Page 1 of 57
2025/2025 MED SURG FINAL EXAM STUDY
GUIDE QUESTIONS WITH VERIFIED
SOLUTIONS
A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus
erythematous (SLE). Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will need to take methotrexate even if I'm in remission."
B. "I'm thankful that this type of lupus only affects the skin."
C. "Each day I should apply a sunblock with a sun protection factor of 15."
D. "A mild fever is common with SLE and usually does not require medical intervention." --
ANSWER--A. "I will need to take methotrexate even if I'm in remission."
The nurse should inform the client that SLE is an autoimmune disorder characterized by
exacerbations and remissions. It affects the skin as well as joints, organs, and any structure in
the body that contains connective tissue. Methotrexate is an immunosuppressive medication
given during remission to help prevent exacerbation. The medication is also given when
exacerbations occur to reduce the severity of manifestations.
A nurse is caring for a client who has thrombocytopenia and develops epitaxis. Which of the
following actions should the nurse take?
A. Have the client gently blow clots from the nose every 5 min.
B. Instruct the client to sit with his head hyperextended.
,C. Apply ice compresses to the back of the client's neck.
D. Apply lateral pressure to the client's nose for 10 min. -- ANSWER--D. Apply lateral
pressure to the client's nose for 10 min.
The nurse should apply direct, lateral pressure to the nose for 10 min to control epistaxis. If
after 10 min the epistaxis continues, the client might require nasal packing or other
interventions.
A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the
following actions should the nurse take? (Select all that apply) A. Place the client on
respiratory isolation.
B. Monitor vital signs every 2 hr.
C. Assess neurological status every 4 hr.
D. Maintain the client in a modified Trendelenburg position.
E. Keep the client's room darkened. -- ANSWER--B, C, E
Monitor vital signs every 2 hr is correct. The nurse should monitor the client's vital signs to
assess for changes consistent with increased intracranial pressure.
Assess neurological status every 4 hr is correct. The nurse should monitor the client's
neurological status at least every 4 hr, or more frequently if the client's status indicates. The
course of encephalitis is unpredictable, so the client should be monitored closely for any
indications of deteriorating neurological functioning.
, Page 3 of 57
Keep the client's room darkened is correct. The nurse should provide the client with a
lowstimulation environment to promote comfort and decrease agitation.
A nurse is assessing a client who has a fractured left femur and is in skeletal traaction, Which
of the following findings should the nurse report to the provider>
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg -- ANSWER--C. Chest petechiae
The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients
who have fractures of the long bones, such as the femur, are at increased risk for fat emboli.
Fat emboli typically occur 12 to 48 hr after the injury when fat droplets from the marrow
enter into the systemic circulation and are deposited in the lungs. The nurse should
immediately notify the provider because the client could progress into acute respiratory
failure.
A nurse is monitoring a client following a thyroidectomy for the presence of
hypoparathyroidism. Which of the following findings should the nurse expect?
A. Elevated blood pressure
B. Involuntary muscle spasms
C. Cold intolerance
D. Weight loss -- ANSWER--B. Involuntary muscle spasms
, The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism,
which can occur if the parathyroid glands are damaged or removed during a thyroidectomy.
Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels
and calcium deficiency.
A nurse is planning care for a client who has thrombophlebitis and a prescription to receive
heparin via continuous IV infusion. Which of the following actions should the nurse include
in the plan of care?
A. Infuse the heparin using an electronic IV pump.
B. Administer vitamin K if the client has indications of hemorrhage.
C. Adjust the dosage of heparin based on the client's PT levels.
D. Inform the client that the heparin will dissolve the thrombus. -- ANSWER--A. Infuse the
heparin using an electronic IV pump.
The nurse should administer heparin using an electronic IV pump, rather than by gravity, to
prevent an accidental increase or change in the rate of infusion.
A nurse is providing teaching to a client who has stomatitis due to chemotherapy and
radiation therapy. Which of the following statements by the client indicates a need for further
teaching?
A. "I will use a soft toothbrush or foam swab for oral care."
B. "I will use lemon and glycerine swabs after meals."
C. "I will remove my dentures except while eating."
D. "I will rinse my mouth frequently with hydrogen peroxide solution." -- ANSWER--B. "I
will use lemon and glycerine swabs after meals."
