Nursing 250 Medical Surgical Proctored Exam ss ss ss ss ss
Questions and Answers. ss ss ss
1. A nurse s s is s s assessing s s a s s client s s who s s has s s left-sided s s heart s s failure. s s Which s s of s s the s s following s s findings
s s
s s should s s the s s nurse s s expect?
a. Bradycardia- s s more s s tachycardia s s cuz s s of s s a s s failing s s ventricle s s , s s SNS s s is s s activated s s to s s compensate s s .
b. Flushed s s skin- s s duskly s s it s s wIll s s look s s like
c. Frothy s s sputum-Left s s sided- s s can s s be s s blood s s tinged
d. Jugular s s vein s s distention→
s s Right Rationale: s s ATI s s MS: s s pg.
s s 198 s s ch
32 s s pdf
Left s s side: s s dyspnea, s s orthopnea, s s fatigue, s s pulmonary s s congestion, s s frothy s s sputum, s s organ s s failure s s such s s as s s oliguria.
Right s s Side: s s Jugular s s vein s s distention, s s ascending s s dependent s s edema, s s abdominal s s distention, s s polyuria s s ar s s rest, s s liver
s s enlargement,
2. A s s nurse s s is s s assessing s s a s s client s s who s s is s s experiencing s s renal s s colic s s from s s a s s calculus
s s in s s left s s renal s s pelvis. s s Identify s s the s s area s s where s s the nurse s s should s s expect s s the s s client
s s to s s have s s referred s s pain. s s ( s s Find s s “hot s s spots” s s in s s the s s artwork) s s Pain s s travels
s s downward s s to s s the s s inguinal area s s and s s lower s s back
Renal s s colic s s occurs s s in s s the s s kidney s s area. s s Referred s s pain s s is s s somewhere s s that s s happens s s in
s s another s s place s s other s s than s s where s s the s s pain s s should s s s s be s s felt.
2. A s s nurse s s is s s caring s s for s s a s s client s s who s s is s s receiving s s peritoneal s s dialysis s s and s s notes
s s a s s decrease s s in s s the s s dialysate s s flow s s rate. s s Which s s of s s the s s s s following s s actions s s should
s s the s s nurse s s take? s s (Select s s all s s the s s apply?). s s Check s s answer s s i s s read s s pg s s 644-647 s s med s s surg
s s it’s s s not s s so s s specific s s s s p. s s s s 370 s s ch s s 57 s s pdf
a. monitor s s the s s access s s site s s for s s drainage.- s s to s s check s s for s s sxs s s of s s infection.
b. Strip s s the s s catheter s s tubing
c. Measure s s the s s amount s s of s s the s s dialysate s s outflow
d. Raise s s the s s client s s to s s high s s fowlers s s position- s s they s s must s s lie s s supine
e. Position s s the s s client s s to s s her s s other s s side.
3. A s s nurse s s is s s planning s s to s s insert s s an s s indwelling s s catheter s s for s s a s s female s s client. s s Which s s of
s s the s s following s s actions s s should s s the s s nurse s s plan s s to take? s s Ati s s video s s tutorials s s foley
a. Collect s s urine s s specimen s s from s s the s s drainage s s bag s s 1 s s hr s s after s s insertion
b. Raise s s the s s head s s of s s the s s bed s s to s s 45 s s degrees s s prior s s to s s insertion
c. Secure s s the s s catheter s s to s s the s s client's s s inner s s thigh
d. Attach s s the s s bag s s to s s the s s rail s s of s s the s s bed. s s –under s s non s s movable s s area
6. A s s nurse s s is s s providing s s teaching s s for s s a s s client s s who s s has s s age-related s s macular s s degeneration
,Nursing 250 Medical Surgical Proctored Exam
ss ss ss ss ss
Questions and Answers. ss ss ss
s s which s s of s s s s the s s following s s information s s should s s the nurse s s include s s in s s the s s teaching
a. A s s possible s s cause s s of s s this s s problem s s is s s long-term s s lack s s of s s dietary s s protein
b. You s s probably s s have s s a s s Detachment s s of s s your s s retina s s -vision s s is s s like s s having s s curtains s s over s s eyes
c. You s s probably s s have s s noticed s s a s s decline s s in s s your s s central s s vision
d. The s s doctor s s can s s perform s s surgery s s to s s correct s s the s s start s s paying s s the s s folds s s in s s your s s retina
Rationale: s s ATI s s MS: s s PG. s s 63 s s Macular s s degeneration, s s often s s called s s age-related s s macular
s s degeneration s s (AMD), s s is s s the s s central s s loss s s of s s s s vision s s that s s affects s s the s s macula
s s of s s the s s eye. s s NO s s cure s s , s s happens s s alot s s in s s old s s people. s s Sxs: s s distorted
s s vision, s s blurred s s vision, s s caused s s by s s s s smoking, s s female, s s HTN, s s diet s s lacking s s carotene.
