Exam (elaborations)
EXAM 2 MED SURG QUESTIONS WITH CORRECT ANSWERS
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EXAM 2 MED SURG QUESTIONS WITH CORRECT ANSWERS
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EXAM 2 MED SURG QUESTIONS WITHCORRECT ANSWERS
The bbnurse bbassesses bba bbsurgical bbpatient bbthe bbmorning bbof bbthe bbfirst
bbpostoperative bbday bband bbnotes bbredness bband bbwarmth bbaround bbthe bbincision.
bbWhich bbaction bbby bbthe bbnurse bbis bbmost bbappropriate?
a. bbObtain bbwound bbcultures.
b. bbDocument bbthe bbassessment.
c. bbNotify bbthe bbhealth bbcare bbprovider.
d. bbAssess bbthe bbwound bbevery bb2 bbhours bb- bbAnswer bbAnswer: bbB bb
Rationale: bbThe bbincisional bbredness bband bbwarmth bbare bbindicators bbof bbthe
bbnormal bbinitial bb(inflammatory) bbstage bbof bbwound bbhealing bbby bbprimary bbintention.
A bb24-year-old bbpatient bbwho bbis bbreceiving bbantibiotics bbfor bban bbinfected bbleg
bbwound bbhas bba bbtemperature bbof bb101.8° bbF bb(38.7° bbC). bbWhich bbaction bbby bbthe
bbnurse bbis bbmost bbappropriate?
a. bbApply bba bbcooling bbblanket.
b. bbNotify bbthe bbhealth bbcare bbprovider.
c. bbGive bbthe bbprescribed bbPRN bbaspirin bb(Ascriptin) bb650 bbmg.
d. bbCheck bbthe bbpatient's bboral bbtemperature bbagain bbin bb4 bbhours. bb- bbAnswer
bbAnswer: bbD bb
Rationale: bbMild bbto bbmoderate bbtemperature bbelevations bb(less bbthan bb103° bbF) bbdo
bbnot bbharm bbthe bbyoung bbadult bbpatient bband bbmay bbbenefit bbhost bbdefense
bbmechanisms. bbThe bbnurse bbshould bbcontinue bbto bbmonitor bbthe bbtemperature.
bbAntipyretics bbare bbnot bbindicated bbunless bbthe bbpatient bbis bbcomplaining bbof bbfever-
related bbsymptoms. bbThere bbis bbno bbneed bbto bbnotify bbthe bbpatient's bbhealth bbcare
bbprovider bbor bbto bbuse bba bbcooling bbblanket bbfor bba bbmoderate bbtemperature
bbelevation.
Which bbnursing bbaction bbis bbmost bblikely bbto bbdetect bbearly bbsigns bbof bbinfection bbin
bba bbpatient bbwho bbis bbtaking bbimmunosuppressive bbmedications?
a. bbMonitor bbwhite bbblood bbcell bbcount.
b. bbCheck bbthe bbskin bbfor bbareas bbof bbredness.
c. bbCheck bbthe bbtemperature bbevery bb2 bbhours.
d. bbAsk bbabout bbfatigue bbor bbfeelings bbof bbmalaise. bb- bbAnswer bbAnswer: bbD
Rationale: bbCommon bbclinical bbmanifestations bbof bbinflammation bband bbinfection bbare
bbfrequently bbnot bbpresent bbwhen bbpatients bbreceive bbimmunosuppressive
,bbmedications. bbThe bbearliest bbmanifestation bbof bban bbinfection bbmay bbbe bb"just bbnot
bbfeeling bbwell."
When bbevaluating bbthe bbresponse bbto bbtreatment bbfor bba bbpatient bbwith bba bbfluid
bbimbalance, bbthe bbmost bbimportant bbassessment bbto bbinclude bbis
a. bbskin bbturgor.
b. bbpresence bbof bbedema.
c. bbhourly bburine bboutput.
d. bbdaily bbweight. bb- bbAnswer bbAnswer: bbD
Rationale: bbDaily bbweight bbis bbthe bbmost bbeasily bbobtained bband bbaccurate bbmeans
bbof bbassessing bbvolume bbstatus. bbSkin bbturgor bbvaries bbconsiderably bbwith bbage.
bbConsiderable bbexcess bbfluid bbvolume bbmay bbbe bbpresent bbbefore bbfluid bbmoves
bbinto bbthe bbinterstitial bbspace bband bbcauses bbedema. bbHourly bburine bboutputs bbdo
bbnot bbtake bbaccount bbof bbfluid bbintake bbor bbof bbfluid bbloss bbthrough bbinsensible
bbloss, bbsweating, bbor bbloss bbfrom bbthe bbgastrointestinal bbtract bbor bbwounds.
When bbcaring bbfor bban bbalert bband bboriented bbelderly bbpatient bbwith bba bbhistory bbof
bbdehydration, bbthe bbhome bbhealth bbnurse bbwill bbteach bbthe bbpatient bbto bbincrease
bbfluid bbintake
a. bbwhen bbthe bbpatient bbfeels bbthirsty.
b. bbin bbthe bblate bbevening bbhours.
c. bbas bbsoon bbas bbchanges bbin bbLOC bboccur.
d. bbif bbthe bboral bbmucosa bbfeels bbdry. bb- bbAnswer bbAnswer: bbD bb
Rationale: bbAn bbalert, bbelderly bbpatient bbwill bbbe bbable bbto bbself-assess bbfor bbsigns
bbof bboral bbdryness bbsuch bbas bbthick bboral bbsecretions bbor bbdry-appearing bbmucosa.
bbThe bbthirst bbmechanism bbdecreases bbwith bbage bband bbis bbnot bban bbaccurate
bbindicator bbof bbvolume bbdepletion. bbMany bbolder bbpatients bbprefer bbto bbrestrict
bbfluids bbslightly bbin bbthe bbevening bbto bbimprove bbsleep bbquality. bbThe bbpatient bbwill
bbnot bbbe bblikely bbto bbnotice bband bbact bbappropriately bbwhen bbchanges bbin bbLOC
bboccur.
