MEDICAL-SURGICAL NURSING EXAM 1 (100%
VERIFIED COREECT 2025)
A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the
perimeter, and bone is exposed. Which is the nurse's best action?
a. Document as a stage I pressure ulcer and apply a transparent dressing.
b. Document as a stage II pressure ulcer and start wet to dry gauze treatments.
c. Document as a stage III pressure ulcer and start antibiotic therapy.
d. Document as a stage IV pressure ulcer and prepare the client for possible surgical
intervention. - ANS: D
The U.S. Department of Health and Human Services pressure ulcer criteria categorize a stage IV
ulcer as one in which skin loss is full thickness, with extensive destruction, tissue necrosis,
and/or damage to muscle, bone, or supporting structures. When the bone of the trochanter
area is visible, there has been tissue loss that includes muscle loss. A potential intervention is
débridement of the necrotic tissue and a possible graft.
A client has numerous skin lesions. Which one will the nurse evaluate first?
a. Beige freckles on the backs of both hands
b. Irregular blue mole with white specks on the lower leg
c. Large cluster of pustules in the right axilla
d. Raised, tubular, white, snake-like areas on the inner aspects of the wrists - ANS: B
This mole fits two of the criteria for being cancerous or precancerous: variation of color within
one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with
the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an
infection, but it is more important to take care of the potentially cancerous lesion first.
A client presents with a pressure ulcer on the ankle. Which is the first intervention that the
nurse will implement?
,a. Blood tests for albumin, prealbumin, and total protein
b. Wound culture
c. Elevation of the foot
d. Assessment of pulses, skin color, and temperature - ANS: D
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area.
This begins with assessment of pulses and color and temperature of the skin. The nurse can also
assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers.
Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound
cultures are done after determining that there is drainage, odor, and other risks for infection.
Tests to determine nutritional status and risk assessment would be completed after the initial
assessment is done.
A client presents with pruritus of the lower extremities. Which nursing assessment is most
appropriate?
a. Blood draw to determine electrolyte imbalance
b. Weight to determine fluid retention
c. Microscopic evaluation to determine presence of fungus
d. Surface evaluation for presence of dry skin - ANS: D
The client with pruritus often has dry skin as a stimulus. The nurse should evaluate this first. If
present, the client should be instructed in how to treat this.
A nurse determines a client as having a Braden scale score of 9. Which is the nurse's best
intervention related to this assessment?
a. Encouraging the client to lay as still as possible in bed
b. Reassessing the client weekly
c. Increasing the client's fluid intake daily
d. Consulting with the health care provider about increased interventions - ANS: D
, A score of 11 or less on the Braden scale indicates severe risk for pressure ulcer development in
terms of decreased sensory perception, exposure to moisture, decreased independent activity,
decreased mobility, poor nutrition, and chronic exposure to friction and shear.
A nurse inspects the site where a client's basal cell carcinoma has been treated with cryosurgery
and finds that the area is red, with a blister in the center. Which action will the nurse take?
a. Culturing the site
b. Notifying the surgeon
c. Applying hydrocortisone cream
d. Continuing to assess - ANS: D
This skin reaction is the expected and normal response to cryosurgery. No other intervention is
necessary other than continued assessment.
A nurse notes that the client who has been using psoralens-ultraviolet A (PUVA) therapy for
psoriasis for 1 month has darkening of the skin. Which is the nurse's best action?
a. Documenting the finding
b. Instructing the client to reduce the dose
c. Instructing the client to drink more water
d. Instruct the client to apply cortisone cream - ANS: A
Darkening of the skin is an expected and normal response to the PUVA therapy. No other
intervention is necessary.
