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NURS 480 MED SURGE FINAL EXAM NEWEST 2024
ACTUAL EXAM COMPLETE 100 QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect? - ANSWER- Intense pain with movement 2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? - ANSWER- Chills 3 A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse take to prevent hip dislocation? - ANSWER- Place two bed pillows between the legs when in bed 4 A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances - ANSWER- Latex
5 A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching? - ANSWER- Hold breaths about 3 to 5 seconds before exhaling 6 A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8mEq/L. Which of the following interventions should the nurse implement first? - ANSWER- Initiate cardiac monitoring for the clients 7 A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? - ANSWER- Hang the drainage bag below the client's abdomen 8 A nurse is preforming a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? - ANSWER- Disequilibrium with movement 9 A nurse is planning care for a client who is one day postoperative Following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care? - ANSWER- apply compression stockings to the lower extremities
14 A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider? - ANSWER- May operate a motor vehicle when no longer taking analgesics A nurse is setting up a sterile field before preforming a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply) - ANSWER- - Grasp 2.5cm (1 in) of the outer edge to open the surgical wrap.
- Open the first flap of the sterile package toward the nurse's body.
- Place a surgical pack with a sterile drape on the work surface. 16 A nurse is an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180mg/dL. Which of the following actions is the nurse's priority? - ANSWER- Insert an NG tube 17 A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the first sign of deteriorating neurological status? - ANSWER- Altered level of Consciousness
18 A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse Identify as an indication of melanoma? - ANSWER- Flat lesion with irregular borders 19 A nurse is caring for a client who has diabetes insipidus. Which Of the following medications should the nurse plan to administer. - ANSWER- Desmopressin 20 A nurse is preparing to assist with the insertion of a non- tunneled Central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take. - ANSWER- Place the client's head on the bed lower than the foot. (Trendelenburg) 21 A nurse is caring for a client who had an arterial revascularization of the lower extremity. Which of the following is the priority action the nurse should plan to take after contacting the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) a) Increase the insulin rate per protocol. ??? b) Increase the heparin infusion rate per protocol. c) Change the PCA timing of the patient control bolus to every 15 min.
26 A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? - ANSWER- Instruct the client to avoid eating raw fruit. 27 A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? - ANSWER- Hemoglobin 10 mg/ dL 28 A nurse is caring for a client who was admitted with nausea, vomiting, and possible bowel obstruction. An Ng tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider? - ANSWER- The client's abdomen becomes distended and firm. 29 A nurse is reviewing the medical record of a client who is scheduled for a CT scan with a contrast media. Which of the following medications should the nurse instruct the client to withhold for 48hr following the procedure? - ANSWER- Metformin 30 A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following
actions should the nurse plan to take first? - ANSWER- Instill 0.9% sodium chloride solution into the affected eye. 31 A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? - ANSWER- "I rest in my recliner with my feet elevated for about an hour every afternoon." 32 A nurse is collecting data from a client who has toxoplasmosis and is HIV positive. Which of the following questions should the nurse ask to gather data about toxoplasmosis? - ANSWER- "Do you have any household pets, such as a cat?" 33 A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility? - ANSWER- Confusion 34 A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes? - ANSWER- To prevent alveolar collapse
40 A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first? - ANSWER- Ensure the tubing connections are secure 41 A nurse is caring for a client who is 6hr postoperative following application of an external fixator for a tibial fracture. Which of the following actions should the nurse take? - ANSWER- Palpate the dorsalis pedis pulse. 42 A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level on a scale of 0 to 10. Which of the following interventions should the nurse take? - ANSWER- Apply ice pack to the client's knee 43 A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? - ANSWER- Cloudy effluent 44 A nurse in a emergency department is caring for a client who is to receive tissue plasminogen activator (TPA) for the treatment of an ischemic stroke. In which order should the nurse
complete the following actions? (Move the steps into the box on the right, placing them into the selected order of performance. Use all the steps.) - ANSWER- 1. Check for contraindications 2.weight the client
- Administer the TPA
- Transfer the client to the CUU 45 A nurse in the emergency department admitted a client who is having a myocardial infarction. The client has been placed on the heart monitor. Which of the following electrocardiogram strips is indicative of a myocardial infraction? - ANSWER- ST Elevation? 46 A nurse is assessing a client who has acute pancreatitis and has been receiving a total parenteral nutrition for the past 72hr. Which of the following findings requires the nurse to intervene?
