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Final Exam Med Surg Exam Questions With Complete Solutions
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Final Exam Med Surg Exam Questions With Complete Solutions
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Final Exam Med Surg Exam Questions With CompleteSolutions
A charge nurse is monitoring a newly licensed nurse who is
caring for a postoperative client who is receiving morphine
through a PCA pump. Which of the following actions by the
newly licensed nurse requires intervention?
a. Instructing the client to administer a PCA dose prior to a
dressing change
b. Providing increased fluids while the client is using the PCA
pump
c. Informing the client's partner that only the client should
administer the PCA doses
d. Maintaining the client on bed rest while the PCA pump is in
use Correct Answers D. Maintaining the client on bed rest
while the PCA pump is in use--- Use of a PCA pump does not
prevent ambulation following surgery. Early ambulation should
be encouraged. The nurse should instruct the client to sit at the
side of the bed prior to standing to reduce the risks of orthostatic
hypotension and falls.
A charge nurse receives notification of the admission of a client
who is coughing frequently and whose sputum is pink, frothy,
and copious. The client has a history of night sweats, anorexia,
and weight loss. Which of the following actions should the nurse
take? (Select all that apply.)
a. Assign the client to a private room with negative-pressure
airflow.
b. Add contact precautions to the client's plan of care.
,c. Wear an N95 respirator when entering the client's room.
d. Ensure the client's environment provides 4 exchanges of fresh
air per minute.
e. Institute protective environment precautions as soon as the
client arrives on the unit. Correct Answers A. Assign the client
to a private room with negative-pressure airflow.
C. Wear an N95 respirator when entering the client's room.---
This client's history and present status suggest tuberculosis, a
communicable infection that mandates a private room with
negative-pressure airflow. Airborne precautions will be required,
including wearing an N95 respirator when entering the client's
room.
A client who reports shortness of breath requests the nurse's help
in changing positions. After repositioning the client, which of
the following actions should the nurse take next?
a. Encourage the client to take deep breaths
b. Observe the rate, depth, and character of the client's
respirations
c. Prepare to administer oxygen
d. Give the client a back rub to promote relaxation Correct
Answers B. Observe the rate, depth, and character of the client's
respirations--- The nurse should apply the nursing process
priority-setting framework when caring for this client in order to
plan client care and prioritize nursing actions. Each step of the
nursing process builds on the previous step, beginning with an
assessment or data collection. Before the nurse can formulate a
plan of action, implement a nursing intervention, or notify a
provider of a change in the client's status, the nurse must first
collect adequate data from the client. Assessing or collecting
,additional data will provide the nurse with the knowledge
needed to make an appropriate decision; therefore, the nurse
should first assess the client's respiratory status.
A nurse delegates the collection of a client's temperature to an
assistive personnel (AP). The nurse notes in the documentation
that the AP obtained the client's axillary temperature; however,
the nurse wanted an oral temperature. The nurse should identify
which of the following rights of delegation should have
prevented this situation from occurring?
a. Right task
b. Right circumstance
c. Right person
d. Right communication Correct Answers D. Right
communication--- The situation could have been avoided if the
right communication was given by the nurse to the AP. The right
communication entails providing clear, concise instructions
regarding the task, including the objective, limits, and
expectations.
A nurse in a clinic is providing teaching for a client who is
scheduled to have a tuberculin skin test. Which of the following
pieces of information should the nurse include?
a. "If the test is positive, it means you have an active case of
tuberculosis."
b. "If the test is positive, you should have another tuberculin
skin test in 3 weeks."
c. "You must return to the clinic to have the test read in 2 or 3
days."
, d. "A nurse will use a small lancet to scratch the skin of your
forearm before applying the tuberculin substance." Correct
Answers C. "You must return to the clinic to have the test read
in 2 or 3 days."---The client should have the skin test read in 2 to
3 days. An area of induration after 48 to 72 hours indicates
exposure to the tubercle bacillus. If the client does not return to
have the test read within 72 hours, another tuberculin skin test is
necessary.
A nurse in a medical-surgical unit is assessing a client. The
nurse should identify which of the following findings is a
manifestation of a pulmonary embolism?
a. Stabbing chest pain
b. Calf tenderness
c. Elevated temperature
d. Bradycardia Correct Answers A. Stabbing chest pain---- A
manifestation of a pulmonary embolism is sudden chest pain
that is sharp and stabbing. Other manifestations include dyspnea,
coughing, hemoptysis (coughing up blood), tachypnea,
tachycardia, diaphoresis, and a feeling of impending doom.
A nurse in a provider's office is reviewing the medical records of
a group of clients. Which of the following clients is at risk for
iron deficiency? (Select all that apply.)
a. A client who is postmenopausal
b. A client who is a vegetarian
c. A middle adult male client
d. A client who is pregnant
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