Med Surg Exam 1 Practice Test

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

"As long as I change my gloves between clients, it is not necessary to wash my hands." -While the use of gloves does reduce contamination, it is still necessary to perform hand hygiene between clients. All health care personnel must perform hand hygiene, either with an alcohol-based product or with soap and water, before and after every client contact, after removing gloves, after contact with body fluids, before eating, and after using the restroom.

​A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following is an appropriate response?

"Can you tell me more about this concern?" -The nurse's response offers a general lead to encourage the client to verbalize her feelings. This will encourage the client to communicate more about her fear so the nurse can intervene effectively.

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

"Tell me more about your concerns." -This response is an example of the therapeutic communication technique of providing general leads. It encourages the client to express his feelings and gives the nurse additional data about the client.

A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They'll improve your circulation to keep blood from pooling in your legs." -Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis (clot formation) and peripheral edema.

A nurse is caring for a client who is scheduled for a blood sampling for a serum creatinine level. The client asks the nurse, "What is the purpose for this test?" Which of the following responses should the nurse give?

"This test will inform your provider how your kidneys are functioning." -The nurse should inform the client that the purpose for the serum creatinine level is to determine the functioning of the client's kidneys.

A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse include?

"Wear loose fitting clothing while you are experiencing itching." -The nurse should advise the client that to help relieve the itching of pruritus, the home environmental temperature should be slightly cool and the client should wear loose clothing.

Which lab value(s) indicates compromised renal function? (SATA)

-Creatinine 3.0mg/dL -BUN 35mg/dL

When is the best time to perform preoperative teaching?

1 to 2 days before surgery

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?

An NG tube to suction -Hypokalemia is low serum potassium. When connected to a suction source, an NG tube empties the stomach of gastric contents. Gastric contents are high in electrolytes and losing them puts the client at risk for hypokalemia and other electrolyte imbalances.

A nurse is contributing to the plan of care for a client who has herpes zoster. Which of the following actions should the nurse recommend including in the plan of care?

Apply cool compresses to the affected area. -Clients who have herpes zoster often complain of itching and pain over the affected area. Applying calamine lotion and cool compresses can assist in decreasing these manifestations.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10. -Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.

Incentive spirometer can help to prevent...

Atelectasis

A nurse is reviewing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? Potassium 4.5 mEq/L Platelets 250,000 cells/mcl BUN 45mg/dL Serum Creatinine 0.8mg/dL

BUN 45mg/dL

A client arrives for initial evaluation following a diagnosis of systemic lupus erythematosus (SLE). The nurse understands that which of the following is a classic cutaneous manifestation of SLE?

Butterfly rash on face -The nurse should identify a butterfly rash as a common cutaneous manifestation for the client who has SLE. Other common findings include hair loss, weakness, and sun sensitivity resulting in a widespread rash.

A nurse is caring for a client who is HIV-positive and is 1 day postoperative following an appendectomy. Which of the following actions requires the nurse to wear a gown as personal protective equipment (PPE)?

Changing a wound dressing -Standard precautions require the nurse to wear PPE when there is a risk of contact with body fluids. While performing a dressing change for a client who is HIV-positive, the nurse is at risk for contact with body fluids, such as wound exudate or drainage, so the nurse should wear gloves and a gown. If the nurse irrigates the wound, she should also wear a face shield.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. -The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Count the apical pulsations for a full minute. -For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds.

A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?

Cover the wound with a moist sterile dressing. -A deep wound open to air is at serious risk for contamination, and exposed organ tissue could become dry and ischemic. The nurse should cover the wound with a moist sterile dressing to prevent further injury.

A nurse is assisting with discharge of a client who is postoperative from a kidney transplant. The nurse should instruct the client that which of the following is an indication of rejection?

Decreased urine output -Following kidney transplant the client is at risk for both acute and chronic rejection. Acute rejection occurs in a few months after the procedure, while chronic rejection may not occur for several years. Indications of rejection include a decrease in urine output.

While examining a client's temporomandibular joint, a nurse identifies pain, crepitus, and a popping sound. Because of these findings, to which of the following providers should the nurse request a referral for the client?

Dentist -The temporomandibular joint connects the mandible to the temporal bone. The clinical manifestations of pain, crepitus, and a popping sound require further evaluation and assessment. Referral to a dentist for evaluation and diagnosis is an appropriate intervention.

A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?

Discontinue the existing IV infusion. -The greatest risk to this client is further injury from the IV infusion or catheter; therefore, the first action the nurse should take is to discontinue the infusion by stopping the fluid flow and removing the catheter. Redness, swelling, and warmth indicate phlebitis.

​A nurse is contributing to the care plan for a client who has developed deep-vein thrombosis. Which of the following interventions should the nurse include?

Elevate the affected extremity when the client is resting. -Supportive treatment for DVT includes elevation of the extremity when the client is in bed or in a chair.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?

Encourage the client to drink more fluids. -Fluids help liquefy and thin pulmonary secretions, which facilitates expectoration to clear the airways. The client should drink 1,500 to 2,500 mL/day to keep secretions thin.

A nurse is verifying informed consent for a client who is having a C-section. Which of the following actions should the nurse take?

Ensure the client understands information about the procedure.

A nurse is caring for a client following the application of an aquathermia pad. Which of the following manifestations should the nurse identify as an indication that the client has a superficial burn?

Erythema -Erythema is a manifestation of a superficial burn.

A nurse is caring for a client who is at risk for shock. Which of the following findings should the nurse expect?

Increased blood pressure -Decreased blood pressure is a manifestation of shock.

A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Grasp a fold of skin on the client's forearm or near the sternum. -Skin turgor is evaluated by grasping a fold of skin on the forearm or near the sternum and then releasing it. Turgor is absent if the skin remains tented and does not return to its normal position.

