Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
Medical-Surgical Nursing Exam 1 Questions and Answers (Latest Update 2024)
Typology: Exams
1 / 27
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 Answer ✅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 Answer ✅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 Answer ✅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 Answer ✅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 Answer ✅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 Answer ✅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 Answer ✅"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 Answer ✅Notify the physician. Which client is most likely to be experiencing hypovolemic shock? - Correct Answer ✅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 Answer ✅pH 7. A 63-year-old Arab American male states his left leg is "hot." What is the nurse's best first response? - Correct Answer ✅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 Answer ✅"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 Answer ✅Mediate 1 hour prior to ambulating the client. The client reports frequent use of acetaminophen. How should the nurse best respond? - Correct Answer ✅"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 Answer ✅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 Answer ✅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 Answer ✅The client receiving Procrit (epoetin alfa) has a T 99.2˚F, P 68, R 24, and BP of 198/ 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 Answer ✅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 Answer ✅"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 Answer ✅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?
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 Answer ✅Inspect the abdominal wound incision The client is one (1) day postoperative major abdominal surgery. Which client problem is a priority? - Correct Answer ✅Fluid and electrolyte imbalance The client has an eviscerated abdominal wound. Which intervention should the practical nurse implement? - Correct Answer ✅Apply sterile normal saline dressing The client is diagnosed with peritonitis. Which information indicates to the practical nurse the client's condition is improving? - Correct Answer ✅The client has a decrease in temperature and a soft abdomen A patient is being released from the hospital with a prescription for tetracycline. What should the nurse include in patient teaching? Select all that apply. - Correct Answer ✅Advise limiting exposure to the sun. Inform patient of the possibility of gastrointestinal upset. Suggest eating crackers and some juice when taking this medicine. The nurse wants to determine if a patient not fully awake from anesthesia for a surgical procedure is experiencing pain. What findings should the nurse use to make this determination?
Select all that apply. - Correct Answer ✅Moaning Restlessness Pulling at a body area Elevated blood pressure A patient is diagnosed with an infection that has spread to the blood stream. Which term should the nurse use to document this patient's health problem?
A patient has an epidural catheter placed for pain control. Which medications should the nurse question before providing them to the patient during routine medication administration? Select all that apply. - Correct Answer ✅Aspirin 325 mg by mouth once a day Warfarin (Coumadin) 2.5 mg by mouth every evening A patient with severe arthritis pain is prescribed celecoxib (Celebrex). What should the nurse instruct the patient about this medication? - Correct Answer ✅Take with food. The nurse is caring for a patient exposed to a toxin. Which is the most potent lethal toxin? - Correct Answer ✅Botulinum The nurse is assisting in the care of a patient with suspected anaphylactic shock. Which orders should the nurse question? Select all that apply. - Correct Answer ✅Morphine 2 mg intravenous (IV) now Transfuse with 1 unit of packed red blood cells over 1 hour The nurse is preparing to assess a patient receiving chemotherapy and radiation for adverse effects of the treatments. In which order (1-5) should the nurse assess the patient for these adverse effects? Place the effects in the order in which they should be assessed. - Correct Answer ✅Emesis
Infection Bleeding Tiredness Skin changes The nurse is caring for a patient who has just returned from an endoscopic examination of the esophagus. Which is the most important observation the nurse should make before offering the patient food and water? - Correct Answer ✅Test for an intact gag reflex. A patient is experiencing a drop in blood pressure. What should the nurse expect to assess in this patient? Select all that apply. - Correct Answer ✅Epinephrine is released. The heart beats faster and stronger. The body retains sodium and water. Blood is shunted away from the skin, intestines, and kidneys. The nurse is evaluating care provided to a patient with a fractured humerus. Which observations indicate that nursing care has been effective? Select all that apply. - Correct Answer ✅Palpable pulses Normal skin color
Capillary refill time 2 seconds Pain level 2 on a scale of 1 to 10 A patient who received an epidural anesthetic for a surgical case is prescribed a blood patch for a spinal headache. What should the nurse explain about the purpose of this blood patch? - Correct Answer ✅Stops cerebrospinal fluid leakage A patient presents with sudden onset of high fever, chills, malaise, dyspnea, cough, and hemoptysis. Laboratory studies show an elevated white blood cell count with a predominance of neutrophils and prolonged clotting values. For which disease should the nurse plan this patient's care? - Correct Answer ✅Plague The nurse is explaining the infectious disease process to a patient awaiting test results for a bacterial infection. What should the nurse explain as destroying the walls of bacteria, resulting in their destruction? - Correct Answer ✅Lysozymes A patient with a systemic infection picks at the meal trays and ingests very litle solid food. What should the nurse do to support this patient's nutritional status for healing? Select all that apply. - Correct Answer ✅Remove the bedpan from the patient's bed area. Ask what types of foods the patient finds enjoyable.
