MED SURG EXAM 2 / EXAM 2 MED SURG QUESTIONS AND VERIFIED SOLUTIONS 2025 GRADED A+ LATEST UPDATE.

MED SURG EXAM 2 / EXAM 2 MED SURG QUESTIONS AND VERIFIED SOLUTIONS 2025 GRADED A+ LATEST UPDATE. 2 / 24 1. The nurse assesses a surgical patientthe morning ofthe first postoperative day and notes redness and warmth around the incision.Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hoursCORRECT AnswerCORRECT B RationaleCORRECTThe incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. 2. A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C).Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.CORRECT AnswerCORRECT D RationaleCORRECT Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms.The nurse should continue to monitor the temperature.Antipyretics are not indicated unlessthe patient is complaining of fever-related symptoms.There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation. 3. Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.CORRECT AnswerCORRECT D RationaleCORRECT Common clinical manifestations of inflammation and infection are fre- quently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be "just not feeling well." 4. When evaluating the response to treatment for a patient with a fluid imbal- ance, the most important assessment to include is a. skin turgor. b. presence of edema. c. hourly urine output. 3 / 24 d. daily weight.CORRECT AnswerCORRECT D 4 / 24 RationaleCORRECTDaily weight isthe most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema.Hourly urine outputs do not take account offluid intake or offluid lossthrough insensible loss, sweating, or loss from the gastrointestinal tract or wounds. 5. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. when the patient feels thirsty. b. in the late evening hours. c. as soon as changes in LOC occur. d. if the oral mucosa feels dry.CORRECT AnswerCORRECT D RationaleCORRECT An alert, elderly patient will be able to self-assess for signs of oral dry- ness such as thick oral secretions or dry-appearing mucosa.The thirst mechanism decreases with age and is not an accurate indicator of volume depletion.Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality.The patient will not be likely to notice and act appropriately when changesin LOC occur. 6. A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension.The nurse will teach the patient to reportsymptoms of adverse effects such as a. generalized weakness. b. facial muscle spasms. c. frequent loose stools. d. personality changes.CORRECT AnswerCORRECT A RationaleCORRECT Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia.Personality changes are not associated with elec- trolyte disturbances, although changesinmentalstatus are commonmanifestations with sodium excess or deficit. 7. The long-term-care nurse is evaluating the effectiveness of protein supple- ments on a patient who has low serum total protein level.Which of these data indicate that the patient's condition has improved? a. Absence of peripheral edema b. Good skin turgor c. Hematocrit 28% d. Blood pressure 110/72 mm HgCORRECT AnswerCORRECT A