2024 Med Surg Final Exam New Latest Versions Best Studying Materials with All Questions, Exams of Nursing

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A nurse assessing a patient who is receiving a blood transfusion finds that the patient is anxiously fidgeting in bed. The patient is afebrile but dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume excess b. Hemolytic reaction c. Anaphylactic shock d. Septicemia -------- Correct Answer ---------- a. Fluid volume excess A nurse preparing to start a blood transfusion will use which type of tubing? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. One with a filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood -------- Correct Answer ---------- c. One with a filter to ensure that clots do not enter the patient Which of the following best describes an iatrogenic infection?

1. It results from a diagnostic or therapeutic procedure.
2. It results from an extended infection of the urinary tract.
3. It involves an incubation period of 3 to 4 weeks before it can be detected.
4. It occurs when patients are infected with their own organisms as a result of immunodeficiency. -------- Correct Answer ---------- 1. It results from a diagnostic or therapeutic procedure. Place the following steps in correct order for performing a wound irrigation.
5. Use slow continuous pressure to irrigate the wound
6. Attach 19-gauge angiocatheter to syringe
7. Fill syringe with irrigation fluid
8. Assess wound
9. Position angiocatheter over wound -------- Correct Answer ---------- 4, 3, 2, 5, 1 A student nurse practicing primary leadership skills would demonstrate all of the following except:
10. Being sensitive to the group's feelings
11. Recognizing others for their contributions
12. Developing listening skills and being aware of personal motivation
13. Assuming primary responsibility for planning, implementation, follow-up, and evaluation -------- Correct Answer ---------- 4. Assuming primary responsibility for planning, implementation, follow-up, and evaluation

The clinic nurse is caring for a patient whose grandmother and sister have both had breast cancer. She requested a screening test to determine her risk of developing breast cancer and it has come back positive. The patient asks you what she can do to help prevent breast cancer from occurring. What would be your best response? A) Research has shown that eating a healthy diet can provide all the protection you need against breast cancer. B) Research has shown that taking the drug tamoxifen can reduce your chance of breast cancer. C) Research has shown that exercising at least 30 minutes every day can reduce your chance of breast cancer. D) Research has shown that there is little you can do to reduce your risk of breast cancer if you have a genetic predisposition. --------- Correct Answer ---------- B) Research has shown that taking the drug tamoxifen can reduce your chance of breast cancer. The nurse sets up a nonbarrier sterile field on the patient's overbed table. In which of the following instances is the field contaminated?

1. Sterile saline solution is spilled on the field.
2. The nurse, who has a cold, wears a double mask.
3. Sterile objects are kept within a 1-inch border of the field.
4. The nurse keeps the top of the table above his or her waist. -------- Correct Answer --- ------- 1. Sterile saline solution is spilled on the field. The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac -------- Correct Answer ---------- d. Cardiac Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany -------- Correct Answer ---------- d. Tingling of extremities with possible tetany While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated.

d. Avoid foods high in acid to avoid metabolic acidosis. -------- Correct Answer ---------- c. Drink plenty of fluids throughout the day to stay hydrated. A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion. -------- Correct Answer ---------- a. Check for contraindications to the extremity. c. Choose a vein with minimal curvature. f. Avoid areas of flexion. Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch -------- Correct Answer ---------- a. Edema of the extremity near the insertion site c. Skin discolored or pale in appearance f. Skin cool to the touch A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal. -------- Correct Answer ------ ---- b. Stop the infusion before removing the IV catheter. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal. A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body's regulators to the function it provides. a. Increases excretion of sodium and water. b. Reduces excretion of sodium and water. c. Reduces excretion of water. d. Major buffer in the extracellular fluid. e. Vasoconstricts and stimulates aldosterone release.

1. Antidiuretic hormone
2. Angiotensin II
3. Aldosterone
4. Atrial natriuretic peptide
5. Bicarbonate -------- Correct Answer ---------- 1. Antidiuretic hormone - C
6. Angiotensin II - E
7. Aldosterone - B
8. Atrial natriuretic peptide - A
9. Bicarbonate - D A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development? a. Decreased level of consciousness b. Adequate dietary intake c. Shortness of breath d. Muscular pain -------- Correct Answer ---------- a. Decreased level of consciousness The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer? a. Resistance b. Pressure c. Weight d. Stress -------- Correct Answer ---------- b. Pressure Which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. Fecal incontinence b. Ate two thirds of breakfast c. A raised red rash on the right shin d. Capillary refill is less than 2 seconds -------- Correct Answer ---------- a. Fecal incontinence The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record? a. Stage I pressure ulcer b. Healing Stage II pressure ulcer c. Healing Stage III pressure ulcer d. Stage III pressure ulcer -------- Correct Answer ---------- c. Healing Stage III pressure ulcer