Explain that a soft or pureed diet is the best for healing. Remove the incentive spirometer from the over the bed table. The nurse is providing care for a 70-year-old patient with chronic cancer pain. Which medication should the nurse expect to be prescribed for this patient? - Correct Answer ✅Oxycodone (OxyContin) PO A patient experiencing painful back spasms plans to stop taking prescribed pain medication and resume weekly massage therapy sessions. How should the nurse respond to this patient's plan? - Correct Answer ✅"Massage therapy should be used in addition to the pain medication." Fory-eight hours after surgery a patient continues to have no bowel sounds. What should the nurse do to promote the return of bowel function in this patient? Select all that apply. - Correct Answer ✅Assist to ambulate. Provide the patient with chewing gum. A patient is diagnosed with conjunctivitis. The nurse should explain that the patient was infected via which mechanism? - Correct Answer ✅Vehicle- borne The nurse is preparing materials to instruct an older patient recovering from septic shock. What should the nurse keep in mind when teaching this patient?
Select all that apply. - Correct Answer ✅Speak slowly and clearly. Speak in a low-pitched tone. Provide materials in large print. Involve family members in teaching. During the primary survey, the nurse has determined that the airway is unobstructed, but the patient is not breathing. What action should take priority? - Correct Answer ✅Ventilate the patient immediately The nurse notes that a patient's laboratory values indicate abnormal clotting, decreased production of proteins, and increased serum ammonia levels. Which organ should the nurse suspect is damaged in this patient? - Correct Answer ✅Liver The nurse is preparing to administer an opioid analgesic. Which assessment findings should be evaluated and documented prior to administering the medication? - Correct Answer ✅Pain level and respiratory rate A patient is diagnosed with an illness caused by a prion. The nurse should plan patient care for which diseases process? - Correct Answer ✅Creutzfeldt-Jakob syndrome A patient is prescribed an antibiotic to treat a lung infection. What should the nurse emphasize to the patient about this medication?
Select all that apply. - Correct Answer ✅Take all of the medication as prescribed. Report evidence of side effects to the HCP. A patient who was impaled on a piece of pipe is brought to the emergency department with a piece of metal rod protruding from the lower chest area. Which action should the nurse take first? - Correct Answer ✅Apply a bulky dressing around the impaled object. A patient is having a regional block where a tourniquet is placed on an extremity to reduce the blood in the extremity and then have a local agent injected into the extremity. What type of block should the nurse document? - Correct Answer ✅Bier block The nurse is reviewing cancer statistics prior to obtaining morning report for a group of oncology patients. Which cancer does the nurse realize is associated with the highest mortality rate? - Correct Answer ✅Lung cancer A patient has been receiving 10 mg morphine IV every 4 to 6 hours for postoperative pain. At discharge, the patient rates the pain as a 4 on a 0- scale. On a prescription to be given to the patient at discharge, the physician has written morphine 10 mg by mouth four times a day as needed. What should the nurse do first? - Correct Answer ✅Contact the physician regarding the prescription. A patient is experiencing moderate-to-severe pain. Which pain medication should the nurse expect to be prescribed for this patient? - Correct Answer ✅Morphine
The nurse plans interventions for a patient in shock to address circulatory collapse. What is the goal for this patient's care? - Correct Answer ✅Prevent organ damage The nurse is caring for a patient with preexisting liver dysfunction experiencing shock. Which acid-base imbalance should the nurse anticipate this patient developing? - Correct Answer ✅Metabolic acidosis An older patient receiving antibiotics for an abdominal wound infection develops a fever and diarrhea. What treatment should the nurse prepare to provide to this patient? Select all that apply. - Correct Answer ✅Provide metronidazole (Flagyl) if prescribed. Provide vancomycin (Vanocin) if prescribed. Use hand washing with soap and water after all patient care. Stop the administration of the currently prescribed antibiotic. The nurse is reviewing the laboratory results for several patients. Which laboratory tests are tumor markers that can confirm the diagnosis of cancer? Select all that apply. - Correct Answer ✅Alpha-fetoprotein Cancer antigen 125