A nurse observes a small opening that is draining purulent material on the skin over the
trochanter area of a bedridden client. Which is the nurse's next best action?
a. Probing for a larger pocket of necrotic tissue
b. Applying a transparent film dressing
c. Measuring the reddened area on the skin surface
d. Applying alginate dressing daily - ANS: A
VERIFIED COREECT 2025)
A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the
perimeter, and bone is exposed. Which is the nurse's best action?
a. Document as a stage I pressure ulcer and apply a transparent dressing.
b. Document as a stage II pressure ulcer and start wet to dry gauze treatments.
c. Document as a stage III pressure ulcer and start antibiotic therapy.
d. Document as a stage IV pressure ulcer and prepare the client for possible surgical
intervention. - ANS: D
The U.S. Department of Health and Human Services pressure ulcer criteria categorize a stage IV
ulcer as one in which skin loss is full thickness, with extensive destruction, tissue necrosis,
and/or damage to muscle, bone, or supporting structures. When the bone of the trochanter
area is visible, there has been tissue loss that includes muscle loss. A potential intervention is
débridement of the necrotic tissue and a possible graft.
A client has numerous skin lesions. Which one will the nurse evaluate first?
a. Beige freckles on the backs of both hands
b. Irregular blue mole with white specks on the lower leg
c. Large cluster of pustules in the right axilla
d. Raised, tubular, white, snake-like areas on the inner aspects of the wrists - ANS: B
This mole fits two of the criteria for being cancerous or precancerous: variation of color within
one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with
the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an
infection, but it is more important to take care of the potentially cancerous lesion first.
A client presents with a pressure ulcer on the ankle. Which is the first intervention that the
nurse will implement?
,a. Blood tests for albumin, prealbumin, and total protein
b. Wound culture
c. Elevation of the foot
d. Assessment of pulses, skin color, and temperature - ANS: D
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area.
This begins with assessment of pulses and color and temperature of the skin. The nurse can also
assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers.
Elevation of the foot would impair the ability of arterial blood to flow to the area. Wound
cultures are done after determining that there is drainage, odor, and other risks for infection.
Tests to determine nutritional status and risk assessment would be completed after the initial
assessment is done.
A client presents with pruritus of the lower extremities. Which nursing assessment is most
appropriate?
a. Blood draw to determine electrolyte imbalance
b. Weight to determine fluid retention
c. Microscopic evaluation to determine presence of fungus
d. Surface evaluation for presence of dry skin - ANS: D
The client with pruritus often has dry skin as a stimulus. The nurse should evaluate this first. If
present, the client should be instructed in how to treat this.
A nurse determines a client as having a Braden scale score of 9. Which is the nurse's best
intervention related to this assessment?
a. Encouraging the client to lay as still as possible in bed
b. Reassessing the client weekly
c. Increasing the client's fluid intake daily
d. Consulting with the health care provider about increased interventions - ANS: D
, A score of 11 or less on the Braden scale indicates severe risk for pressure ulcer development in
terms of decreased sensory perception, exposure to moisture, decreased independent activity,
decreased mobility, poor nutrition, and chronic exposure to friction and shear.
A nurse inspects the site where a client's basal cell carcinoma has been treated with cryosurgery
and finds that the area is red, with a blister in the center. Which action will the nurse take?
a. Culturing the site
b. Notifying the surgeon
c. Applying hydrocortisone cream
d. Continuing to assess - ANS: D
This skin reaction is the expected and normal response to cryosurgery. No other intervention is
necessary other than continued assessment.
A nurse notes that the client who has been using psoralens-ultraviolet A (PUVA) therapy for
psoriasis for 1 month has darkening of the skin. Which is the nurse's best action?
a. Documenting the finding
b. Instructing the client to reduce the dose
c. Instructing the client to drink more water
d. Instruct the client to apply cortisone cream - ANS: A
Darkening of the skin is an expected and normal response to the PUVA therapy. No other
intervention is necessary.
A nurse observes a small opening that is draining purulent material on the skin over the
trochanter area of a bedridden client. Which is the nurse's next best action?
a. Probing for a larger pocket of necrotic tissue
b. Applying a transparent film dressing
c. Measuring the reddened area on the skin surface
d. Applying alginate dressing daily - ANS: A