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV -------- Correct Answer ---------- b. Stage II Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient? a. Disposable measuring tape b. Cotton-tipped applicator c. Sterile gloves d. Natural light -------- Correct Answer ---------- d. Natural light The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a. Partial thickness wound repair b. Full thickness wound repair c. Primary intention d. Tertiary intention -------- Correct Answer ---------- b. Full thickness wound repair The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with a Stage IV pressure ulcer b. A patient with a Braden Scale score of 18 c. A patient with appendicitis using a heating pad d. A patient with an incision that is approximated -------- Correct Answer ---------- c. A patient with appendicitis using a heating pad The nurse is caring for a patient who is experiencing a full thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing? a. Eschar b. Slough c. Granulation d. Purulent drainage -------- Correct Answer ---------- c. Granulation The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention -------- Correct Answer ---------- d. Primary intention The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient? a. Partial-thickness repair b. Secondary intention

c. Tertiary intention d. Primary intention -------- Correct Answer ---------- b. Secondary intention Which nursing observation will indicate the patient's wound healed by the process of secondary intention? a. Minimal loss of tissue function b. Permanent dark redness at site c. Minimal scar tissue d. Scarring that may be severe -------- Correct Answer ---------- d. Scarring that may be severe The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing? a. Patient reporting, ―My incision is hurting.‖ b. Approximation of the incision edges has occurred. c. Patient asks, ―Why has my incision started to itch?‖ d. The incision appears both swollen and bluish in color. -------- Correct Answer ---------- d. The incision appears both swollen and bluish in color. Which finding will alert the nurse to a potential wound dehiscence? a. Protrusion of visceral organs through a wound opening b. Chronic drainage of fluid through the incision site c. Report by patient that something has given way d. Drainage that is odorous and purulent -------- Correct Answer ---------- c. Report by patient that something has given way Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer? a. Vitamin E b. Potassium c. Prealbumin d. Sodium -------- Correct Answer ---------- c. Prealbumin A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing? a. Muscular strength assessment b. Pulse oximetry assessment c. Sensation assessment d. Sleep assessment -------- Correct Answer ---------- b. Pulse oximetry assessment Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to?

a. Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results b. Notifying the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR) c. Consulting the wound care nurse about the change in status and the potential for infection d. Conferring with the charge nurse about the change in status and the potential for infection -------- Correct Answer ---------- a. Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian? a. Fat b. Protein c. Vitamin E d. Carbohydrate -------- Correct Answer ---------- b. Protein The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept? a. ―I am so weak and tired. I just want to feel better.‖ b. ―I been thinking I will be ready to go home early next week.‖ c. ―I really need a bath and linen change right; I feel so awful.‖ d. ―I am hoping there will be something good to eat for my dinner tonight.‖ -------- Correct Answer ---------- c. ―I really need a bath and linen change right; I feel so awful.‖ A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take? a. Inspect the wound for bleeding. b. Irrigate the wound to remove foreign bodies. c. Measure and document the size of the wound. d. Determine when the patient last had a tetanus antitoxin injection. -------- Correct Answer ---------- a. Inspect the wound for bleeding. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? a. Provide analgesic medications as ordered. b. Avoid accidentally removing the drain. c. Don sterile gloves. d. Gather supplies. -------- Correct Answer ---------- a. Provide analgesic medications as ordered.

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially? a. Call the health care provider; a blockage is present in the tubing. b. Chart the results on the intake and output flow sheet. c. Do nothing, as long as the evacuator is compressed. d. Remove the drain; a drain is no longer needed. -------- Correct Answer ---------- a. Call the health care provider; a blockage is present in the tubing. The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? a. Low-air-loss b. Air-fluidized c. Lateral rotation d. Standard mattress -------- Correct Answer ---------- b. Air-fluidized A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular -------- Correct Answer ---------- a. Intracellular The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport -------- Correct Answer ---------- a. Osmosis The nurse observes edema in a patient who is experiencing venous congestion as a result of right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration -------- Correct Answer ---------- c. Hydrostatic The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular

d. From intravascular to interstitial -------- Correct Answer ---------- a. From intracellular to extracellular A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one?