Prostate-specific antigen Prostatic acid phosphatase The nurse is reviewing medication orders for a patient with chronic pain. Which classes of drugs should the nurse recognize as being used as analgesic adjuvants? Select all that apply. - Correct Answer ✅Steroids Anticonvulsants Benzodiazepines The nurse suspects that a patient is developing shock. Which initial manifestations did the nurse most likely observe in this patient? Select all that apply. - Correct Answer ✅Pallor Anxiety Tachypnea Cool, clammy skin The dressing on a patient's abdominal wound is saturated with blood and drainage 16 hours after surgery. What should the nurse do for this patient? - Correct Answer ✅Reinforce the dressing. A patient is demonstrating manifestations of an opioid overdose. Which drug should the nurse expect to be prescribed for this patient? - Correct Answer ✅Naloxone (Narcan)
A patient is experiencing severe diarrhea after each chemotherapy treatment. Which intervention(s) should the nurse incorporate in this patient's plan of care? Select all that apply. - Correct Answer ✅Remove foods with high-fiber content. Eliminate foods containing lactose from the diet. Incorporate apples, strawberries, and citrus foods with each meal. A patient is prescribed to receive an NSAID and an opioid medication at the same time. What should the nurse do when preparing these medications for the patient? - Correct Answer ✅Provide the medication together as prescribed. The nurse is providing information for a patient who wishes to limit analgesic use and instead utilize alternative or complementary therapies. Which cognitive-behavioral methods for treating pain should the nurse include in the teaching? Select all that apply. - Correct Answer ✅Distraction Biofeedback Guided imagery Relaxation exercises A family member of a patient in shock says that being in shock should not be that critical because it can be treated. What should the nurse explain about
the major body damage caused by shock? - Correct Answer ✅Inadequate oxygen delivered to cells A patient with extracardiac obstructive shock is diagnosed with a condition that causes blood to fill the sac around the heart, compressing it and limiting its filling capacity. For which health problem should the nurse plan interventions for this patient? - Correct Answer ✅Pericardial tamponade The nurse is reviewing the process of pain perception and control. In which group of chemical substances should the nurse find prostaglandins and substance P? - Correct Answer ✅Neurotransmitters During a home visit, the nurse is collecting data from a patient recovering from spinal surgery conducted 3 weeks ago. Which wound finding should the nurse expect in the patient? - Correct Answer ✅Raised scar The nurse is assisting in the care of a patient admitted with suspected carbon monoxide poisoning. Which laboratory value should the nurse evaluate first? - Correct Answer ✅Carboxyhemoglobin Five patients with suspected smallpox exposure are brought into the emergency department. What actions should the nurse take to prevent exposure to other patients and health care personnel? Select all that apply. - Correct Answer ✅Cleanse room surfaces with ammonia. Apply surgical masks to each of the patients. Place the patients' laundry and linens in biohazard bags.
Staff should wear fit-tested N95 respirators if not vaccinated against smallpox. The nurse is planning interventions for a patient with shock. On which body organ should the nurse focus interventions first? - Correct Answer ✅Kidneys During morning report, the nurse caring for a patient experiencing chronic pain doubts the patient is in pain and does not want to provide any pain medication all shift. What myths about pain should the nurse manager review with the nurse? Select all that apply. - Correct Answer ✅Pain is often overtreated A patient who is talking on the phone and laughing is not really in pain. Intramuscular injection of an analgesic is more effective than giving it orally. Addiction to opioids given to relieve pain is common, especially in teenagers. Morphine has a ceiling effect; therefore, its use should be reserved for severe pain. A patient is diagnosed with distributive shock. What should the nurse explain to the family as the cause of this type of shock? - Correct Answer ✅Excessive dilation of venules and arterioles
A college student is brought into the emergency department with possible frostbite of both feet after losing consciousness in a snow drift while walking home from a party. What actions should the nurse take at this time? Select all that apply. - Correct Answer ✅Handle the feet gently. Elevate the feet to heart level. Cover the feet with dry sterile gauze. The nurse provides prescribed pain medication to a patient recovering from surgery. What additional actions should the nurse take to provide comfort for this patient? Select all that apply. - Correct Answer ✅Relieve a full bladder Reduce overhead lighting Reduce environmental noise Place in a comfortable position A patient with a neck injury is experiencing nausea and begins to vomit. What should the nurse do to help this patient? - Correct Answer ✅Log roll onto one side. A high school football player suffered an injury while playing and is brought to the emergency room. The primary survey shows an alert patient with