,Nursing 250 Medical Surgical Proctored Exam ss ss ss ss ss
Questions and Answers. ss ss ss
7. ssA s s nurse s s is s s assessing s s a s s client s s who s s has s s cirrhosis. s s Which s s of s s the s s following s s findings
s s is s s the s s priority s s for s s the s s nurse s s to s s report? s s P s s . s s 357 ch s s 55 pdf s s Med s s surg
a. Platelets s s 70,000/mm3- s s risk s s of s s bleed s s normal s s range s s is s s 150,000 s s - s s 300,00- s s s s ABCS s s is
s s compromised s s automatically s s .
b. Distended s s abdomen- s s expected
c. Alkaline s s phosphatase s s 125 s s units/L s s -norm s s s s normal s s is s s 30 s s -120 s s s s D. Clay s s colored s s stools- s s bile
s s not s s on s s your s s shit
8. ssA s s nurse s s is s s preparing s s to s s discontinue s s long-term s s total s s parenteral s s nutrition s s (TPN) s s therapy s s for s s a
s s client s s for s s a s s client. s s The s s nurse s s should s s plan s s to discontinue s s the s s TPN s s gradually s s to s s reduce
s s the s s risk s s of s s which s s of s s the s s following s s adverse s s effects?
Old s s med s s surge s s docs s s we s s used
a. Hyperglycemia
b. Diarrhea
c. Constipation
d. Hypoglycemia s s (Repeat) s s Since s s your s s body s s is s s producing s s enough s s insulin s s to s s take s s on
s s higher s s loads, s s you s s must s s taper s s it down s s to s s avoid s s hypoglycemia s s with s s lower
s s concentrations s s of
TPN
Abruptly s s discontinuing s s TPN s s will s s cause s s rebound s s hypoglycemia
9. A nurse s s is s s preparing s s to s s administer s s a s s unit s s of s s packed s s RBCs s s to s s a s s client. s s Which s s of s s the s s following
s s
actions s s should s s the s s nurse s s plan s s to s s take? s s P
s s
. s s 250 s s chapter s s 40 s s pdf p s s . s s 678 s s lewis
a. Administer s s the s s unit s s of s s packed s s RBC’s s s over s s 1 s s hr- s s 2- s s 4 s s hr s s its s s must s s be s s given s s for s s 2 s s -4
s s hours. s s s s older s s adults
b. Obtain s s the s s client’s s s first s s set s s of s s vital s s signs s s 1 s s hr s s after s s initiating s s the s s transfusion-
s s you s s get s s vital s s signs s s at s s the s s initial s s first s s 15 s s to s s 30 minutes s s of s s the s s transfusion.
c. Initiate s s venous s s access s s with s s a s s 21-gauge s s needle s s - s s no s s more s s than s s 19, s s for s s a s s regular s s adult
s s it s s is s s 18 s s or s s 20 s s .
d. Use s s Y s s tubing s s with s s 0.9% s s sodium s s chloride s s when s s administering s s the s s transfusion. s s Pg s s 249
10. TOXIC s s SHOCK s s SYNDROME- s s same
11. A nurse s s is s s providing s s discharge s s teaching s s to s s an s s older s s adult s s client s s who s s had s s an
s s
s s exacerbation s s of s s COPD. s s The s s client s s is s s to s s start s s s s fluticasone s s by s s metered-dose
s s inhaler. s s WHich s s of s s the s s following s s instructions s s should s s the s s nurse s s include? s s ( s s C) s s p
s s . s s 132 s s ch s s 22
a. Use s s fluticasone s s as s s needed s s for s s shortness s s of s s breath.- s s fluticasone s s used s s to s s treat s s inflammation.
b. Limit s s fluid s s intake s s to s s 1 s s L s s per s s day. s s s s - s s drink s s plenty s s to s s avoid s s dehydration. s s s s 2-3 s s liters.
c. Obtain s s a s s yearly s s influenza s s immunization. s s - s s reduce s s risk s s of s s infection.
d. Assist s s use s s of s s pursed-lip s s breathing.- s s this s s is s s also s s one s s of s s the s s interventions
s s the s s nurse s s does s s but s s the s s question s s ask s s about fluticasone. s s It s s is s s a s s steroid,
s s and s s we s s all s s know s s steroids s s decresaes s s inflammation s s but s s also s s depress s s our s s immunue
s s system. s s So getting s s a s s flu s s shot s s is s s priority.