1. Clean site.
2. Select vein.
3. Apply tourniquet.
4. Release tourniquet.
5. Reapply tourniquet.
6. Advance and secure.
7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6 -------- Correct Answer ---------- d. 3, 2, 4, 1, 5, 7, 6 The nurse is laboratory blood results will expect to observe which cation in the most abundance? a. Sodium b. Chloride c. Potassium d. Magnesium -------- Correct Answer ---------- a. Sodium The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L -------- Correct Answer ---------- b. Calcium of 15.5 mg/dL The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. An increase b. A decrease c. Equal to calcium d. No change in phosphate -------- Correct Answer ---------- b. A decrease Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60 -------- Correct Answer ---------- a. An infant with temperature of 102.2F and diarrhea for 3 days

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one?

1. Remove the sleeve of the gown from the arm without the IV.
2. Remove the sleeve of the gown from the arm with the IV.
3. Remove the IV solution container from its stand.
4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3 -------- Correct Answer ---------- a. 1, 2, 3, 4 A 2-year-old child has ingested a quantity of a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis -------- Correct Answer ---------- b. Respiratory acidosis A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis -------- Correct Answer ---------- b. Metabolic alkalosis Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO

• 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO
• 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO
• 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO
• 23 mEq/L -------- Correct Answer ---------- b. pH 7.53, PaCO2 30 mm Hg, HCO
• 24 mEq/L A nurse is caring for a patient whose electrocardiogram (ECG) presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin -------- Correct Answer ---------- b. Abdominal distention

In which patient will the nurse expect to see a positive Chvostek's sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis -------- Correct Answer ---------- b. A 24-year-old adult admitted for chronic alcohol abuse A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal -------- Correct Answer ---------- a. Renal A nurse is caring for a patient prescribed peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing -------- Correct Answer ---------- a. Recording intake and output The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3 - 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3 - 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3 - 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3 - 25 mEq/L -------- Correct Answer ---------- a. pH 7.3, PaCO2 36 mm Hg, HCO3 - 19 mEq/L The nurse is assessing a patient and notes crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids. -------- Correct Answer ---------- c. Raise head of bed. A patient receiving chemotherapy has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. ―Are you following any weight loss program?‖ b. ―How many calories a day do you consume?‖ c. ―Do you have dry mouth or feel thirsty?‖ d. ―How many times a day do you urinate?‖ -------- Correct Answer ---------- d. ―How many times a day do you urinate?‖

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR) -------- Correct Answer ---------- a. 0.45% sodium chloride (1/2 NS) The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours. -------- Correct Answer ---------- c. Weigh the patients every morning before breakfast. A nurse is caring for a patient diagnosed with cancer who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure. -------- Correct Answer ---------- c. Replace fluid, electrolytes, and nutrients. A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl) -------- Correct Answer ---------- c. 0.9% sodium chloride (NS) A nurse administering a diuretic to a patient is teaching about foods to increase in the diet. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables -------- Correct Answer ---------- b. Potatoes and fresh fruit

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease. -------- Correct Answer ---------- c. Serum sodium concentration returns to normal. The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125 -------- Correct Answer ---------- a. Intake 255; output 375 Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema -------- Correct Answer ---------- b. Postural hypotension A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min -------- Correct Answer ---------- c. 125 drops/min A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday -------- Correct Answer ---------- b. 2345 Monday A nurse caring for a diabetic patient with a bowel obstruction has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low

continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning. -------- Correct Answer ---------- a. Add a potassium supplement to replace loss from output. A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV. -------- Correct Answer ---------- d. Discontinue the IV. A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line- associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion. -------- Correct Answer ---------- d. Uses chlorhexidine skin antisepsis prior to insertion. The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm -------- Correct Answer ---------- a. A patient with D5W hanging with the blood A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/ b. Temperature 101.3F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min -------- Correct Answer ---------- b. Temperature 101.3F A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours

d. 6 hours -------- Correct Answer ---------- c. 4 hours A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at rate to keep vein open using new tubing. -------- Correct Answer ---------- d. Start normal saline at rate to keep vein open using new tubing. The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient? a. Increased monitoring of the wound condition b. Documenting the wound's status daily c. Surgical debridement of the wound d. Increased drainage from wound -------- Correct Answer ---------- c. Surgical debridement of the wound The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question? a. Use a low-air-loss therapy unit. b. Irrigate with Dakin's solution. c. Apply a hydrogel dressing. d. Consult a dietitian. -------- Correct Answer ---------- b. Irrigate with Dakin's solution. The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority? a. Pressure points b. Breath sounds c. Bowel sounds d. Pulse points -------- Correct Answer ---------- a. Pressure points The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient? a. 15 b. 17 c. 20 d. 23 -------- Correct Answer ---------- c. 20 The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?

