MED SURG 1 FINAL EXAM
QUESTIONS & UPDATED PASSED
ANSWERS
the nurse is caring for a client with multiple sclerosis who describes burning pain in both feet.
which type of pain would the nurse suspect?
a. Somatic pain
b. Neuropathic pain
c. Acute pain
d. Procedural pain
Neuropathic pain
the nurse is caring for a client who is unable to self-report pain. which statement would the
nurse make to the client's family regarding pain management?
a. "If the client is resting, it is a good indicator that pain is managed."
b. "Behavioral assessment tools for pain correspond with self-report of pain."
c. "The behavioral assessment score is very low, so intense pain is unlikely."
d. "I will use a behavioral pain scale regularly since the client is unable to self-report pain."
"I will use a behavioral pain scale regularly since the client is unable to self-report pain."
the nurse has received orders for patient-controlled analgesia for four clients. which order
requires the nurse to contact the provider?
a. A 47-year-old client with endometriosis immediately following total abdominal hysterectomy
b. A 56-year-old client with early-onset dementia 1 hour post-total hip arthroplasty
c. A 29-year-old client with diabetes 6 hours postappendectomy following rupture
d. A 60-year-old client with colon cancer who is 12 hours post-colon resection
A 56-year-old client with early-onset dementia 1 hour post-total hip arthroplasty
the nurse is caring for a client who is experiencing myocardial infarction and reports intense
pain in the jaw area and pressure in the chest wall. How would the nurse document the client's
pain?
,a. The client describes localized pain in the jaw area and reports pressure in the chest wall.
b. The client describes referred pain in the jaw and reports localized pressure in the chest wall.
c. The client describes projected pain from the chest wall into the jaw area.
d. The client describes radiating pain in the jaw and referred pressure in the chest wall.
The client describes referred pain in the jaw and reports localized pressure in the chest wall.
a client was admitted 72 hours ago and has a 22-gauge short peripheral intravenous catheter
(short PIVC) in the right forearm. the client has not received any IV medications in the last 12
hours. which of the following nursing actions is appropriate (select all that apply)?
a. Change the location of the short PIVC.
b. Flush the short PIVC with normal saline.
c. Assess the site for redness, swelling, pain.
d. Assess the need for continued short PIVC placement.
e. Change the dressing covering the short PIVC.
- Flush the short PIVC with normal saline.
- Assess the site for redness, swelling, pain.
- Assess the need for continued short PIVC placement.
the health care provider has ordered a 500-mL bolus of Ringer's lactate to infuse over 1 hour
followed by a loading dose of IV vancomycin. which site and gauge would the nurse select for
short PIVC placement?
a. 24 gauge in the wrist
b. 18 gauge in the antecubital fossa
c. 20 gauge in the forearm
d. 22 gauge in the hand
20 gauge in the forearm
the nurse is caring for a client on Friday. The client had a short peripheral intravenous catheter
(short PIVC) inserted earlier in the week on Tuesday. which action would the nurse take?
a. Replace the short PIVC.
b. Assess the PIVC insertion site.
c. Discontinue the short PIVC.
d. Convert the short PIVC to a saline lock.
Assess the PIVC insertion site.
,the nurse is caring for a 44-year-old client who requires IV fluid replacement. the nurse has one
unsuccessful attempt when inserting a short peripheral IV catheter. what action would the
nurse take next?
a. Consult the IV therapy team.
b. Ask a colleague to attempt.
c. Attempt insertion a second time.
d. Notify the provider of limited IV access.
Attempt insertion a second time
the nurse is caring for an older adult who reports, "I don't really want to drink water." which
instruction would the nurse provide?
a. "Insensible water loss rarely occurs in older adults."
b. "As long as you are making urine, the risk of dehydration is low."
c. "Your body is at least 50% water, so it is very important to drink fluids."
d. "It's important to drink enough fluid to produce at least 200 mL of urine daily."