12. A s s nurse s s is s s providing s s discharge s s teaching s s to s s an s s older s s adult s s client s s following
s s a s s left s s total s s hip s s arthroplasty. s s Which s s of s s the s s following instructions s s should s s the
s s nurse s s include s s in s s the s s teaching?
, Nursing 250 Medical Surgical Proctored Exam
ss ss ss ss ss
Questions and Answers. ss ss ss
a. “You s s can s s cross s s your s s legs s s at s s the s s ankles s s when s s sitting s s down.” s s -avoid s s flexion s s contraction
b. “Clean s s the s s incision s s daily s s with s s hydrogen s s peroxide.”- s s soap s s and s s water
c. “Install s s a s s raised s s toilet s s seat s s in s s your s s bathroom.” s s Pg s s 437 s s also s s use s s straight
s s chairs s s with s s arms, s s abduction s s pillow s s between the s s legs, s s avoid s s low s s chairs, s s and
s s flexion s s of s s hip s s greater s s than s s 90 s s degrees. s s NO s s crossing s s legs s s , s s no s s turing s s on
s s operative s s side.
d. “You s s should s s use s s an s s incentive s s spirometer s s every s s 8 s s hrs.”- s s once s s every s s hour s s at s s least
13. Missing
14. A s s nurse s s is s s caring s s for s s a s s client s s who s s is s s postoperative s s following s s a s s femur s s fracture. s s Which
s s of s s the s s following s s findings s s should s s the s s nurse report s s to s s the s s provider s s immediately?
a. The s s client s s reports s s shortness s s of s s breath s s - s s embolism s s ABCS p s s . s s 457 s s s s chapter s s 71
b. The s s client s s has s s a s s temperature s s of s s 38.1 s s C s s (100.5F)
c. The s s clients s s incision s s is s s red s s and s s warm
d. The s s client s s reports s s incision s s pain
Questions and Answers. ss ss ss
1. A nurse s s is s s assessing s s a s s client s s who s s has s s left-sided s s heart s s failure. s s Which s s of s s the s s following s s findings
s s
s s should s s the s s nurse s s expect?
a. Bradycardia- s s more s s tachycardia s s cuz s s of s s a s s failing s s ventricle s s , s s SNS s s is s s activated s s to s s compensate s s .
b. Flushed s s skin- s s duskly s s it s s wIll s s look s s like
c. Frothy s s sputum-Left s s sided- s s can s s be s s blood s s tinged
d. Jugular s s vein s s distention→
s s Right Rationale: s s ATI s s MS: s s pg.
s s 198 s s ch
32 s s pdf
Left s s side: s s dyspnea, s s orthopnea, s s fatigue, s s pulmonary s s congestion, s s frothy s s sputum, s s organ s s failure s s such s s as s s oliguria.
Right s s Side: s s Jugular s s vein s s distention, s s ascending s s dependent s s edema, s s abdominal s s distention, s s polyuria s s ar s s rest, s s liver
s s enlargement,
2. A s s nurse s s is s s assessing s s a s s client s s who s s is s s experiencing s s renal s s colic s s from s s a s s calculus
s s in s s left s s renal s s pelvis. s s Identify s s the s s area s s where s s the nurse s s should s s expect s s the s s client
s s to s s have s s referred s s pain. s s ( s s Find s s “hot s s spots” s s in s s the s s artwork) s s Pain s s travels
s s downward s s to s s the s s inguinal area s s and s s lower s s back
Renal s s colic s s occurs s s in s s the s s kidney s s area. s s Referred s s pain s s is s s somewhere s s that s s happens s s in
s s another s s place s s other s s than s s where s s the s s pain s s should s s s s be s s felt.
