Med surg consolidated test questions (extra practice prior to
final - direct from midterms) With Complete Solutions
A client has a deep wound covered with a wet-to-damp dressing.
Which intervention does the nurse include on this client's care
plan?
A) Apply a new dressing when the seal breaks and the dressing
leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. Correct
Answers D
Wet-to-damp dressings are changed every 4 to 6 hours to
provide maximum débridement. Synthetic dressings can be left
in place for extended periods of time but need to be changed if
the seal breaks and the exudate is leaking. Dry gauze dressings
should be changed when the outer layer becomes saturated.
A client has a small-bore nasoenteric feeding tube. The nurse
assesses the following vital signs: temperature, 100.2° F (37.8°
C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and
blood pressure, 106/62 mm Hg. Which action by the nurse takes
priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care
provider.
C) Auscultate lung sounds and obtain oxygen saturation.
,D) Add blue dye to the feeding tube formula. Correct Answers
C
The client may have aspirated. The nurse should further assess
the client's respiratory and oxygenation status. The client may
have another reason for the abnormal vital signs, so the nurse
should not pull out the tube before performing other
assessments. Adding blue dye to the tube feeding formula is not
recommended to check for aspiration. Slowing the feeding down
will not be helpful.
A client has a urinary tract infection. Which assessment by the
nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries Correct
Answers C
Clients who are severely immune compromised or who have
diabetes mellitus are more prone to fungal urinary tract
infection. The nurse should assess for these factors. A physical
examination and a post-void residual may be needed, but not
until further information is obtained. Travel to foreign countries
probably would not be as important, because even if exposed,
the client needs some degree of immune compromise to develop
a fungal urinary tract infection.
,A client has newly diagnosed diabetes. To delay the onset of
microvascular and macrovascular complications in this client,
the nurse stresses that the client take which action?
A) Restrict fluid intake.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia. Correct Answers C
Hyperglycemia is a critical factor in the pathogenesis of long-
term diabetic complications. Maintaining tight glycemic control
will help delay the onset of complications. Preventing
hypoglycemia and ketosis, although important, is not as
important as maintaining daily glycemic control. Restricting
fluid intake is not part of the treatment plan for clients with
diabetes.
A client is admitted with infection and a high fever. Which
assessments by the nurse take priority? (Select all that apply.)
A) Skin turgor
B) Pulse quality
C) Blood pressure
D) Bowel sounds
E) Respiratory effort
F) Mental status Correct Answers A, B, C, F
Dehydration can accompany fever, especially if the client is
sweating profusely. Blood pressure, pulse quality, and skin
turgor are assessments of fluid status. Mental status changes can
accompany fluid losses, especially in older clients.
, A client is admitted with left lower lung pneumonia. Which
assessment finding does the nurse correlate with this condition?
A) Expiratory wheeze on the right side
B) Crackles heard on expiration bilaterally
C) Dullness to percussion on the lower left side
D) Crepitus of the skin around the left lung Correct Answers C
The client with pneumonia may have dullness to percussion on
the affected side. The other options are all inconsistent with
pneumonia.
A client is hospitalized with a urinary tract infection (UTI).
Which clinical manifestation alerts the nurse to the possibility of
a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination Correct Answers B
Lower urinary tract infections are rarely associated with
systemic symptoms of fever and chills. A client with a UTI who
develops fever and chills should be assessed for the
development of pyelonephritis. The other options can be seen
with UTI.
A client is taking furosemide (Lasix) and becomes confused.
Which potassium level does the nurse correlate with this
condition?
final - direct from midterms) With Complete Solutions
A client has a deep wound covered with a wet-to-damp dressing.
Which intervention does the nurse include on this client's care
plan?
A) Apply a new dressing when the seal breaks and the dressing
leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. Correct
Answers D
Wet-to-damp dressings are changed every 4 to 6 hours to
provide maximum débridement. Synthetic dressings can be left
in place for extended periods of time but need to be changed if
the seal breaks and the exudate is leaking. Dry gauze dressings
should be changed when the outer layer becomes saturated.
A client has a small-bore nasoenteric feeding tube. The nurse
assesses the following vital signs: temperature, 100.2° F (37.8°
C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and
blood pressure, 106/62 mm Hg. Which action by the nurse takes
priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care
provider.
C) Auscultate lung sounds and obtain oxygen saturation.
,D) Add blue dye to the feeding tube formula. Correct Answers
C
The client may have aspirated. The nurse should further assess
the client's respiratory and oxygenation status. The client may
have another reason for the abnormal vital signs, so the nurse
should not pull out the tube before performing other
assessments. Adding blue dye to the tube feeding formula is not
recommended to check for aspiration. Slowing the feeding down
will not be helpful.
A client has a urinary tract infection. Which assessment by the
nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries Correct
Answers C
Clients who are severely immune compromised or who have
diabetes mellitus are more prone to fungal urinary tract
infection. The nurse should assess for these factors. A physical
examination and a post-void residual may be needed, but not
until further information is obtained. Travel to foreign countries
probably would not be as important, because even if exposed,
the client needs some degree of immune compromise to develop
a fungal urinary tract infection.
,A client has newly diagnosed diabetes. To delay the onset of
microvascular and macrovascular complications in this client,
the nurse stresses that the client take which action?
A) Restrict fluid intake.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia. Correct Answers C
Hyperglycemia is a critical factor in the pathogenesis of long-
term diabetic complications. Maintaining tight glycemic control
will help delay the onset of complications. Preventing
hypoglycemia and ketosis, although important, is not as
important as maintaining daily glycemic control. Restricting
fluid intake is not part of the treatment plan for clients with
diabetes.
A client is admitted with infection and a high fever. Which
assessments by the nurse take priority? (Select all that apply.)
A) Skin turgor
B) Pulse quality
C) Blood pressure
D) Bowel sounds
E) Respiratory effort
F) Mental status Correct Answers A, B, C, F
Dehydration can accompany fever, especially if the client is
sweating profusely. Blood pressure, pulse quality, and skin
turgor are assessments of fluid status. Mental status changes can
accompany fluid losses, especially in older clients.
, A client is admitted with left lower lung pneumonia. Which
assessment finding does the nurse correlate with this condition?
A) Expiratory wheeze on the right side
B) Crackles heard on expiration bilaterally
C) Dullness to percussion on the lower left side
D) Crepitus of the skin around the left lung Correct Answers C
The client with pneumonia may have dullness to percussion on
the affected side. The other options are all inconsistent with
pneumonia.
A client is hospitalized with a urinary tract infection (UTI).
Which clinical manifestation alerts the nurse to the possibility of
a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination Correct Answers B
Lower urinary tract infections are rarely associated with
systemic symptoms of fever and chills. A client with a UTI who
develops fever and chills should be assessed for the
development of pyelonephritis. The other options can be seen
with UTI.
A client is taking furosemide (Lasix) and becomes confused.
Which potassium level does the nurse correlate with this
condition?