"Your body is at least 50% water, so it is very important to drink fluids."
the nurse is caring for an 82-year-old client with dehydration who requests to walk to the
bathroom. which nursing assessment is the priority to determine safety with ambulation?
a. Skin turgor over the sternal area
b. Orthostatic blood pressure
c. Review of recent potassium level
d. Oral mucous membranes
Orthostatic blood pressure
the nurse is caring for a client with dehydration. which assessment finding indicates
improvement in hydration status?
a. Equal handgrip strength
b. Negative Trousseau sign
c. Urine output of 100 mL in the last 7 hours
d. Neck vein distention in the supine position
Neck vein distention in the supine position
, which client would the nurse assess most frequently for signs and symptoms of hypokalemia?
a. 72-year-old taking the diuretic spironolactone for hypertension
b. 62-year-old receiving an IV solution of Ringer's lactate at 200 mL/hr
c. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours
d. 22-year-old receiving an IV infusion of regular insulin to manage ketoacidosis
22-year-old receiving an IV infusion of regular insulin to manage ketoacidosis
the nurse is caring for a client in the emergency department whose initial potassium level is 6.5
mEq/L. (Reference range: 3.5-5.0 mEq/L [mmol/L]) what nursing intervention is the priority?
a. Apply a pulse oximeter.
b. Assess the client's magnesium level.
c. Apply a continuous cardiac monitor.
d. Document the potassium level.
Apply a continuous cardiac monitor.
which of the following electrolytes are most affected by low magnesium levels (select all that
apply)?
a. Calcium
b. Chloride
c. Hydrogen
d. Potassium
e. Sodium
- Calcium
- Potassium
the nurse is caring for a client with a hematocrit of 57% and a sodium level of 149 mEq/L. how
would the nurse interpret this data?
a. The client is most likely anemic.
b. The client has an actual increase in sodium intake.
c. The client is experiencing relative hypernatremia.
d. The client is experiencing actual hyponatremia.
The client is experiencing relative hypernatremia.
QUESTIONS & UPDATED PASSED
ANSWERS
the nurse is caring for a client with multiple sclerosis who describes burning pain in both feet.
which type of pain would the nurse suspect?
a. Somatic pain
b. Neuropathic pain
c. Acute pain
d. Procedural pain
Neuropathic pain
the nurse is caring for a client who is unable to self-report pain. which statement would the
nurse make to the client's family regarding pain management?
a. "If the client is resting, it is a good indicator that pain is managed."
b. "Behavioral assessment tools for pain correspond with self-report of pain."
c. "The behavioral assessment score is very low, so intense pain is unlikely."
d. "I will use a behavioral pain scale regularly since the client is unable to self-report pain."
"I will use a behavioral pain scale regularly since the client is unable to self-report pain."
the nurse has received orders for patient-controlled analgesia for four clients. which order
requires the nurse to contact the provider?
a. A 47-year-old client with endometriosis immediately following total abdominal hysterectomy
b. A 56-year-old client with early-onset dementia 1 hour post-total hip arthroplasty
c. A 29-year-old client with diabetes 6 hours postappendectomy following rupture
d. A 60-year-old client with colon cancer who is 12 hours post-colon resection
A 56-year-old client with early-onset dementia 1 hour post-total hip arthroplasty
the nurse is caring for a client who is experiencing myocardial infarction and reports intense
pain in the jaw area and pressure in the chest wall. How would the nurse document the client's
pain?
,a. The client describes localized pain in the jaw area and reports pressure in the chest wall.
b. The client describes referred pain in the jaw and reports localized pressure in the chest wall.
c. The client describes projected pain from the chest wall into the jaw area.
d. The client describes radiating pain in the jaw and referred pressure in the chest wall.
