MED-SURG FINAL EXAM QUESTIONS
& ACCURATE COMPLETE ANSWERS
The nurse assesses a patient's surgical wound on the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours. - Correct Answer ✔✔ ANS: B
The incisional redness and warmth are indicators of the normal initial (inflammatory)
stage of wound healing by primary intention. The nurse should document the wound
appearance and continue to monitor the wound.
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a
band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound.
b. Begin antibiotic administration.
c. Continue to monitor the wound for drainage.
d. Redress the wound with wet-to-dry dressings. - Correct Answer ✔✔ ANS: A
The increase in WBC count with the increased bands (shift to the left) indicates that the
patient probably has a bacterial infection, and the nurse should obtain wound cultures.
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which
assessment finding will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure - Correct Answer ✔✔ ANS: C
The patient's complaints of feeling cold and shivering indicate that the hypothalamic set
point for temperature has been increased and the temperature is increasing.
A young adult patient who is receiving antibiotics for an infected leg wound has a
temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which
action by the nurse is appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - Correct Answer ✔✔ ANS:
C
,Mild to moderate temperature elevations (<103° F) do not harm young adult patients
and may benefit host defense mechanisms. The nurse should continue to monitor the
temperature.
A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse apply
to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing - Correct Answer ✔✔ ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-
green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals
The nurse notes that a patient's open abdominal wound widens as it extends deeper
into the abdomen. How would the nurse document this characteristic?
a. Eschar
b. Slough
c. Maceration
d. Undermining - Correct Answer ✔✔ ANS: D
Undermining is evident when a cotton-tipped applicator is placed in the wound and
there is a narrower "lip" around the wound, which widens as the wound deepens.
Eschar is a crusted cover over a wound. Slough and maceration refer to loosening
friable tissue.
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years.
Which nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - Correct Answer ✔✔ ANS: D
The earliest manifestation of an infection may be "just not feeling well." Common clinical
manifestations of inflammation and infection are frequently not present when patients
receive immunosuppressive medications.
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas - Correct
Answer ✔✔ ANS: D
,Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-
thickness wound filled with eschar will require interventions such as surgical
debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on
approximated surgical incisions. Wet-to-dry dressings are not used on uninfected
granulating wounds because of the damage to the granulation tissue.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure
ulcer. The base of the wound involves subcutaneous tissue. How should the nurse
classify this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV - Correct Answer ✔✔ ANS: C
A stage III pressure ulcer has full-thickness skin damage and extends into the
subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable
damage such as redness or a boggy feel. Stage II pressure ulcers have partial-
thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue
necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
A young male patient with paraplegia has a stage II sacral pressure ulcer and is being
cared for at home by his family. To prevent further tissue damage, what instructions are
most important for the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the ulcer.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the ulcer weekly. - Correct Answer ✔✔ ANS: C
The most important intervention is to avoid prolonged pressure on bony prominences by
frequent repositioning. The other interventions may also be included in family teaching.
The nurse will perform which action when doing a wet-to-dry dressing change on a
patient's stage III sacral pressure ulcer?
a. Administer prescribed PRN hydrocodone 30 minutes before the change.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Apply antimicrobial ointment before repacking the wound with moist dressings.
d. Soak the old dressings with sterile saline 30 minutes before the dressing change -
Correct Answer ✔✔ ANS: A
Mechanical debridement with wet-to-dry dressings is painful, and patients should
receive pain medications before the dressing change begins. The new dressings are
moistened with saline before being applied to the wound but not soaked after packing.
Soaking the old dressings before removing them will eliminate the wound debridement
that is the purpose of this type of dressing. Application of antimicrobial ointments is not
indicated for a wet-to-dry dressing.
, A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which
action by the new nurse indicates a need for further teaching about pressure ulcer care?
a. The new nurse cleans the ulcer with half-strength peroxide.
b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer.
c. The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe.
d. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. -
Correct Answer ✔✔ ANS: A
Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as
hydrogen peroxide. The other actions by the new nurse are appropriate.
