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Med-Surg Midterm 1 – Exam Questions, Rationales & Study Guide – 100%
Toetsgericht – LAATST BIJGEWERKT 2025
When caring for clients using evidence-informed practice, which of the following does the nurse use?
The best available evidence to guide clinical expertise
3 multiple choice options
Which of the following best explains the nurses’ primary use of the nursing process when providing care to
clients?
As a problem-solving tool to identify and treat clients’ health care needs
3 multiple choice options
The nurse is caring for a critically ill client in the intensive care unit and plans an every
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this
turning schedule?
Collaborative
The nurse is caring for a client who has been admitted to the hospital for surgery and tells
the nurse, “I do not feel right about leaving my children with my neighbour.” Which
action should the nurse take next?
Gather more data about the client’s feelings about the childcare arrangements.
3 multiple choice options
The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis for this client?
Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
3 multiple choice options
The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which of the following is an appropriate client outcome?
Client has a balanced intake and output.
3 multiple choice options
Which of the following represents a nursing activity that is carried out during the
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evaluation phase of the nursing process?
Determining if interventions have been effective in meeting client outcomes
3 multiple choice options
Which of the following would the nurse perform during the assessment phase of the
nursing process?
Obtains data with which to diagnose client problems
3 multiple choice options
Which of the following is an example of a correctly written nursing diagnosis statement?
Ineffective coping related to insufficient sense of control.
3 multiple choice options
Which of the following includes the components required for a complete nursing diagnosis statement?
A problem with its etiology and the signs and symptoms of the problem
3 multiple choice options
Which of the following refers to a situation that results in unintended harm to the client
and is related to the care or services provided rather than the client’s medical condition?
Adverse event
3 multiple choice options
When using the Five Steps of the evidence-informed practice (EIP) Process, which of the
flowing elements is the final step when constructing a clinical question?
Timeframe of interest
3 multiple choice options
The nurse is assessing a client the morning of the first postoperative day and notes redness and warmth around
the incision. Which of the following actions should the nurse implement?
Document the assessment
3 multiple choice options
A client with an open abdominal wound has a complete blood cell (CBC) count and
differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the
following actions is priority as a result of this assessment data?
Obtain wound cultures
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3 multiple choice options
The nurse is caring for a client with a systemic bacterial infection that has “goose
pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, which of the following
assessments should the nurse monitor?
Rising body temperature
3 multiple choice options
The nurse is caring for a young adult client who is receiving antibiotics for an infected leg wound and has a
temperature of (101.8°C). Which of the following actions by the nurse is most appropriate?
Check the client’s oral temperature again in 4 hours
3 multiple choice options
A client’s 6 ´ 3 cm leg wound has a 2 mm black area surrounded by yellow-green
semiliquid material. Which of the following dressings should the nurse use for wound
care?
Hydrocolloid dressing (DuoDerm)
3 multiple choice options
The nurse is caring for a client who has an open surgical wound on the abdomen that
contains a creamy exudate and small areas of deep pink granulation tissue. Which of the
following terms should the nurse use to document these findings?
Yellow wound
3 multiple choice options
Which of the following nursing actions is most likely to detect early signs of infection in a client who is taking
immunosuppressive medications?
Ask about fatigue or feelings of malaise.
3 multiple choice options
The nurse is planning care for a client and is preparing to complete a wet-to-dry dressing. Which of the
following wound descriptions is appropriate for this type of dressing?
Wound with purulent drainage and dry brown areas
3 multiple choice options
A client is admitted to the hospital with a pressure injury on the left buttock. The nurse
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notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure
injury wound stages should the nurse document?
3
3 multiple choice options
A client who is confined to bed and who has a stage 2 pressure injury is being cared for in
the home by family members. To prevent further tissue damage, which of the following actions should the nurse
instruct the family members that it is most important?
Change the client’s position every 2 hours
3 multiple choice options
Which nursing action will be included when the nurse is doing a wet-to-dry dressing
change for a client who has a stage III sacral pressure injury?
Administer the ordered PRN oral opioid 30 minutes before the dressing change.
3 multiple choice options
The charge nurse observes a new graduate nurse performing a dressing change on a client with a stage 2 left
heel pressure injury. Which of the following actions by the new
graduate indicates a need for further education about pressure injury care?
Cleans the wound with a sterile dressing soaked in half-strength hydrogen peroxide
3 multiple choice options
A client arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer.
Which of the following actions by the nurse is most appropriate?
Elevate the ankle above heart level
3 multiple choice options
The nurse is admitting a client with stage 3 pressure injuries on both heels. Which of the
following information obtained by the nurse will have the most impact on wound healing?
The client takes corticosteroids daily for rheumatoid arthritis
3 multiple choice options
During wound healing, a wound is resistant to infection during which of the following
phases?