The client describes referred pain in the jaw and reports localized pressure in the chest wall.
a client was admitted 72 hours ago and has a 22-gauge short peripheral intravenous catheter
(short PIVC) in the right forearm. the client has not received any IV medications in the last 12
hours. which of the following nursing actions is appropriate (select all that apply)?
a. Change the location of the short PIVC.
b. Flush the short PIVC with normal saline.
c. Assess the site for redness, swelling, pain.
d. Assess the need for continued short PIVC placement.
e. Change the dressing covering the short PIVC.
- Flush the short PIVC with normal saline.
- Assess the site for redness, swelling, pain.
- Assess the need for continued short PIVC placement.
the health care provider has ordered a 500-mL bolus of Ringer's lactate to infuse over 1 hour
followed by a loading dose of IV vancomycin. which site and gauge would the nurse select for
short PIVC placement?
a. 24 gauge in the wrist
b. 18 gauge in the antecubital fossa
c. 20 gauge in the forearm
d. 22 gauge in the hand
20 gauge in the forearm
the nurse is caring for a client on Friday. The client had a short peripheral intravenous catheter
(short PIVC) inserted earlier in the week on Tuesday. which action would the nurse take?
a. Replace the short PIVC.
b. Assess the PIVC insertion site.
c. Discontinue the short PIVC.
d. Convert the short PIVC to a saline lock.
Assess the PIVC insertion site.
,the nurse is caring for a 44-year-old client who requires IV fluid replacement. the nurse has one
unsuccessful attempt when inserting a short peripheral IV catheter. what action would the
nurse take next?
a. Consult the IV therapy team.
b. Ask a colleague to attempt.
c. Attempt insertion a second time.
d. Notify the provider of limited IV access.
Attempt insertion a second time
the nurse is caring for an older adult who reports, "I don't really want to drink water." which
instruction would the nurse provide?
a. "Insensible water loss rarely occurs in older adults."
b. "As long as you are making urine, the risk of dehydration is low."
c. "Your body is at least 50% water, so it is very important to drink fluids."
d. "It's important to drink enough fluid to produce at least 200 mL of urine daily."
"Your body is at least 50% water, so it is very important to drink fluids."
the nurse is caring for an 82-year-old client with dehydration who requests to walk to the
bathroom. which nursing assessment is the priority to determine safety with ambulation?
a. Skin turgor over the sternal area
b. Orthostatic blood pressure
c. Review of recent potassium level
d. Oral mucous membranes
Orthostatic blood pressure
the nurse is caring for a client with dehydration. which assessment finding indicates
improvement in hydration status?
a. Equal handgrip strength
b. Negative Trousseau sign
c. Urine output of 100 mL in the last 7 hours
d. Neck vein distention in the supine position
Neck vein distention in the supine position
, which client would the nurse assess most frequently for signs and symptoms of hypokalemia?
a. 72-year-old taking the diuretic spironolactone for hypertension
b. 62-year-old receiving an IV solution of Ringer's lactate at 200 mL/hr
c. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours
d. 22-year-old receiving an IV infusion of regular insulin to manage ketoacidosis
22-year-old receiving an IV infusion of regular insulin to manage ketoacidosis
the nurse is caring for a client in the emergency department whose initial potassium level is 6.5
mEq/L. (Reference range: 3.5-5.0 mEq/L [mmol/L]) what nursing intervention is the priority?
a. Apply a pulse oximeter.
b. Assess the client's magnesium level.
c. Apply a continuous cardiac monitor.
d. Document the potassium level.
Apply a continuous cardiac monitor.
which of the following electrolytes are most affected by low magnesium levels (select all that
apply)?
a. Calcium
b. Chloride
c. Hydrogen
d. Potassium
e. Sodium
- Calcium
- Potassium
the nurse is caring for a client with a hematocrit of 57% and a sodium level of 149 mEq/L. how
would the nurse interpret this data?
a. The client is most likely anemic.
b. The client has an actual increase in sodium intake.
c. The client is experiencing relative hypernatremia.
d. The client is experiencing actual hyponatremia.
The client is experiencing relative hypernatremia.