A patient arrives in the emergency department with a swollen ankle after a soccer injury.
Which action by the nurse is appropriate?
a. Elevate the ankle above heart level.
b. Apply a warm moist pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). - Correct Answer ✔✔ ANS: A
Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE).
Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM
will increase swelling and risk further injury. Cold packs should be applied the first 24
hours to reduce swelling. The nurse should not ask the patient to move or bear weight
on the swollen ankle because immobilization of the inflamed or injured area promotes
healing by decreasing metabolic needs of the tissues.
When admitting a patient with stage III pressure ulcers on both heels, which information
obtained by the nurse will have the most impact on wound healing?
a. The patient has had the heel ulcers for 6 months.
b. The patient takes oral hypoglycemic agents daily.
c. The patient states that the ulcers are very painful.
d. The patient has several incisions that formed keloids. - Correct Answer ✔✔ ANS: B
The use of oral hypoglycemics indicates diabetes, which can interfere with wound
healing. The persistence of the ulcers over the past 6 months is a concern, but changes
in care may be effective in promoting healing. Keloids are not disabling or painful,
although the cosmetic effects may be distressing for some patients.
After receiving a change-of-shift report, which patient should the nurse assess first?
a. The patient who has multiple leg wounds with eschar to be debrided
b. The patient receiving chemotherapy who has a temperature of 102° F
c. The patient who requires analgesics before a scheduled dressing change
d. The newly admitted patient with a stage IV pressure ulcer on the coccyx - Correct
Answer ✔✔ ANS: B
Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed
patient is a sign of serious infection and should be treated immediately with cultures and
& ACCURATE COMPLETE ANSWERS
The nurse assesses a patient's surgical wound on the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours. - Correct Answer ✔✔ ANS: B
The incisional redness and warmth are indicators of the normal initial (inflammatory)
stage of wound healing by primary intention. The nurse should document the wound
appearance and continue to monitor the wound.
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a
band count of 11%. What prescribed action should the nurse take first?
a. Obtain cultures of the wound.
b. Begin antibiotic administration.
c. Continue to monitor the wound for drainage.
d. Redress the wound with wet-to-dry dressings. - Correct Answer ✔✔ ANS: A
The increase in WBC count with the increased bands (shift to the left) indicates that the
patient probably has a bacterial infection, and the nurse should obtain wound cultures.
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which
assessment finding will the nurse expect next?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure - Correct Answer ✔✔ ANS: C
The patient's complaints of feeling cold and shivering indicate that the hypothalamic set
point for temperature has been increased and the temperature is increasing.
A young adult patient who is receiving antibiotics for an infected leg wound has a
temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which
action by the nurse is appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - Correct Answer ✔✔ ANS:
C
,Mild to moderate temperature elevations (<103° F) do not harm young adult patients
and may benefit host defense mechanisms. The nurse should continue to monitor the
temperature.
A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound
surrounded by yellow-green semiliquid material. Which dressing should the nurse apply
to the wound?
a. Dry gauze dressing
b. Nonadherent dressing
c. Hydrocolloid dressing
d. Transparent film dressing - Correct Answer ✔✔ ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-
green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals
The nurse notes that a patient's open abdominal wound widens as it extends deeper
into the abdomen. How would the nurse document this characteristic?
a. Eschar
b. Slough
c. Maceration
d. Undermining - Correct Answer ✔✔ ANS: D
Undermining is evident when a cotton-tipped applicator is placed in the wound and
there is a narrower "lip" around the wound, which widens as the wound deepens.
Eschar is a crusted cover over a wound. Slough and maceration refer to loosening
friable tissue.
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years.
Which nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - Correct Answer ✔✔ ANS: D
The earliest manifestation of an infection may be "just not feeling well." Common clinical
manifestations of inflammation and infection are frequently not present when patients
receive immunosuppressive medications.
