Medical-Surgical Nursing Exam 1 with
Complete Solutions
The nurse is caring for a client who has as a son with a streptococcus throat infection.
Which nurse recommendation would be best to advise the client to do in order to
prevent acquiring the infection? - ANSWER-Frequently wash her hands and surfaces of
the home.
The nurse is caring for a client infected with Rocky Mountain spotted fever. The nurse
should ask if the client has experienced which of the following? - ANSWER-Was bitten
by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely mode
of transmission? - ANSWER-Ingestion of contaminated food or water
The nurse is caring for a client who is recovering from an allergic reaction. Which
leukocyte level would the nurse expect to be the most elevated? - ANSWER-
Eosinophils
The nurse is caring for a client who has an infected wound on the great toe that is red
with a purulent exudate. The nurse expects that this client has which type of infection? -
ANSWER-Localized
The client experienced a fall. Nursing assessment reveals that the client is experiencing
tachycardia, hypotension, confusion, tachypnea, and flat jugular veins. What should be
the nurse's first response? - ANSWER-Administer oxygen.
The family wants to know why the nurse is putting a urinary catheter in a client
experiencing shock. What is the nurse's best response? - ANSWER-"It will help monitor
how much urine the kidneys are able to produce."
A client experiencing shock has had a urinary output of 250 mL in the last 10 hours.
What is the nurse's most appropriate response? - ANSWER-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - ANSWER-A client
who had surgery 24 hours ago and who also has a nasogastric tube
The physician has ordered arterial blood gases for a client experiencing shock. The
nurse knows that which value indicates shock? - ANSWER-pH 7.32
,A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best
first response? - ANSWER-Assess for pain
The client is complaining of excruciating pain in a foot that has been amputated. The
family tells the nurse that the client is just addicted to pain medications. What is the
nurse's best response? - ANSWER-"He is experiencing phantom limb pain."
A client has had abdominal surgery and has orders to be ambulated three times a day.
Oral pain medication has been ordered for the client. What should the nurse do to
facilitate ambulation? - ANSWER-Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse best respond?
- ANSWER-"Do you drink alcohol?"
A client with chronic pain has been admitted with a fever. The nursing assessment
reveals that the client has a decreased level of consciousness. What should the nurse
ask the family about? - ANSWER-What medications the client has taken
The practical nurse is reviewing the social history from a client diagnosed with small cell
carcinoma of the lung. Which information is significant for this disease? - ANSWER-The
client has smoked two (2) packs of cigarettes a day for 20 years
The practical nurse and an unlicensed assistive personnel (UAP) are caring for a group
of clients on a medical unit. Which information provided by the UAP warrants immediate
intervention by the practical nurse? - ANSWER-The client receiving Procrit (epoetin
alfa) has a T 99.2˚F, P 68, R 24, and BP of 198/102
The client diagnosed with lung cancer has been told the cancer has metastasized to the
brain. Which intervention should the practical nurse expect to implement? - ANSWER-
Discuss implementing an advance directive
The client diagnosed with lung cancer is being discharged. Which statement made by
the client indicates a reiteration of information is required? - ANSWER-"It doesn't matter
if I smoke now. I already have cancer."
The practical nurse is interviewing clients at the clinic. Which information provided by a
client warrants further investigation? - ANSWER-The client has been coughing up blood
in the mornings
The male client had abdominal surgery and the practical nurse suspects the client has
peritonitis. Which information support the diagnosis of peritonitis? - ANSWER-Hard,
rigid abdomen and white blood cell count 22,000/mm3
, The client who had abdominal surgery tells the practical nurse, "I felt something give
way in my stomach." Which intervention should the practical nurse implement first? -
ANSWER-Inspect the abdominal wound incision
The client is one (1) day postoperative major abdominal surgery. Which client problem
is a priority? - ANSWER-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the practical
nurse implement? - ANSWER-Apply sterile normal saline dressing
The client is diagnosed with peritonitis. Which information indicates to the practical
nurse the client's condition is improving? - ANSWER-The client has a decrease in
temperature and a soft abdomen
A patient is being released from the hospital with a prescription for tetracycline. What
should the nurse include in patient teaching?
Select all that apply. - ANSWER-Advise limiting exposure to the sun.
Inform patient of the possibility of gastrointestinal upset.
Suggest eating crackers and some juice when taking this medicine.
The nurse wants to determine if a patient not fully awake from anesthesia for a surgical
procedure is experiencing pain. What findings should the nurse use to make this
determination?
Select all that apply. - ANSWER-Moaning
Restlessness
Pulling at a body area
Elevated blood pressure
A patient is diagnosed with an infection that has spread to the blood stream. Which term
should the nurse use to document this patient's health problem? - ANSWER-Sepsis
The nurse learns that a patient is being admitted with an infectious disease that is
transmited through the air. For which health problems should the nurse prepare to
provide care?
Select all that apply. - ANSWER-Measles
Tuberculosis
Chickenpox
A patient is diagnosed with Rocky Mountain spotted fever. What should the nurse
explain as the method by which this disease was transmitted to the patient? -
ANSWER-Ticks
Complete Solutions
The nurse is caring for a client who has as a son with a streptococcus throat infection.