A bbpatient bbis bbtaking bbhydrochlorothiazide, bba bbpotassium-wasting bbdiuretic, bbfor
bbtreatment bbof bbhypertension. bbThe bbnurse bbwill bbteach bbthe bbpatient bbto bbreport
bbsymptoms bbof bbadverse bbeffects bbsuch bbas
a. bbgeneralized bbweakness.
b. bbfacial bbmuscle bbspasms.
c. bbfrequent bbloose bbstools.
d. bbpersonality bbchanges. bb- bbAnswer bbAnswer: bbA bb
Rationale: bbGeneralized bbweakness bbprogressing bbto bbflaccidity bbis bba bbmanifestation
bbof bbhypokalemia. bbFacial bbmuscle bbspasms bbmight bboccur bbwith bbhypocalcemia.
bbLoose bbstools bbare bbassociated bbwith bbhyperkalemia. bbPersonality bbchanges bbare
bbnot bbassociated bbwith bbelectrolyte bbdisturbances, bbalthough bbchanges bbin bbmental
bbstatus bbare bbcommon bbmanifestations bbwith bbsodium bbexcess bbor bbdeficit.
, The bblong-term-care bbnurse bbis bbevaluating bbthe bbeffectiveness bbof bbprotein
bbsupplements bbon bba bbpatient bbwho bbhas bblow bbserum bbtotal bbprotein bblevel.
bbWhich bbof bbthese bbdata bbindicate bbthat bbthe bbpatient's bbcondition bbhas bbimproved?
a. bbAbsence bbof bbperipheral bbedema
b. bbGood bbskin bbturgor
c. bbHematocrit bb28%
d. bbBlood bbpressure bb110/72 bbmm bbHg bb- bbAnswer bbAnswer: bbA bb
Rationale: bbEdema bbis bbcaused bbby bblow bboncotic bbpressure bbin bbindividuals bbwith
bblow bbserum bbprotein bblevels; bbthe bbabsence bbof bbedema bbindicates bban
bbimprovement bbin bbthe bbpatient's bbprotein bbstatus. bbGood bbskin bbturgor bbis bban
bbindicator bbof bbfluid bbbalance, bbnot bbprotein bbstatus. bbA bblow bbhematocrit bbcould bbbe
bbcaused bbby bbpoor bbprotein bbintake. bbBlood bbpressure bbdoes bbnot bbprovide bba
bbuseful bbclinical bbtool bbfor bbmonitoring bbprotein bbstatus
A bbnurse bbis bbassessing bba bbnewly bbadmitted bbpatient bbwith bbchronic bbheart bbfailure
bbwho bbforgot bbto bbtake bbprescribed bbmedications bband bbseems bbconfused. bbThe
bbpatient bbcomplains bbof bb"just bbblowing bbup" bband bbhas bbperipheral bbedema bband
bbshortness bbof bbbreath. bbWhich bbassessment bbshould bbthe bbnurse bbcomplete bbfirst?
a. bbSkin bbturgor
b. bbHeart bbsounds
c. bbMental bbstatus
d. bbCapillary bbRefill
Capillary bbrefill bb- bbAnswer bbAnswer: bbC
Increases bbin bbextracellular bbfluid bb(ECF) bbcan bblead bbto bbswelling bbof bbcells bbin
bbthe bbcentral bbnervous bbsystem, bbinitially bbcausing bbconfusion, bbwhich bbmay
bbprogress bbto bbcoma bbor bbseizures. bbAlthough bbskin bbturgor, bbcapillary bbrefill, bband
bbheart bbsounds bbalso bbmay bbbe bbaffected bbby bbincreases bbin bbECF, bbthese bbare
bbsigns bbthat bbdo bbnot bbhave bbas bbimmediate bbimpact bbon bbpatient bboutcomes bbas
bbcerebral bbedema.
After bbreceiving bbchange-of-shift bbreport, bbwhich bbpatient bbshould bbthe bbnurse
bbassess bbfirst?
a. bbPatient bbwith bbserum bbpotassium bblevel bbof bb5.0 bbmEq/L bbwho bbis bbcomplaining
bbof bbabdominal bbcramping
b.Patient bbwith bbserum bbsodium bblevel bbof bb145 bbmEq/L bbwho bbhas bba bbdry bbmouth
bband bbis bbasking bbfor bba bbglass bbof bbwater
c.Patient bbwith bbserum bbmagnesium bblevel bbof bb1.1 bbmEq/L bbwho bbhas bbtremors
bband bbhyperactive bbdeep bbtendon bbreflexes
d.Patient bbwith bbserum bbphosphorus bblevel bbof bb4.5 bbmg/dL bbwho bbhas bbmultiple
bbsoft bbtissue bbcalcium-phosphate bbprecipitates bb- bbAnswer bbAnswer: bbC
Rational: bbThe bblow bbmagnesium bblevel bband bbneuromuscular bbirritability bbsuggest
bbthat bbthe bbpatient bbmay bbbe bbat bbrisk bbfor bbseizures. bbThe bbother bbpatients bbhave
bbmild bbelectrolyte bbdisturbances bband/or bbsymptoms bbthat bbrequire bbaction, bbbut
bbthey bbare bbnot bbat bbrisk bbfor bblife-threatening bbcomplications.
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