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

Low BP and high pulse rate -Shock is a serious complication that develops from a lack of adequate blood flow, decreased tissue perfusion, and decreased cardiac output. Vital signs reflecting shock include low blood pressure, increased respiratory rate, and a rapid pulse as the cardiovascular system tries to compensate.

A nurse is caring for a client who has recurrent herpes simplex type 1 lesions. The nurse should perform a focused assessment of which of the following areas of the client's body?

Mouth -Herpes simplex type 1 most commonly occurs on the client's mouth.

A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect?

Muscle hypotonicity -The nurse should expect a client who has an elevated calcium level to have muscle hypotonicity.

After signing an informed consent form, a client tells the nurse, "I have changed my mind and do not want to have the procedure." Which of the following actions should the nurse take?

Notify the surgeon that the client wishes to withdraw informed consent for the procedure. -The client has the right to withdraw informed consent; therefore, the nurse should notify surgeon of the change in the client's wishes.

A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

Obtain a 12-lead ECG. -This client's potassium level is above the expected reference range. Because hyperkalemia can cause ECG changes, including ventricular dysrhythmias and cardiac arrest, it is essential to obtain a 12-lead ECG and to monitor for such changes.

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Reposition the client at least every 2 hr. -The nurse should change the client's position at least every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?

Obtain a detailed history. -The nurse should first obtain a history in order to determine possible causes of the bruises. While collecting additional data, the nurse should observe the parent and child for other indicators of abuse.

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the client's infection?

Performing hand hygiene before, during, and after direct contact with the client -The nurse interrupts the transmission of micro-organisms .by removing them from her hands frequently before, during, and after client care procedures.

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

Place the dressing in a biohazardous waste container. -The nurse should discard potentially infective material, such as a dressing that contains blood, in a biohazardous waste container separate from the regular trash.

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan?

Provide the client a diet high in vitamin C. -Vitamin C is essential for wound healing to promote formation of new capillaries, synthesis of new tissue and development of collagen.

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed. -According to evidenced-based practice, the nurse should first elevate the head of the bed ton reduce the client's workload and minimize fatigue. It uses gravity to drop the abdominal organs away from the diaphragm, which allows optimal expansion of the lungs.

A nurse is reinforcing teaching with a client who has herpes zoster. The nurse should include which of the following statements in the teaching?

Recurrence of infection can be triggered by stress or trauma. -The virus remains in the body in a dormant state in the nerve ganglia and the client is asymptomatic. Recurrence of herpes zoster is triggered by physical or psychological stressors such as trauma, fever, or malignancy.

A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of the following laboratory values should the nurse review to determine the client's renal function?

Serum creatinine -Many clients with SLE have deposits of protein within the glomeruli of the kidneys and may develop lupus nephritis (persistent inflammation in the kidneys) or chronic renal failure. A disorder of renal function reduces the excretion of creatinine, resulting in increased levels of serum creatinine. The nurse should identify serum creatinine as a sensitive indicator of renal function.

A nurse is caring for a client who is about to undergo exploratory surgery to remove a malignant tumor and to determine the extent of any metastasis. The client tells the nurse that she is not hopeful that she will recover and begins to cry. Which of the following responses should the nurse make?

Sit quietly with the client and follow her cues. -This demonstrates using silence and active listening, therapeutic techniques that offer support and acceptance and encourage further communication.

The nurse is reviewing the presurgical laboratory results for a patient who has history of cardiac problems. Which abnormal result is of greatest concern?

Sodium 155mEq/L

A nurse is collecting date on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

The client produces black colored sputum. -When using the urgent vs. nonurgent approach to client care, the nurse determines the priority finding is black colored sputum which is a manifestation of smoke inhalation and can lead to pulmonary failure and respiratory distress.

A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Urinary catheterization -Invasive nursing procedures are common causes of HAIs. These include urinary catheterization, IV infusions, and administration of parenteral medications.

A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

Thready pulse -A client who has hypovolemia will experience decreased volume of circulating blood and less pressure within the vessels, resulting in weak, thready peripheral pulses and flat neck veins.

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Urine specific gravity 1.034 -The client's urine specific gravity is elevated, reflecting concentrated urine, which is a manifestation of dehydration.

A nurse in a provider's office is reinforcing teaching with a parent of a school-age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching?

Wash all bed linens and dry them in a dryer for at least 20 min. -Pediculosis capitis, or head lice, can be transferred via bed linens. All linens must be washed in hot water and dried in a hot dryer for at least 20 min to destroy lice and their eggs.

A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?

Wear an N95 respirator mask. -The nurse should wear an N95 respirator mask to prevent exposure to infectious particles. Pt should be in negative pressure airflow.

When the postoperative patient complains of sudden chest pain combined with shortness of breath, cyanosis, and anxiety, the nurse recognizes the signs of:

pulmonary embolism

A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

​Atelectasis -Atelectasis is incomplete alveolar expansion or collapse. Breath sounds are absent over areas of alveolar collapse.

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment is should the nurse wear when setting up the client's meal tray?

​Mask -The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client.

A nurse is preparing to administer an IM dose of meperidine to a client. Monitoring which of the following is the nurse's priority data-collection activity?

​Respiratory rate -When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is respiratory rate. Meperidine, an opioid analgesic, can cause respiratory depression; therefore, the nurse should determine the client's baseline respiratory rate and then monitor for changes after administration of the medication.

​A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

​Witness the client's signature. -It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that the client is consenting voluntarily and appears to be competent to do so. The nurse should also verify that the client understands the information the person performing the procedure gave to the client.