Medical-Surgical Nursing Exam 1
A 2-day postoperative patient is receiving 1000 mL normal saline over 10 hours.
The patient has an intake of 4 ounces of orange juice, one 8-ounce cup of coffee,
3 cups of water, and 1 cup of tea. This patient has a total intake of _________ mL
over the 12-hour period. - ANS - 2520
\A 63-year-old Arab American male states his left leg is "hot." What is the nurse's
best first response? - ANS - Assess for pain
\A client experiencing shock has had a urinary output of 250 mL in the last 10
hours. What is the nurse's most appropriate response? - ANS - Notify the
physician.
\A client has had abdominal surgery and has orders to be ambulated three times
a day. Oral pain medication has been ordered for the client. What should the
nurse do to facilitate ambulation? - ANS - Mediate 1 hour prior to ambulating the
client.
\A client with chronic pain has been admitted with a fever. The nursing
assessment reveals that the client has a decreased level of consciousness. What
should the nurse ask the family about? - ANS - What medications the client has
taken
\A college student is brought into the emergency department with possible
frostbite of both feet after losing consciousness in a snow drift while walking
home from a party. What actions should the nurse take at this time?
Select all that apply. - ANS - Handle the feet gently.
Elevate the feet to heart level.
Cover the feet with dry sterile gauze.
\A community is experiencing an epidemic of chickenpox within school age
children. The nurse should realize that which of the following factors results in a
more than 80% infection rate among those exposed? - ANS - The causative virus
has three modes of transmission.
\A family member of a patient in shock says that being in shock should not be
that critical because it can be treated. What should the nurse explain about the
major body damage caused by shock? - ANS - Inadequate oxygen delivered to
cells
\A high school football player suffered an injury while playing and is brought to
the emergency room. The primary survey shows an alert patient with patent
, airway, breathing, a carotid pulse, and skin color within normal limits. The patient
reports, "I can't flex my foot or point my toes." On which area should the nurse
expect diagnostic tests to focus for this patient? - ANS - The lower back
\A nurse is wearing a fit-tested, high-efficiency particulate air respirator when
entering the room of a patient. For which patient is the nurse preparing to provide
care? - ANS - A 36-year-old with tuberculosis
\A patient diagnosed with hypovolemic shock has an estimated blood loss of 500
mL, 250 mL of emesis, and 250 mL of insensible water losses. The health care
provider prescribes the patient to receive 3 mL of 0.9% normal saline via IV
infusion to replace each mL of fluid loss to be infused over 24 hours. How many
mL of the fluid should the patient receive each hour? Calculate to the nearest
whole number. - ANS - 125
\A patient experiencing painful back spasms plans to stop taking prescribed pain
medication and resume weekly massage therapy sessions. How should the nurse
respond to this patient's plan? - ANS - "Massage therapy should be used in
addition to the pain medication."
\A patient has an epidural catheter placed for pain control. Which medications
should the nurse question before providing them to the patient during routine
medication administration?
Select all that apply. - ANS - Aspirin 325 mg by mouth once a day
Warfarin (Coumadin) 2.5 mg by mouth every evening
\A patient has been receiving 10 mg morphine IV every 4 to 6 hours for
postoperative pain. At discharge, the patient rates the pain as a 4 on a 0-10 scale.
On a prescription to be given to the patient at discharge, the physician has
written morphine 10 mg by mouth four times a day as needed. What should the
nurse do first? - ANS - Contact the physician regarding the prescription.
\A patient is being released from the hospital with a prescription for tetracycline.
What should the nurse include in patient teaching?
Select all that apply. - ANS - Advise limiting exposure to the sun.
Inform patient of the possibility of gastrointestinal upset.
Suggest eating crackers and some juice when taking this medicine.
\A patient is being treated for anaphylactic shock caused by a hornet sting. What
should the nurse ensure occurs before the patient is discharged? - ANS - Receive
a prescription for epinephrine auto-injector.