Granulation phase
3 multiple choice options
Med-Surg Midterm 1 – Exam Questions, Rationales & Study Guide – 100%
Toetsgericht – LAATST BIJGEWERKT 2025
When caring for clients using evidence-informed practice, which of the following does the nurse use?
The best available evidence to guide clinical expertise
3 multiple choice options
Which of the following best explains the nurses’ primary use of the nursing process when providing care to
clients?
As a problem-solving tool to identify and treat clients’ health care needs
3 multiple choice options
The nurse is caring for a critically ill client in the intensive care unit and plans an every
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this
turning schedule?
Collaborative
The nurse is caring for a client who has been admitted to the hospital for surgery and tells
the nurse, “I do not feel right about leaving my children with my neighbour.” Which
action should the nurse take next?
Gather more data about the client’s feelings about the childcare arrangements.
3 multiple choice options
The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis for this client?
Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
3 multiple choice options
The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which of the following is an appropriate client outcome?
Client has a balanced intake and output.
3 multiple choice options
Which of the following represents a nursing activity that is carried out during the
,2|Page
evaluation phase of the nursing process?
Determining if interventions have been effective in meeting client outcomes
3 multiple choice options
Which of the following would the nurse perform during the assessment phase of the
nursing process?
Obtains data with which to diagnose client problems
3 multiple choice options
Which of the following is an example of a correctly written nursing diagnosis statement?
Ineffective coping related to insufficient sense of control.
3 multiple choice options
Which of the following includes the components required for a complete nursing diagnosis statement?
A problem with its etiology and the signs and symptoms of the problem
3 multiple choice options
Which of the following refers to a situation that results in unintended harm to the client
and is related to the care or services provided rather than the client’s medical condition?
Adverse event
3 multiple choice options
When using the Five Steps of the evidence-informed practice (EIP) Process, which of the
flowing elements is the final step when constructing a clinical question?
Timeframe of interest
3 multiple choice options
The nurse is assessing a client the morning of the first postoperative day and notes redness and warmth around
the incision. Which of the following actions should the nurse implement?
Document the assessment
3 multiple choice options
A client with an open abdominal wound has a complete blood cell (CBC) count and
differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the
following actions is priority as a result of this assessment data?
Obtain wound cultures
,3|Page
3 multiple choice options
The nurse is caring for a client with a systemic bacterial infection that has “goose
pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, which of the following
assessments should the nurse monitor?
Rising body temperature
3 multiple choice options
The nurse is caring for a young adult client who is receiving antibiotics for an infected leg wound and has a
temperature of (101.8°C). Which of the following actions by the nurse is most appropriate?
Check the client’s oral temperature again in 4 hours
3 multiple choice options
A client’s 6 ´ 3 cm leg wound has a 2 mm black area surrounded by yellow-green
semiliquid material. Which of the following dressings should the nurse use for wound
care?
Hydrocolloid dressing (DuoDerm)
3 multiple choice options
The nurse is caring for a client who has an open surgical wound on the abdomen that
contains a creamy exudate and small areas of deep pink granulation tissue. Which of the
following terms should the nurse use to document these findings?
Yellow wound
3 multiple choice options
Which of the following nursing actions is most likely to detect early signs of infection in a client who is taking
immunosuppressive medications?
Ask about fatigue or feelings of malaise.
3 multiple choice options
The nurse is planning care for a client and is preparing to complete a wet-to-dry dressing. Which of the
following wound descriptions is appropriate for this type of dressing?
Wound with purulent drainage and dry brown areas
3 multiple choice options
A client is admitted to the hospital with a pressure injury on the left buttock. The nurse
, 4|Page
notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure
injury wound stages should the nurse document?
3
3 multiple choice options
A client who is confined to bed and who has a stage 2 pressure injury is being cared for in
the home by family members. To prevent further tissue damage, which of the following actions should the nurse
instruct the family members that it is most important?
Change the client’s position every 2 hours
3 multiple choice options
Which nursing action will be included when the nurse is doing a wet-to-dry dressing
change for a client who has a stage III sacral pressure injury?
Administer the ordered PRN oral opioid 30 minutes before the dressing change.
3 multiple choice options
The charge nurse observes a new graduate nurse performing a dressing change on a client with a stage 2 left
heel pressure injury. Which of the following actions by the new
graduate indicates a need for further education about pressure injury care?
Cleans the wound with a sterile dressing soaked in half-strength hydrogen peroxide
3 multiple choice options
A client arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer.
Which of the following actions by the nurse is most appropriate?
Elevate the ankle above heart level
3 multiple choice options
The nurse is admitting a client with stage 3 pressure injuries on both heels. Which of the
following information obtained by the nurse will have the most impact on wound healing?
The client takes corticosteroids daily for rheumatoid arthritis
3 multiple choice options
During wound healing, a wound is resistant to infection during which of the following
phases?
Granulation phase
3 multiple choice options