- ANSWER- Crackles in bilateral lower lobes 47 A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity for which of the following clients? - ANSWER- A client who has a right upper extremity arteriovenous fistula
experiencing referred pain? - ANSWER- A client who has pancreatitis reports pain in the left shoulder. 53 a nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? - ANSWER- Thrombocytopenia 54 A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? - ANSWER- History if Crohn's disease 55 A nurse is completing discharge teaching with a client who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching? - ANSWER- Use a 10-mL syringe to flush the line 56 A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold? - ANSWER- Metformin
57 A nurse is caring for a client who has developed a heart rate of 38/min and reports tremors and feeling faint. Which of the following medications should the nurse anticipate administering? - ANSWER- Atropine sulfate 58 A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? - ANSWER- WBC count 15,000/mm 59 A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? - ANSWER- Administer Atropine to the client 60 A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red orange in color. Which of the following responses should the nurse make? - ANSWER- "This is an expected adverse effect on this medication. 61 A nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include? - ANSWER- Trim toenails straight across
- A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching? - ANSWER- Decrease time spent outdoors
- A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside? - ANSWER- Protamine sulfate
- A nurse is providing discharge teaching to a client who has ileostomy. Which of the following client statements indicates an understanding of the teaching. - ANSWER- "I will expect my stools to be loose."
- A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permeant peacemaker? - ANSWER- Complete AV block with rates slower than 40/mm 71 A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relive some of the side effects. Which of the following findings should the
nurse identify as a contraindication to receiving this alternate therapy? - ANSWER- Lymphedema 72 A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? - ANSWER- Check the client's urine output 73 A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? - ANSWER- Cachexia 74 A nurse is assessing a client who has a gravity drain in place following an open cholecystectomy. Which of the following images should the nurse identify as a gravity drain? - ANSWER- ? Jackson-Pratt? 75 A home health nurse is assessing the home environment of a client who has cystic fibrosis. Which of the following equipment should the nurse plan to recommend? - ANSWER- Chest physiotherapy vest 76 A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client
82 A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infraction? - ANSWER- ST segment 83 A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? - ANSWER- 200 mL of brown drainage? 84 A nurse is caring for a client who understands a prescribed surgical procedure but cannot read or write. Which of the following actions should the nurse take? - ANSWER- Contact the client's power of attorney to sign the consent. 85 A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching? - ANSWER- "I can season my foods with lemon juice." 86 A nurse is reviewing ECG rhythm strips for a group of clients. The nurse should identify which of the following rhythms indicates bradycardia? - ANSWER-? PR Interval area ?
87 A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? - ANSWER- Clean surfaces with chlorhexidine ? 88 A nurse is preparing to administer a unit of packed RBCs over 1 hr. Which of the following actions should the nurse plan to take? - ANSWER- Use Y tubing with 0.9% sodium chloride when administering the transfusion 89 A nurse is caring for a client following a below-the-knee amputation. The client states. "My life is over." Which of the following responses should the nurse make? - ANSWER- "Why do you think your life is over?"? 90 A nurse is assessing a client who has a pressure ulcer. Which of following findings should the nurse expect as an indication that the wound is healing? - ANSWER- Dark red granulation tissue? 91A nurse is providing teaching to a client who has left sided heart failure. Which of the following manifestations should the nurse include in the teaching. - ANSWER- Hacking cough