a. Explain the risks of immobility to the patient. b. Turn the patient every 3 hours while in bed. c. Encourage the patient to sit up in the chair. d. Provide analgesic medication as ordered. -------- Correct Answer ---------- d. Provide analgesic medication as ordered. The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain -------- Correct Answer ---------- c. Impaired skin integrity The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? a. Imbalanced nutrition: less than body requirements b. Impaired peripheral tissue perfusion c. Risk for infection d. Acute pain -------- Correct Answer ---------- b. Impaired peripheral tissue perfusion The nurse caring for an immobile patient wants to decrease the risk of the formation of pressure ulcers. Which action will the nurse take first? a. Offer favorite fluids. b. Turn the patient every 2 hours. c. Determine the patient's risk factors. d. Encourage increased quantities of carbohydrates and fats. -------- Correct Answer ---- ------ c. Determine the patient's risk factors. Which health care team member will the nurse consult when a patient has received a nursing diagnosis of Impaired skin integrity? a. Respiratory therapist b. Registered dietitian c. Case manager d. Chaplain -------- Correct Answer ---------- b. Registered dietitian When a comatose patient develops a Stage II pressure ulcer, the nurse includes the nursing diagnosis of Risk for infection to the care plan. Which is the best goal for this patient? a. The patient will state what to look for with regard to an infection. b. The patient's family will demonstrate specific care of the wound site. c. The patient's family members will wash their hands when visiting the patient. d. The patient will remain free of odorous or purulent drainage from the wound. -------- Correct Answer ---------- d. The patient will remain free of odorous or purulent drainage from the wound.

When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)? a. Assessing a surgical patient for risk of pressure ulcers b. Applying a gauze bandage to secure a nonsterile dressing c. Treating a pressure ulcer on the buttocks of a medical patient d. Implementing negative pressure wound therapy on a stable patient -------- Correct Answer ---------- b. Applying a gauze bandage to secure a nonsterile dressing The nurse performing a moist-to-dry dressing has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the following steps, starting with the first one?

1. Apply sterile gloves.
2. Cover and secure topper dressing.
3. Assess wound and surrounding skin.
4. Moisten gauze with prescribed solution.
5. Gently wring out excess solution and unfold.
6. Loosely pack until all wound surfaces are in contact with gauze. a. 4, 3, 1, 5, 6, 2 b. 1, 3, 4, 5, 6, 2 c. 4, 1, 3, 5, 6, 2 d. 1, 4, 3, 5, 6, 2 -------- Correct Answer ---------- b. 1, 3, 4, 5, 6, 2 The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk? a. After cleansing thoroughly dry the skin. b. Request a therapeutic bed and mattress. c. Pad the bed with absorbent pads. d. Use products that retain moisture. -------- Correct Answer ---------- a. After cleansing thoroughly dry the skin. A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair? a. 2 hours or less at any one time b. For a total of least than 3 hours daily c. No longer than 30 minutes out of every hour d. Until the patient expresses being uncomfortable -------- Correct Answer ---------- a. 2 hours or less at any one time The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient? a. Place the patient in a 30-degree supine position. b. Utilize a transfer device to lift the patient. c. Elevate the head of the bed 45 degrees. d. Slide the patient into the new position. -------- Correct Answer ---------- b. Utilize a transfer device to lift the patient.

