Med Surg Final Exam 2021

Exam 1 of 4 1. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by auto-contamination? Change gloves between wound care on different parts of the client's body. 2. A student nurse asks the nursing instructor what “apoptosis” means. What response by the instructor is best? Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition. 3. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? Place the client in an upright position. 4. A nurse cares for a dying client. Which manifestation of dying should the nurse treat first? Pain 5. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? Auscultate lung sounds. 6. A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? Assess the IV site at least every 2 hours for thrombophlebitis. 7. A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? Assess the right leg for pulses, skin color, and temperature 8. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg 9. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? Pace activities, allowing for adequate rest. 10. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse conclude about this client’s cancer? There are no distant metastases noted in the report. 11. After teaching a client about advance directives, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching? "An advance directive will specify what I want done when I can no longer make decisions about health care." 12. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? Anal intercourse 13. After educating a caregiver of a home care client, a nurse assesses the caregiver’s understanding. Which statement indicates that the caregiver needs additional education? " If his tailbone is red and tender in the morning, I will massage it with baby oil " 14. A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? "Which method of contraception are you using?" 15. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching?"