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue
b. A patient who has a surgical incision with pink, approximated edges
c. A patient who has a full-thickness burn filled with dry, black material
d. A patient who has a wound with purulent drainage and dry brown areas - Correct
Answer ✔✔ ANS: D
,Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-
thickness wound filled with eschar will require interventions such as surgical
debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on
approximated surgical incisions. Wet-to-dry dressings are not used on uninfected
granulating wounds because of the damage to the granulation tissue.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure
ulcer. The base of the wound involves subcutaneous tissue. How should the nurse
classify this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV - Correct Answer ✔✔ ANS: C
A stage III pressure ulcer has full-thickness skin damage and extends into the
subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable
damage such as redness or a boggy feel. Stage II pressure ulcers have partial-
thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue
necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
A young male patient with paraplegia has a stage II sacral pressure ulcer and is being
cared for at home by his family. To prevent further tissue damage, what instructions are
most important for the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the ulcer.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the ulcer weekly. - Correct Answer ✔✔ ANS: C
The most important intervention is to avoid prolonged pressure on bony prominences by
frequent repositioning. The other interventions may also be included in family teaching.
The nurse will perform which action when doing a wet-to-dry dressing change on a
patient's stage III sacral pressure ulcer?
a. Administer prescribed PRN hydrocodone 30 minutes before the change.
b. Pour sterile saline onto the new dry dressings after the wound has been packed.
c. Apply antimicrobial ointment before repacking the wound with moist dressings.
d. Soak the old dressings with sterile saline 30 minutes before the dressing change -
Correct Answer ✔✔ ANS: A
Mechanical debridement with wet-to-dry dressings is painful, and patients should
receive pain medications before the dressing change begins. The new dressings are
moistened with saline before being applied to the wound but not soaked after packing.
Soaking the old dressings before removing them will eliminate the wound debridement
that is the purpose of this type of dressing. Application of antimicrobial ointments is not
indicated for a wet-to-dry dressing.
, A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which
action by the new nurse indicates a need for further teaching about pressure ulcer care?
a. The new nurse cleans the ulcer with half-strength peroxide.
b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer.
c. The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe.
d. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. -
Correct Answer ✔✔ ANS: A
Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as
hydrogen peroxide. The other actions by the new nurse are appropriate.
A patient arrives in the emergency department with a swollen ankle after a soccer injury.
Which action by the nurse is appropriate?
a. Elevate the ankle above heart level.
b. Apply a warm moist pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). - Correct Answer ✔✔ ANS: A
Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE).
Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM
will increase swelling and risk further injury. Cold packs should be applied the first 24
hours to reduce swelling. The nurse should not ask the patient to move or bear weight
on the swollen ankle because immobilization of the inflamed or injured area promotes
healing by decreasing metabolic needs of the tissues.
When admitting a patient with stage III pressure ulcers on both heels, which information
obtained by the nurse will have the most impact on wound healing?
a. The patient has had the heel ulcers for 6 months.
b. The patient takes oral hypoglycemic agents daily.
c. The patient states that the ulcers are very painful.
d. The patient has several incisions that formed keloids. - Correct Answer ✔✔ ANS: B
The use of oral hypoglycemics indicates diabetes, which can interfere with wound
healing. The persistence of the ulcers over the past 6 months is a concern, but changes
in care may be effective in promoting healing. Keloids are not disabling or painful,
although the cosmetic effects may be distressing for some patients.
After receiving a change-of-shift report, which patient should the nurse assess first?
a. The patient who has multiple leg wounds with eschar to be debrided
b. The patient receiving chemotherapy who has a temperature of 102° F
c. The patient who requires analgesics before a scheduled dressing change
d. The newly admitted patient with a stage IV pressure ulcer on the coccyx - Correct
Answer ✔✔ ANS: B
Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed
patient is a sign of serious infection and should be treated immediately with cultures and
