Medical-Surgical Nursing Exam 1
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? - ANS-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? - ANS-Was bitten by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely mode of
transmission? - ANS-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? - ANS-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? -
ANS-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? - ANS-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? - ANS-"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? - ANS-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - ANS-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? - ANS-pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first
response? - ANS-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?
- ANS-"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? -
ANS-Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse best respond? -
ANS-"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?
- ANS-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? - ANS-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? - ANS-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? - ANS-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? - ANS-"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? - ANS-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? - ANS-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? - ANS-Inspect the
abdominal wound incision
, The client is one (1) day postoperative major abdominal surgery. Which client problem is a
priority? - ANS-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the practical nurse
implement? - ANS-Apply sterile normal saline dressing
The client is diagnosed with peritonitis. Which information indicates to the practical nurse the
client's condition is improving? - ANS-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. - ANS-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. - ANS-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? - ANS-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. - ANS-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? - ANS-Ticks
A patient returning from the recovery room following abdominal surgery to drain an abscess has
a nonsuction-type drain placed in the wound bed to allow drainage. Which drain should the
nurse expect to see? - ANS-Penrose drain
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? - ANS-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? - ANS-Was bitten by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely mode of
transmission? - ANS-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? - ANS-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? -
ANS-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? - ANS-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? - ANS-"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? - ANS-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - ANS-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? - ANS-pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first
response? - ANS-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?
- ANS-"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? -
ANS-Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse best respond? -
ANS-"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?
- ANS-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? - ANS-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? - ANS-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? - ANS-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? - ANS-"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? - ANS-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? - ANS-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? - ANS-Inspect the
abdominal wound incision
, The client is one (1) day postoperative major abdominal surgery. Which client problem is a
priority? - ANS-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the practical nurse
implement? - ANS-Apply sterile normal saline dressing
The client is diagnosed with peritonitis. Which information indicates to the practical nurse the
client's condition is improving? - ANS-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. - ANS-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. - ANS-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? - ANS-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. - ANS-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? - ANS-Ticks
A patient returning from the recovery room following abdominal surgery to drain an abscess has
a nonsuction-type drain placed in the wound bed to allow drainage. Which drain should the
nurse expect to see? - ANS-Penrose drain
