MED SURG FINAL EXAM 1

MED SURG FINAL EXAM 1 [Document subtitle] 1. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? Irregular blue mole with white specks on the lower leg 2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?Change gloves between wound care on different parts of the client's body. 3. A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?Purulent drainage 4. A nurse is caring for a client with systemic sclerosis. The client’s facial skin is very taut, limiting the client’s ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth. 5. A student nurse asks the nursing instructor what “apoptosis” means. What response by the instructor is best? Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition. 6. A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? Use of multiple herbs and supplements 7. Which statement about carcinogenesis is accurate? Tumor cells need to develop their own blood supply. 8. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? Report of headache and stiff neck 9. The nurse caring for oncology clients knows that which form of metastasis is the most common? Bloodborne 10. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How should the nurse respond? "It helps prevent stomach ulcers, which are common after burns." 11. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety? Encourage the client and family to be active partners. 12. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? Place the client in an upright position. 13. A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction? Use the Credé maneuver every 3 hours. 14. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client’s plan of care to prevent pressure sores? (Select all that apply.) Place a small pillow between bony surfaces. Use a lift sheet to assist with re-positioning. Keep the client's heels off the bed surfaces. 15. A nurse assesses an older adult’s skin. Which findings require immediate referral? (Select all that apply. Lesion with various colors Asymmetric 6-mm dark lesion on forehead 16. A nurse reads on a hospitalized client’s chart that the client is receiving teletherapy. What action by the nurse is best? Coordinate continuation of the therapy. 17. A nurse cares for a dying client. Which manifestation of dying should the nurse treat first? Pain 18. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? Auscultate lung sounds. 19. A nurse cares for a client who is prescribed vanco m ycin (Vanco cin) 500 mg IV every 6 hours for a methicillin-resistantStaphylococcus aureus (MRSA) infection. Which action should the nurse take? Assess the IV site at least every 2 hours for thrombophlebitis. 20. A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? Assess the right leg for pulses, skin color, and temperature 21. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin -convert ing enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg 22. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace activities, allowing for adequate rest. 23. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? Anxious client who has tachypnea 24. A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the client’s plan of care? (Select all that apply.) Height, Alcohol use, Prealbumin laboratory results 25. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client’s chart that the cancer classificat ion is TISN0M0. What does the nurse conclude about this client’s cancer? There are no distant metastases noted in the report. 26. A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? Lose weight if needed 27. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? Severe osteoporosis 28. After teaching a client about advance directives, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching?