NSG 239 MEDSURG 3 FINAL EXAM 2025
QUESTIONS AND DETAILED CORRECT
ANSWERS WITH RATIONALES |
A+GRADE
A client with known HIV-II is admitted to the hospital with
fever, night sweats, and severe cough. Laboratory results
include a CD4+ cell count of 180/mm3 and a negative
tuberculosis (TB) skin test 4 days ago. What action would
the nurse take first? Correct Answer Place the client under
Airborne Precautions
A client has just been informed of a positive HIV test. The
client is distraught and does not know what to do. What
intervention by the nurse is best? Correct Answer Assess
the client for support systems.
A nurse is teaching the client with systemic lupus
erythematosus about prednisone. What information is the
priority? Correct Answer Never stop prednisone abruptly.
Rationale: The nurse teaches the client to avoid
stopping the drug abruptly as the priority because this
can lead to a life-threatening adrenal crisis
The nurse is caring for clients on the medical-surgical unit.
What action by the nurse will help prevent a client from
having a type II hypersensitivity reaction? Correct Answer
Correctly identifying the client prior to a blood transfusion
,A client has been newly diagnosed with systemic lupus
erythematosus and is reviewing self-care measures with
the nurse. Which statement by the client indicates a need
to review the material? Correct Answer "Baby powder is
good for the constant sweating."
Rationale: Constant sweating is not a sign of SLE and
powders are drying so they should not be used, at
least not in excess
A nurse has educated a client on an epinephrine
autoinjector. What statement by the client indicates
additional instruction is needed? Correct Answer "I don't
need to go to the hospital after using it."
Rationale: Clients would be instructed to call 911 and
go to the hospital for monitoring after using the
autoinjector.
A client is in the hospital and has received two doses of an
angiotensin-converting enzyme for hypertension. When
the nurse answers the client's call light, the client presents
an appearance as shown below:
"Lady's face is swollen" Correct Answer Ensure a patent
airway while calling the Rapid Response Team.
Rationale: This client has angioedema which is a
severe type I hypersensitivity reaction and is most
commonly caused by ACE-inhibitors. The nurse would
, ensure the client's airway is patent and either call the
Rapid Response Team or delegate this to someone
else.
The nurse is studying hypersensitivity reactions. Which
reactions are correctly matched with their hypersensitivity
types? (Select all that apply.) Correct Answer A. Type I—
examples include hay fever and anaphylaxis.
C. Type III—immune complex deposits in blood vessel
walls.
D. Type IV—examples are poison ivy and transplant
rejection.
The nurse is assessing a client for signs and symptoms of
systemic lupus erythematosus (SLE). Which of the
following would be consistent with this disorder? (Select all
that apply.) Correct Answer A. Discoid rash on skin
exposed to sunlight
B. Urinalysis positive for casts and protein
D. Pain on inspiration
F. Serum positive for antinuclear antibodies (ANA)
A nurse assesses clients at a family practice clinic for risk
factors that could lead to dehydration. Which client is at
greatest risk for dehydration? Correct Answer A 76 year
old who is cognitively impaired.
A nurse is caring for an older client who exhibits
dehydration-induced confusion. Which intervention by the
nurse is best? Correct Answer Assess client further for fall
risk.
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