A 2-day postoperative patient is receiving 1000 mL normal saline over 10 hours.
The patient has an intake of 4 ounces of orange juice, one 8-ounce cup of coffee,
3 cups of water, and 1 cup of tea. This patient has a total intake of _________ mL
over the 12-hour period. - ANS - 2520
\A 63-year-old Arab American male states his left leg is "hot." What is the nurse's
best first response? - ANS - Assess for pain
\A client experiencing shock has had a urinary output of 250 mL in the last 10
hours. What is the nurse's most appropriate response? - ANS - Notify the
physician.
\A client has had abdominal surgery and has orders to be ambulated three times
a day. Oral pain medication has been ordered for the client. What should the
nurse do to facilitate ambulation? - ANS - Mediate 1 hour prior to ambulating the
client.
\A client with chronic pain has been admitted with a fever. The nursing
assessment reveals that the client has a decreased level of consciousness. What
should the nurse ask the family about? - ANS - What medications the client has
taken
\A college student is brought into the emergency department with possible
frostbite of both feet after losing consciousness in a snow drift while walking
home from a party. What actions should the nurse take at this time?
Select all that apply. - ANS - Handle the feet gently.
Elevate the feet to heart level.
Cover the feet with dry sterile gauze.
\A community is experiencing an epidemic of chickenpox within school age
children. The nurse should realize that which of the following factors results in a
more than 80% infection rate among those exposed? - ANS - The causative virus
has three modes of transmission.
\A family member of a patient in shock says that being in shock should not be
that critical because it can be treated. What should the nurse explain about the
major body damage caused by shock? - ANS - Inadequate oxygen delivered to
cells
\A high school football player suffered an injury while playing and is brought to
the emergency room. The primary survey shows an alert patient with patent
, airway, breathing, a carotid pulse, and skin color within normal limits. The patient
reports, "I can't flex my foot or point my toes." On which area should the nurse
expect diagnostic tests to focus for this patient? - ANS - The lower back
\A nurse is wearing a fit-tested, high-efficiency particulate air respirator when
entering the room of a patient. For which patient is the nurse preparing to provide
care? - ANS - A 36-year-old with tuberculosis
\A patient diagnosed with hypovolemic shock has an estimated blood loss of 500
mL, 250 mL of emesis, and 250 mL of insensible water losses. The health care
provider prescribes the patient to receive 3 mL of 0.9% normal saline via IV
infusion to replace each mL of fluid loss to be infused over 24 hours. How many
mL of the fluid should the patient receive each hour? Calculate to the nearest
whole number. - ANS - 125
\A patient experiencing painful back spasms plans to stop taking prescribed pain
medication and resume weekly massage therapy sessions. How should the nurse
respond to this patient's plan? - ANS - "Massage therapy should be used in
addition to the pain medication."
\A patient has an epidural catheter placed for pain control. Which medications
should the nurse question before providing them to the patient during routine
medication administration?
Select all that apply. - ANS - Aspirin 325 mg by mouth once a day
Warfarin (Coumadin) 2.5 mg by mouth every evening
\A patient has been receiving 10 mg morphine IV every 4 to 6 hours for
postoperative pain. At discharge, the patient rates the pain as a 4 on a 0-10 scale.
On a prescription to be given to the patient at discharge, the physician has
written morphine 10 mg by mouth four times a day as needed. What should the
nurse do first? - ANS - Contact the physician regarding the prescription.
\A patient is being released from the hospital with a prescription for tetracycline.
What should the nurse include in patient teaching?
Select all that apply. - ANS - Advise limiting exposure to the sun.
Inform patient of the possibility of gastrointestinal upset.
Suggest eating crackers and some juice when taking this medicine.
\A patient is being treated for anaphylactic shock caused by a hornet sting. What
should the nurse ensure occurs before the patient is discharged? - ANS - Receive
a prescription for epinephrine auto-injector.