Which nurse recommendation would be best to advise the client to do in order to
prevent acquiring the infection? - ANSWER-Frequently wash her hands and surfaces of
the home.
The nurse is caring for a client infected with Rocky Mountain spotted fever. The nurse
should ask if the client has experienced which of the following? - ANSWER-Was bitten
by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely mode
of transmission? - ANSWER-Ingestion of contaminated food or water
The nurse is caring for a client who is recovering from an allergic reaction. Which
leukocyte level would the nurse expect to be the most elevated? - ANSWER-
Eosinophils
The nurse is caring for a client who has an infected wound on the great toe that is red
with a purulent exudate. The nurse expects that this client has which type of infection? -
ANSWER-Localized
The client experienced a fall. Nursing assessment reveals that the client is experiencing
tachycardia, hypotension, confusion, tachypnea, and flat jugular veins. What should be
the nurse's first response? - ANSWER-Administer oxygen.
The family wants to know why the nurse is putting a urinary catheter in a client
experiencing shock. What is the nurse's best response? - ANSWER-"It will help monitor
how much urine the kidneys are able to produce."
A client experiencing shock has had a urinary output of 250 mL in the last 10 hours.
What is the nurse's most appropriate response? - ANSWER-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - ANSWER-A client
who had surgery 24 hours ago and who also has a nasogastric tube
The physician has ordered arterial blood gases for a client experiencing shock. The
nurse knows that which value indicates shock? - ANSWER-pH 7.32
,A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best
first response? - ANSWER-Assess for pain
The client is complaining of excruciating pain in a foot that has been amputated. The
family tells the nurse that the client is just addicted to pain medications. What is the
nurse's best response? - ANSWER-"He is experiencing phantom limb pain."
A client has had abdominal surgery and has orders to be ambulated three times a day.
Oral pain medication has been ordered for the client. What should the nurse do to
facilitate ambulation? - ANSWER-Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse best respond?
- ANSWER-"Do you drink alcohol?"
A client with chronic pain has been admitted with a fever. The nursing assessment
reveals that the client has a decreased level of consciousness. What should the nurse
ask the family about? - ANSWER-What medications the client has taken
The practical nurse is reviewing the social history from a client diagnosed with small cell
carcinoma of the lung. Which information is significant for this disease? - ANSWER-The
client has smoked two (2) packs of cigarettes a day for 20 years
The practical nurse and an unlicensed assistive personnel (UAP) are caring for a group
of clients on a medical unit. Which information provided by the UAP warrants immediate
intervention by the practical nurse? - ANSWER-The client receiving Procrit (epoetin
alfa) has a T 99.2˚F, P 68, R 24, and BP of 198/102
The client diagnosed with lung cancer has been told the cancer has metastasized to the
brain. Which intervention should the practical nurse expect to implement? - ANSWER-
Discuss implementing an advance directive
The client diagnosed with lung cancer is being discharged. Which statement made by
the client indicates a reiteration of information is required? - ANSWER-"It doesn't matter
if I smoke now. I already have cancer."
The practical nurse is interviewing clients at the clinic. Which information provided by a
client warrants further investigation? - ANSWER-The client has been coughing up blood
in the mornings
The male client had abdominal surgery and the practical nurse suspects the client has
peritonitis. Which information support the diagnosis of peritonitis? - ANSWER-Hard,
rigid abdomen and white blood cell count 22,000/mm3
, The client who had abdominal surgery tells the practical nurse, "I felt something give
way in my stomach." Which intervention should the practical nurse implement first? -
ANSWER-Inspect the abdominal wound incision
The client is one (1) day postoperative major abdominal surgery. Which client problem
is a priority? - ANSWER-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the practical
nurse implement? - ANSWER-Apply sterile normal saline dressing
The client is diagnosed with peritonitis. Which information indicates to the practical
nurse the client's condition is improving? - ANSWER-The client has a decrease in
temperature and a soft abdomen
A patient is being released from the hospital with a prescription for tetracycline. What
should the nurse include in patient teaching?
Select all that apply. - ANSWER-Advise limiting exposure to the sun.
Inform patient of the possibility of gastrointestinal upset.
Suggest eating crackers and some juice when taking this medicine.
The nurse wants to determine if a patient not fully awake from anesthesia for a surgical
procedure is experiencing pain. What findings should the nurse use to make this
determination?
Select all that apply. - ANSWER-Moaning
Restlessness
Pulling at a body area
Elevated blood pressure
A patient is diagnosed with an infection that has spread to the blood stream. Which term
should the nurse use to document this patient's health problem? - ANSWER-Sepsis
The nurse learns that a patient is being admitted with an infectious disease that is
transmited through the air. For which health problems should the nurse prepare to
provide care?
Select all that apply. - ANSWER-Measles
Tuberculosis
Chickenpox
A patient is diagnosed with Rocky Mountain spotted fever. What should the nurse
explain as the method by which this disease was transmitted to the patient? -
ANSWER-Ticks
