Medical-Surgical Nursing I Test 2
Questions and Answers
A 30-year-old African American had surgery 6 months ago and the incision site is now
raised, indurated, and shiny. This is most likely which type of tissue growth? - ANS-
Keloid
A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which
is most appropriate? - ANS-"Because of the incidence of shingles in your age group,
you should consider taking the vaccination.
After a medicated bath, the patient is assisted from the tub. Which statement about
lotion application is correct? - ANS-Apply lotion immediately after drying the patient
An 84-year-old patient has had a low-grade fever for 2 days. This morning, the patient
complains about burning, tingling hip pain that shoots down the leg. The nurse observes
a small group of vesicles on the leg. These findings are consistent with which disorder?
- ANS-Herpes zoster
An older patient is admitted for treatment of fluid volume excess. For which serious
respiratory complication of fluid volume excess should the nurse assist this patient? -
ANS-Pulmonary edema
A patient admitted in a state of extreme anxiety has vital signs of: T 96.6 F, P 81, BP
130/86, R 32. What will result if this hyperventilation continues? - ANS-Respiratory
alkalosis
A patient began vomiting and continued to do so for several hours. What is the result of
this loss of stomach contents? - ANS-metabolic alkalosis
A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a
thyroidectomy. Which emergency medication should the nurse anticipate being
prescribed for this patient? - ANS-calcium gluconate
A patient has been admitted to the hospital with burns to the upper chest. The nurse
notes singed nasal hairs. The nurse needs to assess this patient frequently for which
condition? - ANS-respiratory complications
A patient has the following risk factors for melanoma. Which risk factor should the nurse
assign as the priority focus of patient teaching? - ANS-The patient uses tanning booth
weekly.
, A patient is admitted to the emergency department with severe fatigue and confusion.
Laboratory studies are done. Which laboratory value will require the most immediate
action by the nurse? - ANS-Serum calcium is 18 mg/dL.
A patient is having a surgical procedure done to promote peripheral tissue perfusion in
an extremity with full-thickness circumferential burns. What term should the nurse use to
document this procedure? - ANS-Escharotomy
A patient is in the intensive care unit with acute renal failure secondary to septic shock
and is receiving IV fluids of 0.9% NaCI at 125 mL/hr. The patient develops crackles in
the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain
from the previous day. What nursing diagnosis is most appropriate for this situation? -
ANS-Excess fluid volume
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial
blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16
mEq/L. How should the nurse interpret these results? - ANS-Metabolic acidosis
A patient with acute abdominal pain has a serum potassium level of 2 mEq/L. What
should the nurse do first? - ANS-Call the physician STAT
A patient with a history of renal failure is admitted to the hospital because of decreasing
urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the
patient to avoid? - ANS-potatoes
A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that
further teaching is necessary if the patient chooses which menu? - ANS-Tomato soup,
grilled cheese sandwich, salad, and chocolate chip cookie
The nurse is preparing to provide a patient with an IV fluid that has a lower osmolarity
than body fluid. Which type of fluid should the nurse document that the patient is going
to receive? - ANS-Hypotonic
The nurse is providing care to a patient who has herpes zoster. What nursing diagnosis
should the nurse identify as a priority for this patient? - ANS-acute pain
The nurse is teaching a group of teenagers about skin care and sun damage. Which
statement by a participant indicates the need for further instruction? - ANS-"The safest
time of day to engage in water sports and avoid sun damage is from 10 AM to noon."
The nurse must keep an accurate intake and output record to assess kidney efficiency.
In order for the kidneys to remove waste, what is the least amount of hourly urine output
the kidneys must produce to remove waste? - ANS-30 mL
Questions and Answers
A 30-year-old African American had surgery 6 months ago and the incision site is now
raised, indurated, and shiny. This is most likely which type of tissue growth? - ANS-
Keloid
A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which
is most appropriate? - ANS-"Because of the incidence of shingles in your age group,
you should consider taking the vaccination.
After a medicated bath, the patient is assisted from the tub. Which statement about
lotion application is correct? - ANS-Apply lotion immediately after drying the patient
An 84-year-old patient has had a low-grade fever for 2 days. This morning, the patient
complains about burning, tingling hip pain that shoots down the leg. The nurse observes
a small group of vesicles on the leg. These findings are consistent with which disorder?
- ANS-Herpes zoster
An older patient is admitted for treatment of fluid volume excess. For which serious
respiratory complication of fluid volume excess should the nurse assist this patient? -
ANS-Pulmonary edema
A patient admitted in a state of extreme anxiety has vital signs of: T 96.6 F, P 81, BP
130/86, R 32. What will result if this hyperventilation continues? - ANS-Respiratory
alkalosis
A patient began vomiting and continued to do so for several hours. What is the result of
this loss of stomach contents? - ANS-metabolic alkalosis
A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a
thyroidectomy. Which emergency medication should the nurse anticipate being
prescribed for this patient? - ANS-calcium gluconate
A patient has been admitted to the hospital with burns to the upper chest. The nurse
notes singed nasal hairs. The nurse needs to assess this patient frequently for which
condition? - ANS-respiratory complications
A patient has the following risk factors for melanoma. Which risk factor should the nurse
assign as the priority focus of patient teaching? - ANS-The patient uses tanning booth
weekly.
, A patient is admitted to the emergency department with severe fatigue and confusion.
Laboratory studies are done. Which laboratory value will require the most immediate
action by the nurse? - ANS-Serum calcium is 18 mg/dL.
A patient is having a surgical procedure done to promote peripheral tissue perfusion in
an extremity with full-thickness circumferential burns. What term should the nurse use to
document this procedure? - ANS-Escharotomy
A patient is in the intensive care unit with acute renal failure secondary to septic shock
and is receiving IV fluids of 0.9% NaCI at 125 mL/hr. The patient develops crackles in
the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain
from the previous day. What nursing diagnosis is most appropriate for this situation? -
ANS-Excess fluid volume
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial
blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16
mEq/L. How should the nurse interpret these results? - ANS-Metabolic acidosis
A patient with acute abdominal pain has a serum potassium level of 2 mEq/L. What
should the nurse do first? - ANS-Call the physician STAT
A patient with a history of renal failure is admitted to the hospital because of decreasing
urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the
patient to avoid? - ANS-potatoes
A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that
further teaching is necessary if the patient chooses which menu? - ANS-Tomato soup,
grilled cheese sandwich, salad, and chocolate chip cookie
The nurse is preparing to provide a patient with an IV fluid that has a lower osmolarity
than body fluid. Which type of fluid should the nurse document that the patient is going
to receive? - ANS-Hypotonic
The nurse is providing care to a patient who has herpes zoster. What nursing diagnosis
should the nurse identify as a priority for this patient? - ANS-acute pain
The nurse is teaching a group of teenagers about skin care and sun damage. Which
statement by a participant indicates the need for further instruction? - ANS-"The safest
time of day to engage in water sports and avoid sun damage is from 10 AM to noon."
The nurse must keep an accurate intake and output record to assess kidney efficiency.
In order for the kidneys to remove waste, what is the least amount of hourly urine output
the kidneys must produce to remove waste? - ANS-30 mL