patent airway, breathing, a carotid pulse, and skin color within normal limits. The patient reports, "I can't flex my foot or point my toes." On which area should the nurse expect diagnostic tests to focus for this patient? - Correct Answer ✅The lower back The nurse suspects a patient is experiencing anaphylaxis after a bee sting to the arm. What did the nurse most likely assess in this patient? Select all that apply. - Correct Answer ✅Decreasing blood pressure Respiratory distress with stridor Increased fluid and mucus in bronchial passages The nurse is assisting the patient who has a urinary catheter with bathing. The urinary bag has 300 milliliters of clear pale yellow urine and is placed below the level of the bladder. The nurse notes that the catheter moves freely when the patient turns. Which action should the nurse take to decrease the patient's risk for urinary infection? - Correct Answer ✅Secure urinary catheter per agency policy. A patient is experiencing blurred vision, dysphagia, dysphonia, dysarthria, diplopia, and descending flaccid paralysis. For which type of poisoning should the nurse plan care for this patient? - Correct Answer ✅Botulism A patient suffered a head injury in a boating accident. Upon admission, the patient is conscious and responsive to questions. About 2 hours later, the patient reports headache, nausea, and drowsiness and has slurred speech. Which of the following nursing actions is best? - Correct Answer ✅Raise head of bed.
The transmission of genetic information in the cell involves several steps. Place the following steps in order (1-5) as they occur. - Correct Answer ✅DNA replicates, forming mRNA. mRNA attaches to a ribosome. tRNA carries amino acids to the ribosome. mRNA leaves the nucleus of the cell. Peptide bonds form between amino acids. A patient is diagnosed with shingles. What organism should the nurse explain as causing this health problem in the patient? - Correct Answer ✅Varicella zoster A patient is being treated for anaphylactic shock caused by a hornet sting. What should the nurse ensure occurs before the patient is discharged? - Correct Answer ✅Receive a prescription for epinephrine auto-injector. The nurse is reviewing risk factors for the development of lung cancer. What percentage of lung cancer is related to smoking in men? - Correct Answer ✅90% While volunteering at a community 5K (5-kilometer) race, the nurse suspects a runner is suffering from heat exhaustion. What manifestations did the nurse assess in this runner?
Select all that apply. - Correct Answer ✅Dizziness Vomiting Irritability Temperature 100.5°F A patient is scheduled for a diagnostic test used to outline tissue density and masses within the pelvis and breast. Which diagnostic test is this patient having? - Correct Answer ✅Ultrasound A patient is diagnosed with the Epstein-Barr virus. Epstein-Barr put the patient at increased risk for which type of cancer? - Correct Answer ✅Lymphoma A patient with chronic renal failure has been diagnosed with a foot wound. What should the nurse expect when antibiotic orders are written by the health care provider (HCP)? - Correct Answer ✅Prescribed dose will be lower than recommended. A patient rates a pain level of 5 on a scale of 0 to 10. Which type of analgesic should the nurse prepare to provide the patient? - Correct Answer ✅Low- dose opioid In the perianesthesia care unit, the nurse monitors the patient's temperature, pulse rate, respiration rate, blood pressure, and pain level. What additional bodily function should the nurse monitor in this patient? - Correct Answer ✅Oxygen saturation The nurse is reviewing pain control approaches in preparation for a patient care conference. Which theory of pain developed in the mid-1960s should
the nurse realize is most likely being used for patient pain control today? - Correct Answer ✅Gate A patient is diagnosed with a type of cancer that affects the skin and urinary system. What term should the nurse use to describe this type of cancer? - Correct Answer ✅Carcinoma During pre-admission, the data collection for a 24-year-old woman scheduled for a cholecystectomy includes a complete blood count and chest radiograph based on her age and medical history. What other test should the nurse anticipate being ordered? - Correct Answer ✅Pregnancy test A 2-day postoperative patient is receiving 1000 mL normal saline over 10 hours. The patient has an intake of 4 ounces of orange juice, one 8-ounce cup of coffee, 3 cups of water, and 1 cup of tea. This patient has a total intake of _________ mL over the 12-hour period. - Correct Answer ✅ 2520 The nurse is beginning an assessment of a patient suspected of being in shock. What should the nurse do first? - Correct Answer ✅Determine if the airway is patent. The nurse is assisting with the assessment of a patient undergoing chemotherapy with doxorubicin. Which side effect(s) should the nurse observe? Select all that apply. - Correct Answer ✅Alopecia Red urine Cardiac damage Nausea and vomiting
