MEDSURG EXAM 1 QUESTIONS WITH
CORRECT ANSWERS GRADED A+
A client is receiving a continuous bladder irrigation at 1000 ml/hour after a
prostatectomy. The nurse determines the client's urine output for the past
hour is 200 ml. What action should the nurse implement first?
A) Notify the healthcare provider.
B) Stop the irrigation flow.
C) Document the finding and continue to observe.
D) Irrigate the catheter with a large piston syringe.
The urinary output should be at least the volume of irrigation input plus the client's
actual urine. A significant decrease in output indicates obstruction in the drainage
system, and the irrigation flow should be stopped (B) to prevent severe bladder
distention. The next action is to check the external system for kinks or obstruction. If
no output occurs, the
catheter is irrigated with 30 to 50 ml of normal saline using a large iston syringe (D).
If the obstruction is not resolved, then the healthcare provider (A) should be
implemented.
What is the primary nursing diagnosis for a client with asymptomatic primary
syphilis?
A) Acute pain.
B) Risk for injury.
C) Sexual dysfunction.
D) Deficient knowledge.
An asymptomatic client with primary syphilis is most likely unaware of this disease,
so to prevent transmission to others and recurrence in the client, the priority nursing
diagnosis is deficient knowledge (D). Asymptomatic primary syphilis is not painful, so
(A) is not applicable at this time. Although the client is at risk for injury (B) and sexual
dysfunction (C) related to complications, teaching the client about transmission and
, treatment is instrumental in preventing the progression to systemic secondary or
tertiary syphilis.
What assessment findings should the nurse identify before referring a client
for furtherevaluation to rule out skin cancer? (Select all that apply.)
A) White patches.
B) Cherry angiomas.
C) Border irregularity.
D) Lesion with asymmetry.
E) Lesion with color variations.
F) Lesion of 3 to 5 mm diameter.
Correct selections are (C, D, and E). ABCDE is the acronym used by the American
Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin
cancer: A for asymmetry of the lesion (D); B for irregular border (C); C for color,
usually dark (E); D
for diameter equal to or greater than 6 mm; and E for elevation. A lesion with any of
the characteristics of ABCDE should be evaluated by a healthcare provider. (A) lack
the color variable. (B) are raised, dome-shaped, benign clusters of blood vessels that
do not require treatment. Lesions of 3 to 5 mm diameter are small and may be
monitored instead of treated (F).
A Korean-American client, who speaks very little English, is being discharged
following surgery. Which nurse should the nurse manager assign to provide
the discharge instructions for the client?
A) A graduate registered nurse (RN) with three weeks of experience.
B) The registered nurse (RN) case manager for the unit with 1 year's
experience.
C) A floating registered nurse (RN) with five years of nursing experience.
D) A Korean-American practical nurse (PN) with six years of nursing
experience.
CORRECT ANSWERS GRADED A+
A client is receiving a continuous bladder irrigation at 1000 ml/hour after a
prostatectomy. The nurse determines the client's urine output for the past
hour is 200 ml. What action should the nurse implement first?
A) Notify the healthcare provider.
B) Stop the irrigation flow.
C) Document the finding and continue to observe.
D) Irrigate the catheter with a large piston syringe.
The urinary output should be at least the volume of irrigation input plus the client's
actual urine. A significant decrease in output indicates obstruction in the drainage
system, and the irrigation flow should be stopped (B) to prevent severe bladder
distention. The next action is to check the external system for kinks or obstruction. If
no output occurs, the
catheter is irrigated with 30 to 50 ml of normal saline using a large iston syringe (D).
If the obstruction is not resolved, then the healthcare provider (A) should be
implemented.
What is the primary nursing diagnosis for a client with asymptomatic primary
syphilis?
A) Acute pain.
B) Risk for injury.
C) Sexual dysfunction.
D) Deficient knowledge.
An asymptomatic client with primary syphilis is most likely unaware of this disease,
so to prevent transmission to others and recurrence in the client, the priority nursing
diagnosis is deficient knowledge (D). Asymptomatic primary syphilis is not painful, so
(A) is not applicable at this time. Although the client is at risk for injury (B) and sexual
dysfunction (C) related to complications, teaching the client about transmission and
, treatment is instrumental in preventing the progression to systemic secondary or
tertiary syphilis.
What assessment findings should the nurse identify before referring a client
for furtherevaluation to rule out skin cancer? (Select all that apply.)
A) White patches.
B) Cherry angiomas.
C) Border irregularity.
D) Lesion with asymmetry.
E) Lesion with color variations.
F) Lesion of 3 to 5 mm diameter.
Correct selections are (C, D, and E). ABCDE is the acronym used by the American
Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin
cancer: A for asymmetry of the lesion (D); B for irregular border (C); C for color,
usually dark (E); D
for diameter equal to or greater than 6 mm; and E for elevation. A lesion with any of
the characteristics of ABCDE should be evaluated by a healthcare provider. (A) lack
the color variable. (B) are raised, dome-shaped, benign clusters of blood vessels that
do not require treatment. Lesions of 3 to 5 mm diameter are small and may be
monitored instead of treated (F).
A Korean-American client, who speaks very little English, is being discharged
following surgery. Which nurse should the nurse manager assign to provide
the discharge instructions for the client?
A) A graduate registered nurse (RN) with three weeks of experience.
B) The registered nurse (RN) case manager for the unit with 1 year's
experience.
C) A floating registered nurse (RN) with five years of nursing experience.
D) A Korean-American practical nurse (PN) with six years of nursing
experience.
