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Herzing University NSG 223 Med Surg II Final Exam
Newest 2025/2026 Complete Questions And Correct Detailed
Answers (Verified Answers) |Brand New Version!!
The nurse is completing a preoperative assessment on a male client who states, "I
am allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist.
2. Label the client's allergies on the front of the chart.
3. Ask the client what happens when he takes the codeine.
4. Document the allergy on the medication administration record -
SOLUTION=3.The nurse should first assess theevents which occurred when the
clienttook this medication because manyclients think a side effect, such as nausea,
is an allergic reaction.
Which laboratory result would require immediate intervention by the nurse for the
client scheduled for surgery?
1. Calcium 9.2 mg/dL.
2. Bleeding time 2 minutes.
3. Hemoglobin 15 g/dL.
4. Potassium 2.4 mEq/L. - SOLUTION=4.This potassium level is low and
shouldbe reported to the health-care providerbecause potassium is important
formuscle function, including the cardiacmuscle.
Which activities are the circulating nurse's responsibilities in the operating room?
1. Monitor the position of the client, prepare the surgical site, and ensure the
client's safety.
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2. Give preoperative medication in the holding area and monitor the client's
response to anesthesia.
3. Prepare sutures; set up the sterile field; and count all needles, sponges, and
instruments.
4. Prepare the medications to be administered by the anesthesiologist and change
the tubing for the anesthesia machine. - SOLUTION=1.The circulating nurse has
many responsibilities in the OR, including coordinating the activities in the
OR;keeping the OR clean; ensuring thesafety of the client; and maintainingthe
humidity, lighting, and safety of the equipment
The circulating nurse observes the surgical scrub technician remove a sponge from
the edge of the sterile field with a clamp and place the sponge and clamp in a
designated area. Which action should the nurse implement?
1. Place the sponge back where it was.
2. Tell the technician not to waste supplies.
3. Do nothing because this is the correct procedure.
4. Take the sponge out of the room immediately. - SOLUTION=3.The technician
followed the correctprocedure. Sponges are counted tomaintain client safety, so all
spongesmust be kept together to repeat thecount before the incision site is su-tured.
The sponge must be removed,not used, and placed in a designatedarea to be
counted later
The circulating nurse and the scrub technician find a discrepancy in the sponge
count. Which action should the circulating nurse take first?
1. Notify the client's surgeon.
2. Complete an occurrence report.
3. Contact the surgical manager.
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4. Re-count all sponges. - SOLUTION=4.A re-count of sponges may lead to
thediscovery of the cause of the presumederror. Usually it is just a miscount or
aresult of a sponge being placed in a location other than the sterile field,such as the
floor or a lower shelf
The nurse is assigned to care for a child with spina bifida that requires routine
urinary catheterization. What priority action by the nurse is important to prevent
complications caused by an IgE-mediated reaction?
a. Use non-latex gloves for all procedures.
b. Administer epinephrine prior to performing the procedure.
c. Administer Benadryl every 4 hours to prevent an allergic reaction.
d. Ensure that the child does not receive antibiotics. - SOLUTION=Answer: a
Cognitive Level: Apply
Explanation: A child with spina bifida (a congenital defect in the spinal column) is
at increased risk for latex allergies because the mucous membranes of the bladder
and rectum are exposed to latex during frequent examinations and procedures, such
as urinary catheterization. It is suggested that non-latex gloves and other materials
be used as much as is possible for all children, particularly those with this disorder.
An older adult client has a decrease in the number of T cells and B cells. What
nursing action is a high priority for this patient?
a. Monitor for signs of infection.
b. Give warm blankets and keep the room warm.
c. Encourage the patient to eat 6 small meals a day.
d. Obtain strict intake and output. - SOLUTION=Answer: a
Cognitive Level: Apply
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Explanation: One of the effects of aging on the immune system is the decrease in
the T cell and B-cell count which will increase the client's risk of infection. The
client should be closely monitored for the development of signs of infection. Warm
blankets and a warm room will assist with the age related change of decreased
basal body temperature but is not the priority action in this scenario. Eating small
frequent meals and obtaining strict intake and output will not address the decrease
in T and B cells and the associated risk for infection.
A client has a decrease in T cells and B cells. What nursing action is a priority?
a. Monitor for altered kidney function.
b. Monitor regularly for blood loss.
c. Monitor for joint swelling and tenderness.
d. Monitor regularly for signs of infection. - SOLUTION=Answer: d
Cognitive Level: Analyze
Explanation: As a client ages there is a decrease in T cells and B cells. This puts
the client at risk for infection. The client should be monitored regularly for any
signs of infection so that early intervention can be provided to reduce the risk of
complications.
A client arrives in the emergency department after being bitten by a raccoon that
wandered into the yard. What nursing action does the nurse anticipate preparing
for?
a. Administering a rabies vaccine to provide naturally acquired active immunity
b. Administering a rabies vaccine to provide artificially acquired passive immunity
c. Administering a rabies vaccine to create an antibody-mediated immunity
Herzing University NSG 223 Med Surg II Final Exam
Newest 2025/2026 Complete Questions And Correct Detailed
Answers (Verified Answers) |Brand New Version!!