As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. Which stage of ulcer did the nurse appropriately treat? a. A Stage I b. A Stage II c. A Stage III d. A Stage IV -------- Correct Answer ---------- a. A Stage I The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take? a. Distract the patient with the television. b. Offer to explain what they should expect. c. Suggest that the patient ―Close your eyes.‖ d. Wait until family is visiting to support the patient. -------- Correct Answer ---------- b. Offer to explain what they should expect. Which intervention should be included as the nurse cleanses a wound? a. Allow the solution to flow from the most contaminated to the least contaminated. b. Scrub vigorously when applying noncytotoxic solution to the skin. c. Cleanse in a direction from the least contaminated area. d. Utilize clean gauze and clean gloves to cleanse a site. -------- Correct Answer ---------- c. Cleanse in a direction from the least contaminated area. Which is the best explanation for the nurse to provide when teaching the patient, the reason for the binder after an open abdominal aortic aneurysm repair? a. It reduces edema at the surgical site. b. It secures the dressing in place. c. It immobilizes the abdomen. d. It supports the abdomen. -------- Correct Answer ---------- d. It supports the abdomen. The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management? a. Monitor vital signs every 15 minutes. b. Check pulses in the right foot. c. Keep the leg dependent. d. Apply ice. -------- Correct Answer ---------- d. Apply ice. The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? a. 12 b. 13 c. 20 d. 23 -------- Correct Answer ---------- d. 23

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.) a. Place moist sterile gauze over the site. b. Gently place the organs back. c. Contact the surgical team. d. Offer a glass of water. e. Monitor for shock. -------- Correct Answer ---------- a. Place moist sterile gauze over the site. c. Contact the surgical team. e. Monitor for shock. The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.) a. Hemostasis b. Maturation c. Inflammatory d. Proliferative e. Reproduction f. Reestablishment of epidermal layers -------- Correct Answer ---------- a. Hemostasis b. Maturation c. Inflammatory d. Proliferative The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. ―Can you easily change your position?‖ b. ―Do you have sensitivity to heat or cold?‖ c. ―How often do you need to use the toilet?‖ d. ―What medications do you take?‖ e. ―Is movement painful?‖ f. ―Have you ever fallen?‖ -------- Correct Answer ---------- a. ―Can you easily change your position?‖ b. ―Do you have sensitivity to heat or cold?‖ c. ―How often do you need to use the toilet?‖ e. ―Is movement painful?‖ The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) a. Vision b. Hyperemia c. Induration d. Blanching e. Temperature of skin -------- Correct Answer ---------- b. Hyperemia c. Induration d. Blanching

e. Temperature of skin The nurse is caring for a patient who will have a large abdominal bandage secured with an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.) a. Cover exposed wounds. b. Mark the sites of all abrasions. c. Assess the condition of current dressings. d. Inspect the skin for abrasions and edema. e. Cleanse the area with hydrogen peroxide. f. Assess the skin at underlying areas for circulatory impairment. -------- Correct Answer ---------- a. Cover exposed wounds. c. Assess the condition of current dressings. d. Inspect the skin for abrasions and edema. f. Assess the skin at underlying areas for circulatory impairment. The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) a. The patient's expectations are not being met. b. Skin is intact with no redness or swelling. c. Non-blanchable erythema is absent. d. No injuries to the skin and tissues are evident. e. Granulation tissue is present. -------- Correct Answer ---------- b. Skin is intact with no redness or swelling. c. Non-blanchable erythema is absent. d. No injuries to the skin and tissues are evident. e. Granulation tissue is present. The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. a. Absorbs drainage through the use of exudate absorbers in the dressing b. Very soothing to the patient and do not adhere to the wound bed c. Barrier to external fluids/bacteria but allows wound to ―breathe‖ d. Manufactured from seaweed and comes in sheet and rope form e. Oldest and most common absorbent dressing

1. Gauze
2. Transparent
3. Hydrocolloid
4. Hydrogel
5. Calcium alginate -------- Correct Answer ---------- 1. Gauze - E
6. Transparent - C
7. Hydrocolloid - A
8. Hydrogel - B
9. Calcium alginate - D The severity of a patient's illness depends on all of the following except:

1. Incubation period
2. Extent of infection
3. Susceptibility of the host
4. Pathogenicity of the microorganism -------- Correct Answer ---------- 1. Incubation period When a patient on respiratory isolation must be transported to another part of the hospital, the nurse:
5. Places a mask on the patient before leaving the room
6. Obtains a health care provider's order to prohibit the patient from being transported
7. Instructs the patient to cover his or her mouth and nose with a tissue when coughing or sneezing
8. Advises other health team members to wear masks and gowns when coming in contact with the patient -------- Correct Answer ---------- 1. Places a mask on the patient before leaving the room In what order would you prepare to enter the room of a patient in contact and droplet isolation precautions for MRSA?
9. Put on eyewear
10. Perform hand hygiene
11. Put on gloves
12. Put on mask
13. Put on gown -------- Correct Answer ---------- 2, 5, 4, 1, 3 The skin plays a role in temperature regulation by:
14. Insulating the body
15. Constricting blood vessels
16. Sensing external temperature variations
17. All of the above -------- Correct Answer ---------- 1. Insulating the body
18. Constricting blood vessels
19. Sensing external temperature variations The nurse bathes the patient who has a fever with cool water. The nurse does this to increase heat loss by means of:
20. Radiation
21. Convection
22. Conduction
23. Condensation -------- Correct Answer ---------- 3. Conduction The nurse is assessing a patient who she suspects has the nursing diagnosis hyperthermia related to vigorous exercise in hot weather. In reviewing the data, the nurse knows that the most important sign of heatstroke is:
24. Confusion
25. Excess thirst
26. Hot, dry skin
27. Muscle cramps -------- Correct Answer ---------- 3. Hot, dry skin