2. A s s nurse s s is s s caring s s for s s a s s client s s who s s is s s receiving s s peritoneal s s dialysis s s and s s notes
s s a s s decrease s s in s s the s s dialysate s s flow s s rate. s s Which s s of s s the s s s s following s s actions s s should
s s the s s nurse s s take? s s (Select s s all s s the s s apply?). s s Check s s answer s s i s s read s s pg s s 644-647 s s med s s surg
s s it’s s s not s s so s s specific s s s s p. s s s s 370 s s ch s s 57 s s pdf
a. monitor s s the s s access s s site s s for s s drainage.- s s to s s check s s for s s sxs s s of s s infection.
b. Strip s s the s s catheter s s tubing
c. Measure s s the s s amount s s of s s the s s dialysate s s outflow
d. Raise s s the s s client s s to s s high s s fowlers s s position- s s they s s must s s lie s s supine
e. Position s s the s s client s s to s s her s s other s s side.
3. A s s nurse s s is s s planning s s to s s insert s s an s s indwelling s s catheter s s for s s a s s female s s client. s s Which s s of
s s the s s following s s actions s s should s s the s s nurse s s plan s s to take? s s Ati s s video s s tutorials s s foley
a. Collect s s urine s s specimen s s from s s the s s drainage s s bag s s 1 s s hr s s after s s insertion
b. Raise s s the s s head s s of s s the s s bed s s to s s 45 s s degrees s s prior s s to s s insertion
c. Secure s s the s s catheter s s to s s the s s client's s s inner s s thigh
d. Attach s s the s s bag s s to s s the s s rail s s of s s the s s bed. s s –under s s non s s movable s s area
6. A s s nurse s s is s s providing s s teaching s s for s s a s s client s s who s s has s s age-related s s macular s s degeneration
,Nursing 250 Medical Surgical Proctored Exam
ss ss ss ss ss
Questions and Answers. ss ss ss
s s which s s of s s s s the s s following s s information s s should s s the nurse s s include s s in s s the s s teaching
a. A s s possible s s cause s s of s s this s s problem s s is s s long-term s s lack s s of s s dietary s s protein
b. You s s probably s s have s s a s s Detachment s s of s s your s s retina s s -vision s s is s s like s s having s s curtains s s over s s eyes
c. You s s probably s s have s s noticed s s a s s decline s s in s s your s s central s s vision
d. The s s doctor s s can s s perform s s surgery s s to s s correct s s the s s start s s paying s s the s s folds s s in s s your s s retina
Rationale: s s ATI s s MS: s s PG. s s 63 s s Macular s s degeneration, s s often s s called s s age-related s s macular
s s degeneration s s (AMD), s s is s s the s s central s s loss s s of s s s s vision s s that s s affects s s the s s macula
s s of s s the s s eye. s s NO s s cure s s , s s happens s s alot s s in s s old s s people. s s Sxs: s s distorted
s s vision, s s blurred s s vision, s s caused s s by s s s s smoking, s s female, s s HTN, s s diet s s lacking s s carotene.
,Nursing 250 Medical Surgical Proctored Exam ss ss ss ss ss
Questions and Answers. ss ss ss
7. ssA s s nurse s s is s s assessing s s a s s client s s who s s has s s cirrhosis. s s Which s s of s s the s s following s s findings
s s is s s the s s priority s s for s s the s s nurse s s to s s report? s s P s s . s s 357 ch s s 55 pdf s s Med s s surg
a. Platelets s s 70,000/mm3- s s risk s s of s s bleed s s normal s s range s s is s s 150,000 s s - s s 300,00- s s s s ABCS s s is
s s compromised s s automatically s s .
b. Distended s s abdomen- s s expected
c. Alkaline s s phosphatase s s 125 s s units/L s s -norm s s s s normal s s is s s 30 s s -120 s s s s D. Clay s s colored s s stools- s s bile
s s not s s on s s your s s shit
8. ssA s s nurse s s is s s preparing s s to s s discontinue s s long-term s s total s s parenteral s s nutrition s s (TPN) s s therapy s s for s s a
s s client s s for s s a s s client. s s The s s nurse s s should s s plan s s to discontinue s s the s s TPN s s gradually s s to s s reduce
s s the s s risk s s of s s which s s of s s the s s following s s adverse s s effects?
