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MED SURG FINAL ACTUAL EXAM| ALL QUESTIONS AND
CORRECT ANSWERS |ALREADY GRADED A+ |PDF
A nurse is caring for a client who is to have his chest tube removed. Which of the following
actions should the nurse take?
A. Cover the insertion site with a hydrocolloid dressing after removal.
B. Provide pain medication immediately after removal.
C. Instruct the client to perform the Valsalva maneuver during removal.
D. Delegate removal of the chest tube to a licensed practical nurse (LPN). - CORRECT
ANSWER C. Instruct the client to perform the Valsalva maneuver during removal.
The nurse should instruct the client to perform the Valsalva maneuver during removal to
maintain the appropriate amount of negative pressure in the chest to prevent air entry into
the pleural space.
A nurse is providing teaching to a client who has a history of tonic-clonic seizures and
is scheduled for a standard EEG. Which of the following instructions should the nurse
include in the teaching? A. Remain NPO 6 to 8 hr prior to the EEG.
B. Take a sedative the night prior to the EEG.
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C. Thoroughly shampoo hair prior to the EEG.
D. Sleep for at least 8 hr the night prior to the test. - CORRECT ANSWER C.
Thoroughly shampoo hair prior to the EEG.
The nurse should instruct the client to thoroughly wash her hair prior to the EEG because
hairsprays, oils, and other hair preparations interfere with recording results of the EEG.
A home health nurse enters a client's home and finds a used insulin syringe, without a cap,
on the table. Which of the following actions should the nurse take?
A. Recap the needle on the syringe.
B. Schedule a nurse to administer future injections for this client.
C. Explain to the client that the syringe should be disposed of in the bathroom trash can.
D. Place the syringe in a puncture-proof disposal container. - CORRECT ANSWER D.
Place the syringe in a puncture-proof disposal container.
The nurse should place the uncapped syringe in a puncture-proof sharps disposal
container or rigid plastic container to prevent a needlestick injury. The nurse should keep
the syringe uncapped to prevent a needlestick injury while placing the cap on the needle.
The nurse should then provide client education on safety and proper disposal of syringes.
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A nurse is providing discharge teaching to a client who has a new diagnosis of systemic
lupus erythematous (SLE). Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will need to take methotrexate even if I'm in remission."
B. "I'm thankful that this type of lupus only affects the skin."
C. "Each day I should apply a sunblock with a sun protection factor of 15."
D. "A mild fever is common with SLE and usually does not require medical intervention." -
CORRECT ANSWER A. "I will need to take methotrexate even if I'm in remission."
The nurse should inform the client that SLE is an autoimmune disorder characterized by
exacerbations and remissions. It affects the skin as well as joints, organs, and any
structure in the body that contains connective tissue. Methotrexate is an
immunosuppressive medication given during remission to help prevent exacerbation. The
medication is also given when exacerbations occur to reduce the severity of
manifestations.
A nurse is caring for a client who has thrombocytopenia and develops epitaxis.
Which of the following actions should the nurse take? A. Have the client gently
blow clots from the nose every 5 min.
B. Instruct the client to sit with his head hyperextended.
C. Apply ice compresses to the back of the client's neck.
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D. Apply lateral pressure to the client's nose for 10 min. - CORRECT ANSWER D.
Apply lateral pressure to the client's nose for 10 min.
The nurse should apply direct, lateral pressure to the nose for 10 min to control epistaxis. If
after 10 min the epistaxis continues, the client might require nasal packing or other
interventions.
A nurse is caring for a client who is receiving TPN. Which of the following actions should the
nurse take?
A. Administer 0.9% sodium chloride until TPN is available from the pharmacy.
B. Check the client's capillary blood glucose level every 4 hr.
C. Obtain the client's weight each week.
D. Change the IV tubing every 3 days. - CORRECT ANSWER B. Check the client's
capillary blood glucose level every 4 hr.
The nurse should check the client's capillary blood glucose level every 4 hr, or according to
facility policy, due to the client's risk for hyperglycemia while receiving TPN. The dextrose
concentration in TPN places the client at risk for this complication.