The nurse is auscultating Mrs. McKinnon's blood pressure. The nurse inflates the cuff to 180 mm Hg. At 156 mm Hg, the nurse hears the onset of a tapping sound. At 130 mm Hg, the sound changes to a murmur or swishing. At 100 mm Hg, the sound momentarily becomes sharper, and at 92 mm Hg, it becomes muffled. At 88 mm Hg, the sound disappears. Mrs. McKinnon's blood pressure is:

1. 130/88 mm Hg
2. 156/88 mm Hg
3. 180/92 mm Hg
4. 180/130 mm Hg -------- Correct Answer ---------- 2. 156/88 mm Hg The nursing instructor is explaining to the student nurse how to use the two-step method of blood pressure assessment to obtain accurate measurements. Place the steps in correct order:
5. Place stethoscope in ears
6. Palpate the brachial artery while inflating blood pressure cuff 30 mm Hg over the pulse disappearance
7. Note point where you hear first Korotkoff sound
8. Wait 30 seconds
9. Apply blood pressure cuff 1 inch above brachial artery
10. Continue to deflate cuff until sound disappears -------- Correct Answer ---------- 5, 2, 4, 1, 3, 6 The component that should receive the highest priority before a physical examination is:
11. Preparation of the equipment
12. Preparation of the environment
13. Physical preparation of the patient
14. Psychological preparation of the patient -------- Correct Answer ---------- 4. Psychological preparation of the patient The nurse assesses the skin turgor of the patient by:
15. Inspecting the buccal mucosa with a penlight
16. Palpating the skin with the dorsum of the hand
17. Grasping a fold of skin on the back of the forearm and releasing
18. Pressing the skin for 5 seconds, releasing, and noting each centimeter of depth -------

• Correct Answer ---------- 3. Grasping a fold of skin on the back of the forearm and releasing While examining Mr. Parker, the nurse notes a circumscribed elevation of skin filled with serous fluid on his upper lip. The lesion is 0.4 cm in diameter. This type of lesion is called a:

1. Macule
2. Nodule
3. Vesicle
4. Pustule -------- Correct Answer ---------- 3. Vesicle

When assessing the patient's thorax, the nurse should:

1. Complete the left side and then the right side
2. Compare symmetrical areas from side to side
3. Begin with the posterior lobes on the right side
4. Change the position of the stethoscope between inspiration and expiration -------- Correct Answer ---------- 2. Compare symmetrical areas from side to side The second heart sound (S2) occurs when:
5. Systole begins
6. There is rapid ventricular filling
7. The mitral and tricuspid valves close
8. The aortic and pulmonic valves close -------- Correct Answer ---------- 4. The aortic and pulmonic valves close Which statements describe accurate completion of a vascular assessment? (Select all that apply.)
9. Simultaneously palpate the carotid arteries
10. Measure blood pressure
11. Ask about any pain, cramping, or discomfort in the legs
12. Count an irregular pulse for 30 seconds and multiply by 2
13. Rate the strength of a pulse on a scale of 0 to 4. -------- Correct Answer ---------- 2, 3, 5 The study of how drugs enter the body, reach their sites of action, are metabolized, and exit from the body is called:
14. Pharmacology
15. Pharmacopoeia
16. Pharmacokinetics
17. Biopharmaceutical -------- Correct Answer ---------- 3. Pharmacokinetics Which statement correctly characterizes drug absorption?
18. Most drugs must enter the systemic circulation to have a therapeutic effect.
19. Oral medications are absorbed more quickly when administered with meals.
20. Mucous membranes are relatively impermeable to chemicals, making absorption slow.
21. Drugs administered subcutaneously are absorbed more quickly than those injected intramuscularly. -------- Correct Answer ---------- 1. Most drugs must enter the systemic circulation to have a therapeutic effect. The onset of drug action is the time it takes for a drug to:
22. Produce a response
23. Accelerate the cellular process
24. Reach its highest effective concentration
25. Produce blood serum concentration and maintenance -------- Correct Answer ----------
26. Produce a response

Which of the following is not a parenteral route of administration?