2025/2025 MED SURG FINAL EXAM STUDY
GUIDE QUESTIONS WITH VERIFIED
SOLUTIONS
A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus
erythematous (SLE). Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will need to take methotrexate even if I'm in remission."
B. "I'm thankful that this type of lupus only affects the skin."
C. "Each day I should apply a sunblock with a sun protection factor of 15."
D. "A mild fever is common with SLE and usually does not require medical intervention." --
ANSWER--A. "I will need to take methotrexate even if I'm in remission."
The nurse should inform the client that SLE is an autoimmune disorder characterized by
exacerbations and remissions. It affects the skin as well as joints, organs, and any structure in
the body that contains connective tissue. Methotrexate is an immunosuppressive medication
given during remission to help prevent exacerbation. The medication is also given when
exacerbations occur to reduce the severity of manifestations.
A nurse is caring for a client who has thrombocytopenia and develops epitaxis. Which of the
following actions should the nurse take?
A. Have the client gently blow clots from the nose every 5 min.
B. Instruct the client to sit with his head hyperextended.
,C. Apply ice compresses to the back of the client's neck.
D. Apply lateral pressure to the client's nose for 10 min. -- ANSWER--D. Apply lateral
pressure to the client's nose for 10 min.
The nurse should apply direct, lateral pressure to the nose for 10 min to control epistaxis. If
after 10 min the epistaxis continues, the client might require nasal packing or other
interventions.
A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the
following actions should the nurse take? (Select all that apply) A. Place the client on
respiratory isolation.
B. Monitor vital signs every 2 hr.
C. Assess neurological status every 4 hr.
D. Maintain the client in a modified Trendelenburg position.
E. Keep the client's room darkened. -- ANSWER--B, C, E
Monitor vital signs every 2 hr is correct. The nurse should monitor the client's vital signs to
assess for changes consistent with increased intracranial pressure.
Assess neurological status every 4 hr is correct. The nurse should monitor the client's
neurological status at least every 4 hr, or more frequently if the client's status indicates. The
course of encephalitis is unpredictable, so the client should be monitored closely for any
indications of deteriorating neurological functioning.
, Page 3 of 57
Keep the client's room darkened is correct. The nurse should provide the client with a
lowstimulation environment to promote comfort and decrease agitation.
A nurse is assessing a client who has a fractured left femur and is in skeletal traaction, Which
of the following findings should the nurse report to the provider>
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg -- ANSWER--C. Chest petechiae
The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients
who have fractures of the long bones, such as the femur, are at increased risk for fat emboli.
Fat emboli typically occur 12 to 48 hr after the injury when fat droplets from the marrow
enter into the systemic circulation and are deposited in the lungs. The nurse should
immediately notify the provider because the client could progress into acute respiratory
failure.
A nurse is monitoring a client following a thyroidectomy for the presence of
hypoparathyroidism. Which of the following findings should the nurse expect?
A. Elevated blood pressure
B. Involuntary muscle spasms
C. Cold intolerance
D. Weight loss -- ANSWER--B. Involuntary muscle spasms
, The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism,
which can occur if the parathyroid glands are damaged or removed during a thyroidectomy.
Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels
and calcium deficiency.
A nurse is planning care for a client who has thrombophlebitis and a prescription to receive
heparin via continuous IV infusion. Which of the following actions should the nurse include
in the plan of care?
A. Infuse the heparin using an electronic IV pump.
B. Administer vitamin K if the client has indications of hemorrhage.
C. Adjust the dosage of heparin based on the client's PT levels.
D. Inform the client that the heparin will dissolve the thrombus. -- ANSWER--A. Infuse the
heparin using an electronic IV pump.
The nurse should administer heparin using an electronic IV pump, rather than by gravity, to
prevent an accidental increase or change in the rate of infusion.
A nurse is providing teaching to a client who has stomatitis due to chemotherapy and
radiation therapy. Which of the following statements by the client indicates a need for further
teaching?
A. "I will use a soft toothbrush or foam swab for oral care."
B. "I will use lemon and glycerine swabs after meals."
C. "I will remove my dentures except while eating."
D. "I will rinse my mouth frequently with hydrogen peroxide solution." -- ANSWER--B. "I
will use lemon and glycerine swabs after meals."
