and increase fluid intake. Smoking cessation is an important lifestyle modification to prevent
Arthur sclerosis and preventing obesity through diet and exercise can help prevent
atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis.
CORRECT ANSWER A nurse is caring for a client who is 12 hours post-operative following a
total hip arthroplasty. Which of the following actions should the nurse take? Place a pillow
between the clients legs. The nurse should place a pillow between the clients legs to prevent hip
dislocation. CORRECT ANSWER A nurse is reviewing the medication history of a client who
is to undergo allergy testing. The nurse should instruct the client to discontinue which of the
