MED SURG II FINAL PAPER UPDATED EXAM QUESTIONS
AND ANSWERS RATED A+
✔✔The community health nurse is conducting a research study and is identifying clients
in the community at risk for latex allergy. Which client population is at most risk for
developing this type of allergy? - ✔✔Hairdressers
Rationale:
Individuals most at risk for developing a latex allergy include health care workers,
individuals who work in the rubber industry, or those who have had multiple surgeries,
have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto
mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, or water chestnuts.
✔✔A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal
movement?" Which response should the nurse make? - ✔✔Between 16 and 20 weeks
Rationale:
Fetal movement, called quickening, is not perceived until the second trimester. Between
16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements
that gradually increase in intensity.
✔✔A nurse is preparing to measure the apical pulse on an assigned client. The nurse
places the diaphragm of the stethoscope over which cardiac site? - ✔✔Mitral area
Rationale:
The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to
the apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be
counted for a full minute.
✔✔A nursing student is preparing to instruct a pregnant client in performing Kegel
exercises. The nursing instructor asks the student the purpose of Kegel exercises.
Which response made by the student indicates an understanding of the purpose? -
✔✔"The exercises will help strengthen the pelvic floor in preparation for delivery."
Rationale:
Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt exercises will help
reduce backaches. Leg elevation will assist in preventing ankle edema. Instructing a
client to drink 8 oz of fluids six times a day will help prevent urinary tract infections.
✔✔According to the American Cancer Society, fecal occult blood testing should be
done annually after which age? - ✔✔50 years old
Rationale:
Fecal occult blood testing for colorectal cancer should be done annually for both men
and women after the age of 50 years. The other options are incorrect.
,✔✔The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains
that to give the eardrops correctly, the mother needs to take which action? - ✔✔Pull
down and back on the earlobe and direct the solution toward the wall of the canal.
Rationale:
The infant should be turned onto the side, with the affected ear uppermost. With the
wrist of the nondominant hand resting on the infant's head, the mother pulls down and
back on the earlobe and aims the solution at the wall of the canal, rather than directly
onto the eardrum. In the adult, the auricle is pulled up and back to straighten the
auditory canal.
✔✔The nurse is caring for a client with a respiratory disorder who is attempting to stop
smoking. The health care provider has recommended nicotine (Nicorette) gum. When
reviewing this treatment with the client, the nurse should provide which instruction to the
client? - ✔✔Hold the gum between the cheek and teeth periodically.
Rationale:
Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum
between the cheek and teeth; food and drink should be avoided 15 minutes before or
during use.
✔✔The nurse is providing instructions to the mother of a child with human
immunodeficiency virus (HIV) infection regarding immunizations. Which statement by
the mother indicates an understanding of the immunization schedule? - ✔✔"Family
members in the household need to receive the influenza vaccine."
Rationale:
A child with HIV infection will receive the same immunizations as other children except
for live vaccines. All household members receive the influenza vaccine. Option 4 is not
necessary and is inaccurate.
✔✔Rationale:
A child with HIV infection will receive the same immunizations as other children except
for live vaccines. All household members receive the influenza vaccine. Option 4 is not
necessary and is inaccurate. - ✔✔"Family members in the household need to receive
the influenza vaccine."
Rationale:
A child with HIV infection will receive the same immunizations as other children except
for live vaccines. All household members receive the influenza vaccine. Option 4 is not
necessary and is inaccurate.
✔✔A nurse is caring for a client in labor. The nurse determines that the client is
beginning the second stage of labor when which is documented in the client's record? -
✔✔The cervix is completely dilated.
Rationale:
The second stage of labor begins when the cervix is completely dilated and ends with
birth of the infant. The other options are not specific assessment findings of the second
stage of labor.