1. Buccal
2. Intradermal
3. Intramuscular
4. Subcutaneous -------- Correct Answer ---------- 1. Buccal The nurse is preparing an insulin injection in which both regular and NPH will be mixed. Into which vial should the nurse inject air first?
5. The vial of regular insulin
6. The vial of NPH
7. Either vial, as long as modified insulin is drawn up first
8. Neither vial; it is not necessary to put air into vials before withdrawing medication ----- --- Correct Answer ---------- 2. The vial of NPH A young adult patient tells her nurse that she is afraid of injections. The nurse is preparing to administer the patient a flu vaccine. Which of the following techniques can the nurse use to reduce the patient's discomfort? (Select all that apply.)
9. Ask the patient to think about why the injection is necessary
10. Position the patient comfortably
11. Apply a vapocoolant to the skin before giving the injection
12. Use a large-gauge needle
13. Carefully use anatomical landmarks to select injection site -------- Correct Answer ----- ----- 2. Position the patient comfortably
14. Apply a vapocoolant to the skin before giving the injection
15. Carefully use anatomical landmarks to select injection site The body fluids constituting the interstitial fluid and blood plasma are:
16. Hypotonic
17. Hypertonic
18. Intracellular
19. Extracellular -------- Correct Answer ---------- 4. Extracellular Mrs. Green's arterial blood gas results are as fol-lows: pH, 7.32; PaCO2, 52 mm Hg; Pa02, 78 mm Hg; HCO3, 24 mE/L. Mrs. Green has:
20. Metabolic acidosis
21. Metabolic alkalosis
22. Respiratory acidosis
23. Respiratory alkalosis -------- Correct Answer ---------- 3. Respiratory acidosis Mr. Frank is an 82-year-old patient who has had a 3-day history of vomiting and diarrhea. Which symptom would you expect to find on a physical examination?
24. Tachycardia
25. Hypertension
26. Neck vein distention
27. Crackles in the lungs -------- Correct Answer ---------- 1. Tachycardia

Which of the following is most likely to result in respiratory alkalosis?

1. Steroid use
2. Fad dieting
3. Hyperventilation
4. Chronic alcoholism -------- Correct Answer ---------- 3. Hyperventilation You need to discontinue a VAD. Place the steps in the correct order.
5. Turn off the roller clamp on the IV tubing
6. Place sterile gauze over the VAD insertion site and apply light pressure while removing the catheter
7. Document VAD removal
8. Review the health care provider's order for discontinuing the VAD
9. Perform hand hygiene and apply clean gloves
10. Inspect the catheter end for intactness while applying firm pressure with the gauze
11. Explain to the patient the reason for discontinuing the VAD
12. Maintain continuous firm pressure with the gauze for 2-3 minutes or longer if need
13. Remove IV site dressings and tape, and clean any secretions -------- Correct Answer - --------- 4, 7, 5, 1, 9, 2, 6, 8, 3 Mrs. Rantz complains of leaking urine when she coughs and laughs. This is known as:
14. Urge incontinence
15. Stress incontinence
16. Reflex incontinence
17. Functional incontinence -------- Correct Answer ---------- 2. Stress incontinence Ms. Hathaway has a UTI. Which of the following symptoms would you expect her to exhibit?
18. Dysuria
19. Oliguria
20. Polyuria
21. Proteinuria -------- Correct Answer ---------- 1. Dysuria The nurse is working in the radiology department with a patient who is having an intravenous pyelogram. Which of the following complaints by the patient is an abnormal response?
22. Frequent, loose stools
23. Thirst and feeling "worn out"
24. Shortness of breath and audible wheezing
25. Feeling dizzy and warm with obvious facial flushing -------- Correct Answer ---------- 3. Shortness of breath and audible wheezing The urinalysis of Ms. Hathaway reveals a high bacteria count. Ampicillin is prescribed for her UTI. The teaching plan for the prevention of a UTT should include all of the following except:
26. Drink at least 2000 mL of fuid daily.