Page
MED SURG FINAL ACTUAL EXAM| ALL QUESTIONS AND
CORRECT ANSWERS |ALREADY GRADED A+ |PDF
A nurse is caring for a client who is to have his chest tube removed. Which of the following
actions should the nurse take?
A. Cover the insertion site with a hydrocolloid dressing after removal.
B. Provide pain medication immediately after removal.
C. Instruct the client to perform the Valsalva maneuver during removal.
D. Delegate removal of the chest tube to a licensed practical nurse (LPN). - CORRECT
ANSWER C. Instruct the client to perform the Valsalva maneuver during removal.
The nurse should instruct the client to perform the Valsalva maneuver during removal to
maintain the appropriate amount of negative pressure in the chest to prevent air entry into
the pleural space.
A nurse is providing teaching to a client who has a history of tonic-clonic seizures and
is scheduled for a standard EEG. Which of the following instructions should the nurse
include in the teaching? A. Remain NPO 6 to 8 hr prior to the EEG.
B. Take a sedative the night prior to the EEG.
,2|Page
C. Thoroughly shampoo hair prior to the EEG.
D. Sleep for at least 8 hr the night prior to the test. - CORRECT ANSWER C.
Thoroughly shampoo hair prior to the EEG.
The nurse should instruct the client to thoroughly wash her hair prior to the EEG because
hairsprays, oils, and other hair preparations interfere with recording results of the EEG.
A home health nurse enters a client's home and finds a used insulin syringe, without a cap,
on the table. Which of the following actions should the nurse take?
A. Recap the needle on the syringe.
B. Schedule a nurse to administer future injections for this client.
C. Explain to the client that the syringe should be disposed of in the bathroom trash can.
D. Place the syringe in a puncture-proof disposal container. - CORRECT ANSWER D.
Place the syringe in a puncture-proof disposal container.
The nurse should place the uncapped syringe in a puncture-proof sharps disposal
container or rigid plastic container to prevent a needlestick injury. The nurse should keep
the syringe uncapped to prevent a needlestick injury while placing the cap on the needle.
The nurse should then provide client education on safety and proper disposal of syringes.
,3|Page
A nurse is providing discharge teaching to a client who has a new diagnosis of systemic
lupus erythematous (SLE). Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will need to take methotrexate even if I'm in remission."
B. "I'm thankful that this type of lupus only affects the skin."
C. "Each day I should apply a sunblock with a sun protection factor of 15."
D. "A mild fever is common with SLE and usually does not require medical intervention." -
CORRECT ANSWER A. "I will need to take methotrexate even if I'm in remission."
The nurse should inform the client that SLE is an autoimmune disorder characterized by
exacerbations and remissions. It affects the skin as well as joints, organs, and any
structure in the body that contains connective tissue. Methotrexate is an
immunosuppressive medication given during remission to help prevent exacerbation. The
medication is also given when exacerbations occur to reduce the severity of
manifestations.
A nurse is caring for a client who has thrombocytopenia and develops epitaxis.
Which of the following actions should the nurse take? A. Have the client gently
blow clots from the nose every 5 min.
B. Instruct the client to sit with his head hyperextended.
C. Apply ice compresses to the back of the client's neck.
, 4|Page
D. Apply lateral pressure to the client's nose for 10 min. - CORRECT ANSWER D.
Apply lateral pressure to the client's nose for 10 min.
The nurse should apply direct, lateral pressure to the nose for 10 min to control epistaxis. If
after 10 min the epistaxis continues, the client might require nasal packing or other
interventions.
A nurse is caring for a client who is receiving TPN. Which of the following actions should the
nurse take?
A. Administer 0.9% sodium chloride until TPN is available from the pharmacy.
B. Check the client's capillary blood glucose level every 4 hr.
C. Obtain the client's weight each week.
D. Change the IV tubing every 3 days. - CORRECT ANSWER B. Check the client's
capillary blood glucose level every 4 hr.
The nurse should check the client's capillary blood glucose level every 4 hr, or according to
facility policy, due to the client's risk for hyperglycemia while receiving TPN. The dextrose
concentration in TPN places the client at risk for this complication.
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