An older patient with a fulminating foot wound is entering the late phase of septic shock. Which actions should the nurse take to support the patient at this time? Select all that apply. - Correct Answer ✅Provide meticulous skin care. Provide oxygen via face mask as prescribed. Administer IV antibiotics as prescribed. Monitor infusion of prescribed IV fluids. The adult daughter of a skilled facility resident is concerned because the patient is becoming increasingly irritable and nasty to the daughter and care providers. What should the nurse suspect is occuring with the patient? - Correct Answer ✅An infection The nurse is preparing to provide acetaminophen (Tylenol) as needed to the following patients. For which patient should the nurse question the order? - Correct Answer ✅A 38-year-old with history of alcoholism When preparing to witness the signing of the consent form, the patient starts asking many questions about the surgery and its possible complications. What action should the nurse take? - Correct Answer ✅Have the physician answer the patient's questions before consent signing. The nurse is providing care for a patient returning from knee replacement surgery who is taking maintenance doses of methadone related to a history of drug abuse. Postoperative orders include Tylenol with codeine, 2 tablets every 4 hours as needed for pain, and methadone, 5 mg every 6 hours. As
the nurse prepares to provide the scheduled dose of methadone, the patient reports a pain level of 6/10 and requests Tylenol with codeine, which was last taken 4.5 hours ago. Which action by the nurse is best? - Correct Answer ✅Give the methadone and the Tylenol with codeine. While reviewing laboratory results the nurse suspects that a patient receiving chemotherapy for cancer has reached the nadir. What action(s) should the nurse take at this time? Select all that apply. - Correct Answer ✅Maximize infection control practices. Closely examine the skin and mucous membranes for bleeding. A patient diagnosed with hypovolemic shock has an estimated blood loss of 500 mL, 250 mL of emesis, and 250 mL of insensible water losses. The health care provider prescribes the patient to receive 3 mL of 0.9% normal saline via IV infusion to replace each mL of fluid loss to be infused over 24 hours. How many mL of the fluid should the patient receive each hour? Calculate to the nearest whole number. - Correct Answer ✅ 125 A student nurse is observing surgery in which a general anesthetic is being administered. After the intravenous (IV) induction agent is given, what action should the nurse anticipate the anesthesia provider will take next? - Correct Answer ✅Use an endotracheal tube to intubate the patient. A patient is prescribed a dose of ondansetron (Zofran) before surgery. What should the nurse explain to the patient about the purpose of this medication?
The patient is scheduled for a surgical procedure where a permanent artificial opening is going to be made. Which suffix should the nurse use when documenting this patient's surgery? - Correct Answer ✅-ostomy The nurse is explaining cancer to a group of community members. Which should the nurse use as the best definition of cancer? - Correct Answer ✅A cluster of disorganized cells that grow out of control A patient is having procedural sedation and analgesia for a short surgical procedure. How often should the nurse monitor the patient's vital signs? - Correct Answer ✅Every 5 minutes A patient receiving amifostine (Ethyol) as a cytoprotectant asks, "Is that the medication that prevents vomiting?" What should the nurse respond to the patient? - Correct Answer ✅"No, this medication is given to prevent kidney damage by the chemotherapy agents." The nurse is working on a medical surgical unit that has recently noticed an increase in the incidence of vancomycin-resistant enterococci infections. Which patients are at increased risk for vancomycin-resistant enterococci? Select all that apply. - Correct Answer ✅An 84-year-old man with pneumonia who is receiving intravenous (IV) vancomycin A 92-year-old woman with a cerebrovascular attack who has an indwelling catheter A 74-year-old woman with lymphoma receiving chemotherapy via an implanted port
A patient is experiencing respiratory depression, constipation, nausea and vomiting, and hypotension after receiving pain medication. Which class of analgesics is this patient most likely receiving? - Correct Answer ✅Opioid analgesics The nurse is doing discharge teaching with a chemotheray patient who has developed leukopenia. Which statement by the patient to the nurse indicates that additional teaching is needed? - Correct Answer ✅"I should report bleeding or bruising." A patient is diagnosed with the most common type of distributive shock. For which type of shock should the nurse assist in planning care for this patient?