, ✔✔A nurse is reviewing the record of a client who has just been told that her pregnancy
test is positive. The health care provider has documented the presence of Goodell's
sign. What should the nurse determine that this sign indicates? - ✔✔A softening of the
cervix
Rationale:
In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic
vasoconstriction, causing Goodell's sign. Cervical softening is noted by the examiner
during pelvic examination. Goodell's sign does not indicate the presence of fetal
movement. The presence of hCG is noted in the maternal urine in a urine pregnancy
test. A soft blowing sound that corresponds to the maternal pulse may be auscultated
over the uterus and is caused by blood circulation through the placenta.
✔✔A 16-year-old is admitted to the hospital for acute appendicitis and an
appendectomy is performed. Which nursing intervention is most appropriate to facilitate
normal growth and development postoperatively? - ✔✔Allow the child to interact with
others in his or her same age group.
Rationale:
Adolescents often are not sure whether they want their parents with them when they are
hospitalized. Because of the importance of their peer group, separation from friends is a
source of anxiety. Ideally, the members of the peer group will support their ill friend.
Options 1, 2, and 3 isolate the child from the peer group.
✔✔The nurse has instructed a pregnant client in measures to prevent varicose veins
during pregnancy. Which statement by the client indicates a need for further
instructions? - ✔✔"I should wear knee-high hose, but I should not leave them on longer
than 8 hours."
Rationale:
Varicose veins often develop in the lower extremities during pregnancy. Any constrictive
clothing, such as knee-high hose, impedes venous return from the lower legs and
places the client at risk for developing varicosities. The client should be encouraged to
wear support hose or panty hose. Flat nonslip shoes with proper support are important
to assist the pregnant woman to maintain proper posture and balance and to minimize
falls.
✔✔The nurse is providing postpartum instructions to a client who will be breast-feeding
her newborn. The nurse determines that the client has understood the instructions if she
makes which statements? Select all that apply. - ✔✔1."I should wear a bra that provides
support."
2."Drinking alcohol can affect my milk supply."
3."The use of caffeine can decrease my milk supply."
4."I plan on having bottled water available in the refrigerator so I can get additional
fluids easily."
Rationale:
AND ANSWERS RATED A+
✔✔The community health nurse is conducting a research study and is identifying clients
in the community at risk for latex allergy. Which client population is at most risk for
developing this type of allergy? - ✔✔Hairdressers
Rationale:
Individuals most at risk for developing a latex allergy include health care workers,
individuals who work in the rubber industry, or those who have had multiple surgeries,
have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto
mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, or water chestnuts.
✔✔A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal
movement?" Which response should the nurse make? - ✔✔Between 16 and 20 weeks
Rationale:
Fetal movement, called quickening, is not perceived until the second trimester. Between
16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements
that gradually increase in intensity.
✔✔A nurse is preparing to measure the apical pulse on an assigned client. The nurse
places the diaphragm of the stethoscope over which cardiac site? - ✔✔Mitral area
Rationale:
The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to
the apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be
counted for a full minute.
✔✔A nursing student is preparing to instruct a pregnant client in performing Kegel
exercises. The nursing instructor asks the student the purpose of Kegel exercises.
Which response made by the student indicates an understanding of the purpose? -
✔✔"The exercises will help strengthen the pelvic floor in preparation for delivery."
Rationale:
Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt exercises will help
reduce backaches. Leg elevation will assist in preventing ankle edema. Instructing a
client to drink 8 oz of fluids six times a day will help prevent urinary tract infections.
✔✔According to the American Cancer Society, fecal occult blood testing should be
done annually after which age? - ✔✔50 years old
Rationale:
Fecal occult blood testing for colorectal cancer should be done annually for both men
and women after the age of 50 years. The other options are incorrect.
,✔✔The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains
that to give the eardrops correctly, the mother needs to take which action? - ✔✔Pull
down and back on the earlobe and direct the solution toward the wall of the canal.