The nurse is completing a preoperative assessment on a male client who states, "I
am allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist.
2. Label the client's allergies on the front of the chart.
3. Ask the client what happens when he takes the codeine.
4. Document the allergy on the medication administration record -
SOLUTION=3.The nurse should first assess theevents which occurred when the
clienttook this medication because manyclients think a side effect, such as nausea,
is an allergic reaction.
Which laboratory result would require immediate intervention by the nurse for the
client scheduled for surgery?
1. Calcium 9.2 mg/dL.
2. Bleeding time 2 minutes.
3. Hemoglobin 15 g/dL.
4. Potassium 2.4 mEq/L. - SOLUTION=4.This potassium level is low and
shouldbe reported to the health-care providerbecause potassium is important
formuscle function, including the cardiacmuscle.
Which activities are the circulating nurse's responsibilities in the operating room?
1. Monitor the position of the client, prepare the surgical site, and ensure the
client's safety.
,2|Page
2. Give preoperative medication in the holding area and monitor the client's
response to anesthesia.
3. Prepare sutures; set up the sterile field; and count all needles, sponges, and
instruments.
4. Prepare the medications to be administered by the anesthesiologist and change
the tubing for the anesthesia machine. - SOLUTION=1.The circulating nurse has
many responsibilities in the OR, including coordinating the activities in the
OR;keeping the OR clean; ensuring thesafety of the client; and maintainingthe
humidity, lighting, and safety of the equipment
The circulating nurse observes the surgical scrub technician remove a sponge from
the edge of the sterile field with a clamp and place the sponge and clamp in a
designated area. Which action should the nurse implement?
1. Place the sponge back where it was.
2. Tell the technician not to waste supplies.
3. Do nothing because this is the correct procedure.
4. Take the sponge out of the room immediately. - SOLUTION=3.The technician
followed the correctprocedure. Sponges are counted tomaintain client safety, so all
spongesmust be kept together to repeat thecount before the incision site is su-tured.
The sponge must be removed,not used, and placed in a designatedarea to be
counted later
The circulating nurse and the scrub technician find a discrepancy in the sponge
count. Which action should the circulating nurse take first?
1. Notify the client's surgeon.
2. Complete an occurrence report.
3. Contact the surgical manager.
,3|Page
4. Re-count all sponges. - SOLUTION=4.A re-count of sponges may lead to
thediscovery of the cause of the presumederror. Usually it is just a miscount or
aresult of a sponge being placed in a location other than the sterile field,such as the
floor or a lower shelf
The nurse is assigned to care for a child with spina bifida that requires routine
urinary catheterization. What priority action by the nurse is important to prevent
complications caused by an IgE-mediated reaction?
a. Use non-latex gloves for all procedures.
b. Administer epinephrine prior to performing the procedure.
c. Administer Benadryl every 4 hours to prevent an allergic reaction.
d. Ensure that the child does not receive antibiotics. - SOLUTION=Answer: a
Cognitive Level: Apply
Explanation: A child with spina bifida (a congenital defect in the spinal column) is
at increased risk for latex allergies because the mucous membranes of the bladder
and rectum are exposed to latex during frequent examinations and procedures, such
as urinary catheterization. It is suggested that non-latex gloves and other materials
be used as much as is possible for all children, particularly those with this disorder.
An older adult client has a decrease in the number of T cells and B cells. What
nursing action is a high priority for this patient?
a. Monitor for signs of infection.
b. Give warm blankets and keep the room warm.
c. Encourage the patient to eat 6 small meals a day.
d. Obtain strict intake and output. - SOLUTION=Answer: a
Cognitive Level: Apply
, 4|Page
Explanation: One of the effects of aging on the immune system is the decrease in
the T cell and B-cell count which will increase the client's risk of infection. The
client should be closely monitored for the development of signs of infection. Warm
blankets and a warm room will assist with the age related change of decreased
basal body temperature but is not the priority action in this scenario. Eating small
frequent meals and obtaining strict intake and output will not address the decrease
in T and B cells and the associated risk for infection.
A client has a decrease in T cells and B cells. What nursing action is a priority?
a. Monitor for altered kidney function.
b. Monitor regularly for blood loss.
c. Monitor for joint swelling and tenderness.
d. Monitor regularly for signs of infection. - SOLUTION=Answer: d
Cognitive Level: Analyze
Explanation: As a client ages there is a decrease in T cells and B cells. This puts
the client at risk for infection. The client should be monitored regularly for any
signs of infection so that early intervention can be provided to reduce the risk of
complications.
A client arrives in the emergency department after being bitten by a raccoon that
wandered into the yard. What nursing action does the nurse anticipate preparing
for?
a. Administering a rabies vaccine to provide naturally acquired active immunity
b. Administering a rabies vaccine to provide artificially acquired passive immunity
c. Administering a rabies vaccine to create an antibody-mediated immunity
