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? - Correct Answers-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? - Correct Answers-Was bitten by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely mode of
transmission? - Correct Answers-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? - Correct Answers-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? - Correct
Answers-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? - Correct Answers-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? - Correct Answers-"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? - Correct Answers-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - Correct Answers-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? - Correct Answers-pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first
response? - Correct Answers-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?
- Correct Answers-"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? -
Correct Answers-Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse best respond? -
Correct Answers-"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? -
Correct Answers-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? - Correct Answers-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? - Correct Answers-The client receiving Procrit (epoetin alfa) has a T 99.2F̊, 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? - Correct Answers-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? - Correct Answers-"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? - Correct Answers-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? - Correct Answers-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? - Correct Answers-
Inspect the abdominal wound incision
The client is one (1) day postoperative major abdominal surgery. Which client problem is a
priority? - Correct Answers-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the practical nurse
implement? - Correct Answers-Apply sterile normal saline dressing
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? - Correct Answers-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? - Correct Answers-Was bitten by a tick
The nurse is caring for a client with a protozoa infection. Which is the most likely mode of
transmission? - Correct Answers-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? - Correct Answers-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? - Correct
Answers-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? - Correct Answers-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? - Correct Answers-"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? - Correct Answers-Notify the physician.
Which client is most likely to be experiencing hypovolemic shock? - Correct Answers-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? - Correct Answers-pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first
response? - Correct Answers-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?
- Correct Answers-"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? -
Correct Answers-Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse best respond? -
Correct Answers-"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? -
Correct Answers-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? - Correct Answers-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? - Correct Answers-The client receiving Procrit (epoetin alfa) has a T 99.2F̊, 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? - Correct Answers-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? - Correct Answers-"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? - Correct Answers-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? - Correct Answers-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? - Correct Answers-
Inspect the abdominal wound incision
The client is one (1) day postoperative major abdominal surgery. Which client problem is a
priority? - Correct Answers-Fluid and electrolyte imbalance
The client has an eviscerated abdominal wound. Which intervention should the practical nurse
implement? - Correct Answers-Apply sterile normal saline dressing