Rationale:
The infant should be turned onto the side, with the affected ear uppermost. With the
wrist of the nondominant hand resting on the infant's head, the mother pulls down and
back on the earlobe and aims the solution at the wall of the canal, rather than directly
onto the eardrum. In the adult, the auricle is pulled up and back to straighten the
auditory canal.
✔✔The nurse is caring for a client with a respiratory disorder who is attempting to stop
smoking. The health care provider has recommended nicotine (Nicorette) gum. When
reviewing this treatment with the client, the nurse should provide which instruction to the
client? - ✔✔Hold the gum between the cheek and teeth periodically.
Rationale:
Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum
between the cheek and teeth; food and drink should be avoided 15 minutes before or
during use.
✔✔The nurse is providing instructions to the mother of a child with human
immunodeficiency virus (HIV) infection regarding immunizations. Which statement by
the mother indicates an understanding of the immunization schedule? - ✔✔"Family
members in the household need to receive the influenza vaccine."
Rationale:
A child with HIV infection will receive the same immunizations as other children except
for live vaccines. All household members receive the influenza vaccine. Option 4 is not
necessary and is inaccurate.
✔✔Rationale:
A child with HIV infection will receive the same immunizations as other children except
for live vaccines. All household members receive the influenza vaccine. Option 4 is not
necessary and is inaccurate. - ✔✔"Family members in the household need to receive
the influenza vaccine."
Rationale:
A child with HIV infection will receive the same immunizations as other children except
for live vaccines. All household members receive the influenza vaccine. Option 4 is not
necessary and is inaccurate.
✔✔A nurse is caring for a client in labor. The nurse determines that the client is
beginning the second stage of labor when which is documented in the client's record? -
✔✔The cervix is completely dilated.
Rationale:
The second stage of labor begins when the cervix is completely dilated and ends with
birth of the infant. The other options are not specific assessment findings of the second
stage of labor.
, ✔✔A nurse is reviewing the record of a client who has just been told that her pregnancy
test is positive. The health care provider has documented the presence of Goodell's
sign. What should the nurse determine that this sign indicates? - ✔✔A softening of the
cervix
Rationale:
In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic
vasoconstriction, causing Goodell's sign. Cervical softening is noted by the examiner
during pelvic examination. Goodell's sign does not indicate the presence of fetal
movement. The presence of hCG is noted in the maternal urine in a urine pregnancy
test. A soft blowing sound that corresponds to the maternal pulse may be auscultated
over the uterus and is caused by blood circulation through the placenta.
✔✔A 16-year-old is admitted to the hospital for acute appendicitis and an
appendectomy is performed. Which nursing intervention is most appropriate to facilitate
normal growth and development postoperatively? - ✔✔Allow the child to interact with
others in his or her same age group.
Rationale:
Adolescents often are not sure whether they want their parents with them when they are
hospitalized. Because of the importance of their peer group, separation from friends is a
source of anxiety. Ideally, the members of the peer group will support their ill friend.
Options 1, 2, and 3 isolate the child from the peer group.
✔✔The nurse has instructed a pregnant client in measures to prevent varicose veins
during pregnancy. Which statement by the client indicates a need for further
instructions? - ✔✔"I should wear knee-high hose, but I should not leave them on longer
than 8 hours."
Rationale:
Varicose veins often develop in the lower extremities during pregnancy. Any constrictive
clothing, such as knee-high hose, impedes venous return from the lower legs and
places the client at risk for developing varicosities. The client should be encouraged to
wear support hose or panty hose. Flat nonslip shoes with proper support are important
to assist the pregnant woman to maintain proper posture and balance and to minimize
falls.
✔✔The nurse is providing postpartum instructions to a client who will be breast-feeding
her newborn. The nurse determines that the client has understood the instructions if she
makes which statements? Select all that apply. - ✔✔1."I should wear a bra that provides
support."
2."Drinking alcohol can affect my milk supply."
3."The use of caffeine can decrease my milk supply."
4."I plan on having bottled water available in the refrigerator so I can get additional
fluids easily."
Rationale:
