The home health nurse is caring for a patient with congestive heart failure (CHF). Which
assessment finding should the nurse report immediately to the physician?
A. Moderate shortness of breath after walking down the hall.
B. A 3 pound weight gain over the course of a week.
C. Heart rate of 104 beats/min after ambulating to the bathroom.
D. Increase urinary output to 50 mL in the last hour. - correct answer Answer:
A. Shortness of breath after walking down the hall.
The nurse is caring for a patient with C. difficile infection. Which action is most important for
the nurse to take?
A. Only use alcohol-based hand cleanser for hand hygiene.
B. Always wear an impervious mask.
C. Don proper eye protection before providing care.
D. Put the patient on contact plus isolation. - correct answer Answer:
D. Put the patient on contact plus isolation
The nurse is caring for a patient with general sepsis. Which finding should first alert the nurse to
a potential complication that warrants immediate attention?
A. Increased lethargy
B. Sudden coughing
C. Elevated blood pressure
D. Cloudy urine - correct answer Answer:
A. Increased lethargy
,PN Medical-Surgical Nursing Final Exam deWit 3rd edition
The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates
the nurse's teaching has been successful?
A. "I will need to stay in bed when the monitor is reading my heart waves."
B. "This test will help determine if I have a blockage in my arteries."
C. "If there is a problem with my heart valves, it will show up with telemetry."
D. "The nurses will be able to monitor my heart rate and rhythm." - correct answer Answer:
D. The nurses will be able to monitor my heart rate and rhythm.
The nurse is working in a trauma unit and is accidentally stuck with an IV needle following
venipuncture of the patient. What is the nurses first action?
A. Immediately begin taking the two- to three-drug regimen.
B. Report the stick to the charge nurse immediately so follow-up can be initiated.
C. Wash the punctured area with soap and water.
D. Complete an incident report so immediate testing of the patient and nurse can begin. -
correct answer Answer:
C. Wash the punctured area with soap and water.
The nurse is caring for a post-myocardial infarction (MI) patient who has been started on daily
simvastatin (Zocor) and a low-fat diet. Which statement best indicates the nurse's teaching has
been successful?
A. "I will need to have blood work every month while taking Zocor."
B. "I should take Zocor with grapefruit juice to help absorption."
C. " I should call my doctor if I experience unexplained muscle pain."
D. "I should take Zocor an hour before my biggest meal of the day." - correct answer Answer:
C. "I should call my doctor if I experience unexplained muscle pain."
, PN Medical-Surgical Nursing Final Exam deWit 3rd edition
Which area is the major focus of Healthy People 2020 and the primary mechanism through
which to improve the health of Americans in the second decade of the century?
A. Research funding
B. Health information distribution
C. Healthy lifestyle encouragement
D. Health improvement program designs - correct answer Answer:
C. Healthy lifestyle encouragement
A 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and
agitated. The patient's temperature is 100 F, and his pulse, blood pressure, and respirations are
elevated since the last assessment 6 hours ago. What action should the nurse take first?
A. Auscultate the patient's lungs
B. Assess the patient's oxygen saturation
C. Administer the mild sedative as ordered
D. Administer an ordered analgesic for discomfort - correct answer Answer:
B. Assess the patient's oxygen saturation
When caring for a 10-hour post-abdominal surgery patient, which finding should the nurse
report to the charge nurse?
A. 20mL of clear-green emesis
B. Pain level of 5/10
C. No urine output since surgery
D. A weak cough ability - correct answer Answer:
C. No urine output since surgery