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MED SURG EXAM 2 QUESTIONS AND ANSWERS
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MED SURG EXAM 2 QUESTIONS AND ANSWERS
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MED SURG EXAM 2 QUESTIONS AND ANSWERSThe nurse assesses a surgical patient the morning of the first postoperative day and
notes redness and warmth around the incision. Which action by the nurse is most
appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours - Answers -Answer: B
Rationale: The incisional redness and warmth are indicators of the normal initial
(inflammatory) stage of wound healing by primary intention.
A 24-year-old patient who is receiving antibiotics for an infected leg wound has a
temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Give the prescribed PRN aspirin (Ascriptin) 650 mg.
d. Check the patient's oral temperature again in 4 hours. - Answers -Answer: D
Rationale: Mild to moderate temperature elevations (less than 103° F) do not harm the
young adult patient and may benefit host defense mechanisms. The nurse should
continue to monitor the temperature. Antipyretics are not indicated unless the patient is
complaining of fever-related symptoms. There is no need to notify the patient's health
care provider or to use a cooling blanket for a moderate temperature elevation.
Which nursing action is most likely to detect early signs of infection in a patient who is
taking immunosuppressive medications?
a. Monitor white blood cell count.
b. Check the skin for areas of redness.
c. Check the temperature every 2 hours.
d. Ask about fatigue or feelings of malaise. - Answers -Answer: D
Rationale: Common clinical manifestations of inflammation and infection are frequently
not present when patients receive immunosuppressive medications. The earliest
manifestation of an infection may be "just not feeling well."
When evaluating the response to treatment for a patient with a fluid imbalance, the most
important assessment to include is
a. skin turgor.
b. presence of edema.
c. hourly urine output.
d. daily weight. - Answers -Answer: D
Rationale: Daily weight is the most easily obtained and accurate means of assessing
volume status. Skin turgor varies considerably with age. Considerable excess fluid
volume may be present before fluid moves into the interstitial space and causes edema.
, Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible
loss, sweating, or loss from the gastrointestinal tract or wounds.
When caring for an alert and oriented elderly patient with a history of dehydration, the
home health nurse will teach the patient to increase fluid intake
a. when the patient feels thirsty.
b. in the late evening hours.
c. as soon as changes in LOC occur.
d. if the oral mucosa feels dry. - Answers -Answer: D
Rationale: An alert, elderly patient will be able to self-assess for signs of oral dryness
such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases
with age and is not an accurate indicator of volume depletion. Many older patients
prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will
not be likely to notice and act appropriately when changes in LOC occur.
A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of
hypertension. The nurse will teach the patient to report symptoms of adverse effects
such as
a. generalized weakness.
b. facial muscle spasms.
c. frequent loose stools.
d. personality changes. - Answers -Answer: A
Rationale: Generalized weakness progressing to flaccidity is a manifestation of
hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are
associated with hyperkalemia. Personality changes are not associated with electrolyte
disturbances, although changes in mental status are common manifestations with
sodium excess or deficit.
The long-term-care nurse is evaluating the effectiveness of protein supplements on a
patient who has low serum total protein level. Which of these data indicate that the
patient's condition has improved?
a. Absence of peripheral edema
b. Good skin turgor
c. Hematocrit 28%
d. Blood pressure 110/72 mm Hg - Answers -Answer: A
Rationale: Edema is caused by low oncotic pressure in individuals with low serum
protein levels; the absence of edema indicates an improvement in the patient's protein
status. Good skin turgor is an indicator of fluid balance, not protein status. A low
hematocrit could be caused by poor protein intake. Blood pressure does not provide a
useful clinical tool for monitoring protein status
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to
take prescribed medications and seems confused. The patient complains of "just
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