EXAM 2 MED SURG EXAM WITH
CORRECT QUESTIONS AND ANSWERS
2025
The nurse assesses a surgical patient the morning of the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is most appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours - CORRECT-ANSWERSAnswer: B
Rationale: The incisional redness and warmth are indicators of the normal initial (inflammatory)
stage of wound healing by primary intention.
A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature
of 101.8° F (38.7° C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Give the prescribed PRN aspirin (Ascriptin) 650 mg.
,d. Check the patient's oral temperature again in 4 hours. - CORRECT-ANSWERSAnswer: D
Rationale: Mild to moderate temperature elevations (less than 103° F) do not harm the young
adult patient and may benefit host defense mechanisms. The nurse should continue to monitor
the temperature. Antipyretics are not indicated unless the patient is complaining of fever-
related symptoms. There is no need to notify the patient's health care provider or to use a
cooling blanket for a moderate temperature elevation.
Which nursing action is most likely to detect early signs of infection in a patient who is taking
immunosuppressive medications?
a. Monitor white blood cell count.
b. Check the skin for areas of redness.
c. Check the temperature every 2 hours.
d. Ask about fatigue or feelings of malaise. - CORRECT-ANSWERSAnswer: D
Rationale: Common clinical manifestations of inflammation and infection are frequently not
present when patients receive immunosuppressive medications. The earliest manifestation of
an infection may be "just not feeling well."
,When evaluating the response to treatment for a patient with a fluid imbalance, the most
important assessment to include is
a. skin turgor.
b. presence of edema.
c. hourly urine output.
d. daily weight. - CORRECT-ANSWERSAnswer: D
Rationale: Daily weight is the most easily obtained and accurate means of assessing volume
status. Skin turgor varies considerably with age. Considerable excess fluid volume may be
present before fluid moves into the interstitial space and causes edema. Hourly urine outputs
do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from
the gastrointestinal tract or wounds.
When caring for an alert and oriented elderly patient with a history of dehydration, the home
health nurse will teach the patient to increase fluid intake
a. when the patient feels thirsty.
b. in the late evening hours.
c. as soon as changes in LOC occur.
d. if the oral mucosa feels dry. - CORRECT-ANSWERSAnswer: D
, Rationale: An alert, elderly patient will be able to self-assess for signs of oral dryness such as
thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is
not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids
slightly in the evening to improve sleep quality. The patient will not be likely to notice and act
appropriately when changes in LOC occur.
A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of
hypertension. The nurse will teach the patient to report symptoms of adverse effects such as
a. generalized weakness.
b. facial muscle spasms.
c. frequent loose stools.
d. personality changes. - CORRECT-ANSWERSAnswer: A
Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia.
Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although
changes in mental status are common manifestations with sodium excess or deficit.
CORRECT QUESTIONS AND ANSWERS
2025
The nurse assesses a surgical patient the morning of the first postoperative day and notes
redness and warmth around the incision. Which action by the nurse is most appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours - CORRECT-ANSWERSAnswer: B
Rationale: The incisional redness and warmth are indicators of the normal initial (inflammatory)
stage of wound healing by primary intention.
A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature
of 101.8° F (38.7° C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Give the prescribed PRN aspirin (Ascriptin) 650 mg.
,d. Check the patient's oral temperature again in 4 hours. - CORRECT-ANSWERSAnswer: D
Rationale: Mild to moderate temperature elevations (less than 103° F) do not harm the young
adult patient and may benefit host defense mechanisms. The nurse should continue to monitor
the temperature. Antipyretics are not indicated unless the patient is complaining of fever-
related symptoms. There is no need to notify the patient's health care provider or to use a
cooling blanket for a moderate temperature elevation.
Which nursing action is most likely to detect early signs of infection in a patient who is taking
immunosuppressive medications?
a. Monitor white blood cell count.
b. Check the skin for areas of redness.
c. Check the temperature every 2 hours.
d. Ask about fatigue or feelings of malaise. - CORRECT-ANSWERSAnswer: D
Rationale: Common clinical manifestations of inflammation and infection are frequently not
present when patients receive immunosuppressive medications. The earliest manifestation of
an infection may be "just not feeling well."
,When evaluating the response to treatment for a patient with a fluid imbalance, the most
important assessment to include is
a. skin turgor.
b. presence of edema.
c. hourly urine output.
d. daily weight. - CORRECT-ANSWERSAnswer: D
Rationale: Daily weight is the most easily obtained and accurate means of assessing volume
status. Skin turgor varies considerably with age. Considerable excess fluid volume may be
present before fluid moves into the interstitial space and causes edema. Hourly urine outputs
do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from
the gastrointestinal tract or wounds.
When caring for an alert and oriented elderly patient with a history of dehydration, the home
health nurse will teach the patient to increase fluid intake
a. when the patient feels thirsty.
b. in the late evening hours.
c. as soon as changes in LOC occur.
d. if the oral mucosa feels dry. - CORRECT-ANSWERSAnswer: D
, Rationale: An alert, elderly patient will be able to self-assess for signs of oral dryness such as
thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is
not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids
slightly in the evening to improve sleep quality. The patient will not be likely to notice and act
appropriately when changes in LOC occur.
A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of
hypertension. The nurse will teach the patient to report symptoms of adverse effects such as
a. generalized weakness.
b. facial muscle spasms.
c. frequent loose stools.
d. personality changes. - CORRECT-ANSWERSAnswer: A
Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia.
Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although
changes in mental status are common manifestations with sodium excess or deficit.