Old s s med s s surge s s docs s s we s s used
a. Hyperglycemia
b. Diarrhea
c. Constipation
d. Hypoglycemia s s (Repeat) s s Since s s your s s body s s is s s producing s s enough s s insulin s s to s s take s s on
s s higher s s loads, s s you s s must s s taper s s it down s s to s s avoid s s hypoglycemia s s with s s lower
s s concentrations s s of
TPN
Abruptly s s discontinuing s s TPN s s will s s cause s s rebound s s hypoglycemia
9. A nurse s s is s s preparing s s to s s administer s s a s s unit s s of s s packed s s RBCs s s to s s a s s client. s s Which s s of s s the s s following
s s
actions s s should s s the s s nurse s s plan s s to s s take? s s P
s s
. s s 250 s s chapter s s 40 s s pdf p s s . s s 678 s s lewis
a. Administer s s the s s unit s s of s s packed s s RBC’s s s over s s 1 s s hr- s s 2- s s 4 s s hr s s its s s must s s be s s given s s for s s 2 s s -4
s s hours. s s s s older s s adults
b. Obtain s s the s s client’s s s first s s set s s of s s vital s s signs s s 1 s s hr s s after s s initiating s s the s s transfusion-
s s you s s get s s vital s s signs s s at s s the s s initial s s first s s 15 s s to s s 30 minutes s s of s s the s s transfusion.
c. Initiate s s venous s s access s s with s s a s s 21-gauge s s needle s s - s s no s s more s s than s s 19, s s for s s a s s regular s s adult
s s it s s is s s 18 s s or s s 20 s s .
d. Use s s Y s s tubing s s with s s 0.9% s s sodium s s chloride s s when s s administering s s the s s transfusion. s s Pg s s 249
10. TOXIC s s SHOCK s s SYNDROME- s s same
11. A nurse s s is s s providing s s discharge s s teaching s s to s s an s s older s s adult s s client s s who s s had s s an
s s
s s exacerbation s s of s s COPD. s s The s s client s s is s s to s s start s s s s fluticasone s s by s s metered-dose
s s inhaler. s s WHich s s of s s the s s following s s instructions s s should s s the s s nurse s s include? s s ( s s C) s s p
s s . s s 132 s s ch s s 22
a. Use s s fluticasone s s as s s needed s s for s s shortness s s of s s breath.- s s fluticasone s s used s s to s s treat s s inflammation.
b. Limit s s fluid s s intake s s to s s 1 s s L s s per s s day. s s s s - s s drink s s plenty s s to s s avoid s s dehydration. s s s s 2-3 s s liters.
c. Obtain s s a s s yearly s s influenza s s immunization. s s - s s reduce s s risk s s of s s infection.
d. Assist s s use s s of s s pursed-lip s s breathing.- s s this s s is s s also s s one s s of s s the s s interventions
s s the s s nurse s s does s s but s s the s s question s s ask s s about fluticasone. s s It s s is s s a s s steroid,
s s and s s we s s all s s know s s steroids s s decresaes s s inflammation s s but s s also s s depress s s our s s immunue
s s system. s s So getting s s a s s flu s s shot s s is s s priority.
12. A s s nurse s s is s s providing s s discharge s s teaching s s to s s an s s older s s adult s s client s s following
s s a s s left s s total s s hip s s arthroplasty. s s Which s s of s s the s s following instructions s s should s s the
s s nurse s s include s s in s s the s s teaching?
, Nursing 250 Medical Surgical Proctored Exam
ss ss ss ss ss
Questions and Answers. ss ss ss
a. “You s s can s s cross s s your s s legs s s at s s the s s ankles s s when s s sitting s s down.” s s -avoid s s flexion s s contraction
b. “Clean s s the s s incision s s daily s s with s s hydrogen s s peroxide.”- s s soap s s and s s water
c. “Install s s a s s raised s s toilet s s seat s s in s s your s s bathroom.” s s Pg s s 437 s s also s s use s s straight
s s chairs s s with s s arms, s s abduction s s pillow s s between the s s legs, s s avoid s s low s s chairs, s s and
s s flexion s s of s s hip s s greater s s than s s 90 s s degrees. s s NO s s crossing s s legs s s , s s no s s turing s s on
s s operative s s side.
d. “You s s should s s use s s an s s incentive s s spirometer s s every s s 8 s s hrs.”- s s once s s every s s hour s s at s s least
13. Missing
14. A s s nurse s s is s s caring s s for s s a s s client s s who s s is s s postoperative s s following s s a s s femur s s fracture. s s Which
s s of s s the s s following s s findings s s should s s the s s nurse report s s to s s the s s provider s s immediately?
a. The s s client s s reports s s shortness s s of s s breath s s - s s embolism s s ABCS p s s . s s 457 s s s s chapter s s 71
b. The s s client s s has s s a s s temperature s s of s s 38.1 s s C s s (100.5F)
c. The s s clients s s incision s s is s s red s s and s s warm
d. The s s client s s reports s s incision s s pain
