NURS 102: MEDSURG EXAM Q & A WITH
RATIONALS
i. A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of
the prostate (TURP) gland. Which of the following assessments should the nurse view to be an
indication of a postoperative complication?
Output of burgundy colored urine
Rational
Output of burgundy colored urine may indicate venous bleeding, a potential complication
following a TURP. S
ii. A nurse is assessing a client before administering a unit of packed RBCs. The nurse
should identify which of the following data as most important to obtain prior to the infusion?
Temperature
Rational
The greatest risk to the client is injury from a blood transfusion reaction. Therefore, the priority
action is to take a baseline temperature measurement. The nurse should then monitor the client's
temperature throughout the infusion as an increase in temperature can indicate an adverse
reaction.
iii. A nurse in an ophthalmology clinic is interviewing a client who was referred by his
primary care provider for suspicion of cataracts. The nurse should expect the client to report?
Having a decreased ability to perceive colors.
Rational
Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive
colors.
iv. A nurse is evaluating a client's laboratory results. The nurse should recognize that an
increase in the client's prostate specific antigen (PSA) laboratory value is indicative of which of
the following diagnoses?
Prostatic cancer
, NURS 102: MEDSURG EXAM Q & A WITH
RATIONALS
v. A nurse is providing postoperative care for a client who has two chest tubes in place
following a lobectomy. The client asks the nurse the reason for having two chest tubes. The
nurse should inform the client that the lower chest tube is placed for which of the following
reasons?
draining blood and fluid from the pleural space
vi. A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who
has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the
following responses should the nurse make?
Herpes zoster is not contagious to people who have had chickenpox
vii. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of
the following actions should the nurse take?
check the clients capillary blood glucose level every 4 hr
1…. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse
should expect to find an elevation of which of following values?
Amylase
Rational
Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the
body. It is produced by the pancreas and salivary glands and released into the mouth,
stomach, and intestines to aid in digestion. The amylase level of a client who has acute
pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days.
2…. A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis.
Which of the following findings in the client's history should the nurse recognize as consistent
with a diagnosis of endometriosis?
Dysmenorrhea that is unresponsive to NSAIDs.
Rational
Endometriosis is a condition in which the type of tissue that lines the uterus implants in
locations outside the uterus. This typically causes pelvic pain around the time of the menstrual
, NURS 102: MEDSURG EXAM Q & A WITH
RATIONALS
period but can cause pain at other times in the cycle. The discomfort is often unrelieved by the
use of NSAIDs.
3…. A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in
paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and
increasingly resistant to rehabilitative efforts by the staff. Which of the following actions
should the nurse take?
Establish a plan of care with the client that sets attainable goals.
Rational
The nurse should develop a plan of care for this client with mutually set goals. This action
invests the client in the rehabilitation process, which encourages feelings of ownership for it,
and sees the goals as more attainable
, NURS 102: MEDSURG EXAM Q & A WITH
RATIONALS
4….A nurse in a burn treatment center is caring for a client who is admitted with severe burns
to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the
nurse what the procedure entails. Which of the following nursing statements is appropriate?
Large incisions will be made in the eschar to improve circulation.
Rational
An escharotomy is a surgical incision made to release pressure and improve circulation in a part
of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that
encircle a body part, such as an arm or the chest, can cause swelling and tightness in the
affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue
allows the skin to expand, reduces tightness and pressure, and improves circulation.
5….A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the
client's urine to appear which of the following colors?
Dark and foamy
Rational
The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are
filtering excess bilirubin from the blood.
6….A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking
aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor
to evaluate the effectiveness of this medication?
Erythrocyte sedimentation rate (ESR)
Rational
Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and
monitoring tissue inflammation in clients with RA. As the disease improves the ESR
decreases.
7….A nurse is providing dietary teaching to a client who has a history of recurring calcium
RATIONALS
i. A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of
the prostate (TURP) gland. Which of the following assessments should the nurse view to be an
indication of a postoperative complication?
Output of burgundy colored urine
Rational
Output of burgundy colored urine may indicate venous bleeding, a potential complication
following a TURP. S
ii. A nurse is assessing a client before administering a unit of packed RBCs. The nurse
should identify which of the following data as most important to obtain prior to the infusion?
Temperature
Rational
The greatest risk to the client is injury from a blood transfusion reaction. Therefore, the priority
action is to take a baseline temperature measurement. The nurse should then monitor the client's
temperature throughout the infusion as an increase in temperature can indicate an adverse
reaction.
iii. A nurse in an ophthalmology clinic is interviewing a client who was referred by his
primary care provider for suspicion of cataracts. The nurse should expect the client to report?
Having a decreased ability to perceive colors.
Rational
Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive
colors.
iv. A nurse is evaluating a client's laboratory results. The nurse should recognize that an
increase in the client's prostate specific antigen (PSA) laboratory value is indicative of which of
the following diagnoses?
Prostatic cancer
, NURS 102: MEDSURG EXAM Q & A WITH
RATIONALS
v. A nurse is providing postoperative care for a client who has two chest tubes in place
following a lobectomy. The client asks the nurse the reason for having two chest tubes. The
nurse should inform the client that the lower chest tube is placed for which of the following
reasons?
draining blood and fluid from the pleural space
vi. A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who
has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the
following responses should the nurse make?
Herpes zoster is not contagious to people who have had chickenpox
vii. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of
the following actions should the nurse take?
check the clients capillary blood glucose level every 4 hr
1…. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse
should expect to find an elevation of which of following values?
Amylase
Rational
Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the
body. It is produced by the pancreas and salivary glands and released into the mouth,
stomach, and intestines to aid in digestion. The amylase level of a client who has acute
pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days.
2…. A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis.
Which of the following findings in the client's history should the nurse recognize as consistent
with a diagnosis of endometriosis?
Dysmenorrhea that is unresponsive to NSAIDs.
Rational
Endometriosis is a condition in which the type of tissue that lines the uterus implants in
locations outside the uterus. This typically causes pelvic pain around the time of the menstrual
, NURS 102: MEDSURG EXAM Q & A WITH
RATIONALS
period but can cause pain at other times in the cycle. The discomfort is often unrelieved by the
use of NSAIDs.
3…. A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in
paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and
increasingly resistant to rehabilitative efforts by the staff. Which of the following actions
should the nurse take?
Establish a plan of care with the client that sets attainable goals.
Rational
The nurse should develop a plan of care for this client with mutually set goals. This action
invests the client in the rehabilitation process, which encourages feelings of ownership for it,
and sees the goals as more attainable
, NURS 102: MEDSURG EXAM Q & A WITH
RATIONALS
4….A nurse in a burn treatment center is caring for a client who is admitted with severe burns
to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the
nurse what the procedure entails. Which of the following nursing statements is appropriate?
Large incisions will be made in the eschar to improve circulation.
Rational
An escharotomy is a surgical incision made to release pressure and improve circulation in a part
of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that
encircle a body part, such as an arm or the chest, can cause swelling and tightness in the
affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue
allows the skin to expand, reduces tightness and pressure, and improves circulation.
5….A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the
client's urine to appear which of the following colors?
Dark and foamy
Rational
The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are
filtering excess bilirubin from the blood.
6….A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking
aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor
to evaluate the effectiveness of this medication?
Erythrocyte sedimentation rate (ESR)
Rational
Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and
monitoring tissue inflammation in clients with RA. As the disease improves the ESR
decreases.
7….A nurse is providing dietary teaching to a client who has a history of recurring calcium
