Medsurg 2 Final Exam 121 Questions with Complete

Medsurg 2 Final Exam 121 Questions with Complete Solutions 100% Verified The client reports that a previously sensitive area of skin no longer responds to temperature changes or painful stimuli. This finding indicates a functional abnormality for which skin layer?

• Stratum corneum
• Adipose layer
• Epidermis
• Dermis - Correct Answers D. Dermis

During skin inspection the nurse observes three lesions on the client's right knee. The lesions are round, have a raised border, and are grouped in a "smiley face" pattern. Which descriptors does the nurse use to document these observations?

• Annular, circinate, clustered
• Linear, confluent, vesicular
• Circumscribed, universal, pustular
• Serpiginous, coalesced, wheal-like - Correct Answers A. Annular, circinate, clustered

Which technique for obtaining a specimen for bacterial culture is most correct for the nurse to use with a client who has crusted skin lesions on the upper back?

• Remove several crusts, and swab the underlying exudate.
• Dampen the culture swab with sterile water, and then roll the swab over the central crusts.
• Apply a gauze bandage to the area, remove it after 1 hour, and send the entire gauze to the

laboratory.

• Clean the area with an antibacterial solution, remove a crust from the center of the cluster of

lesions, and send it to the laboratory. - Correct Answers A. Remove several crusts, and swab the underlying exudate.An 88-year-old man is admitted to the ED from home with weakness and acute confusion.What is the nurse's priority for his care to maintain client safety? 1 / 4

• Assess his mental status every 30minutes
• Ensure that siderails are raised on his stretcher
• Check his bowel sounds for intestinal obstruction
• Teach him to move slowly when walking - Correct Answers B. Ensure that siderails are raised on his

stretcher A client is admitted to the ED with multiple stab wounds to his chest, abdomen and arms. What is the nurse's priority upon admission to the ED?

• Check for bleeding from the stab wounds
• Assess and maintain the client's airway
• Start 2 large-bore IV lines
• Assess the level of consciousness - Correct Answers B. Assess and maintain the client's airway

An older client with heat stroke is being cooled with a cooling blanket and ice packs under her arms and behind her neck. What assessment indicates to the nurse that the cooling process is effective?

• The client is alert and oriented
• The client states that she feels cooler
• The client's temperature is 100 degrees F
• The client's urinary output is 30 mL/hr - Correct Answers C. The client's temperature is 100

degrees F An older client is preparing for a trip to a cold-weather area and asks the nurse how he can prevent hypothermia while visiting there. Which preventative actions will the nurse include in the health teaching? Select all that apply.

• Wear cotton clothing to help absorb moisture
• Layer clothing to keep heat near the body
• Avoid skiing if it is snowing heavily
• Be sure to wear gloves and a hat
• Do not wear too many pairs of socks - Correct Answers B. Layer clothing to keep heat near the

body 2 / 4

• Avoid skiing if it is snowing heavily
• Be sure to wear gloves and a hat
• Do not wear too many pairs of socks

A client experiences altitude-related illness after visiting a ski resort in Colorado. What is the nurse's priority action when the client is admitted to the emergency department?

• Provide supplemental oxygen
• Place the client on a ventilator
• Perform an electrocardiogram
• Insert a nasogastric tube - Correct Answers A. Provide supplemental oxygen

The nurse is preparing to triage clients at the scene of an airplane crash. Which of these clients will the nurse identify as emergent?

• Young woman with closed fractures of her right leg and arm
• Older woman with abdominal bleeding who is dzed and confused
• Middle-aged man with third-degree burns over 90% of his body
• Young man with numerous bruises and superficial lacerations - Correct Answers C. Middle-aged

man with third-degree burns over 90% of his body A nurse needs to discharge two medical-surgical clients to make room for two victims of a tornado.Which of these clients could be discharged from the unit now? Select all that apply.

• 78-year-old with telemetry monitoring for chest pain last night
• 57-year-old who had a bowel resection for cancer 2 days ago
• 44-year-old who has received 3 days of IV antibiotics for pneumonia
• 61-year-old who had a thyroidectomy this morning
• 72-year-old who had a total hip replacement 2 days ago - Correct Answers B. 57-year-old who had

a bowel resection for cancer 2 days ago

• 44-year-old who has received 3 days of IV antibiotics for pneumonia 3 / 4

A female business woman has extremely dry skin on her legs. In addition to using lotions after bathing, she asks the nurse about other measures to help reduce the dryness. What is the nurse's best response?

• "Wear long-legged pajamas to sleep in rather than nightgowns."
• "Avoid wearing pantyhose or nylon stockings for more than 2 hours at a time."
• "Leave the fat-containing soap on your skin when bathing rather than rinsing it off."
• "Bathe in water that is as warm as you can stand to stimulate the release of body oils from your

sebaceous glands." - Correct Answers B. "Avoid wearing pantyhose or nylon stockings for more than

• hours at a time."

The newly admitted client has all of the following laboratory test values. Which value suggests to the nurse that the client may be at an increased risk for pressure ulcer formation?

• International normalized ratio (INR) of 1.5
• White blood cell (WBC) count of 5200/mm3
• Serum sodium concentrationof 134 mEq/L
• Serum prealbumin concentration of 15.2mg/dL - Correct Answers D. Serum prealbumin

concentration of 15.2mg/dL Which intervention does the nurse use to promote "take" of a graft placed on the client's right heel?

• Elevate the client's right foot by placing pillows under the leg from the knees to the ankles
• Position the client on the abdomen with the right foot hyperextended for at least 4 hours daily
• Ensure that the grafted area is pressed tightly to the bed to promote adherence to the wound bed
• Assess the circulation distal to the graft every hour and compare the findings with those from the

left foot - Correct Answers A. Elevate the client's right foot by placing pillows under the leg from the knees to the ankles Which precaution is most important for the nurse to teach a client prescribed adalimumab (Humira)?

• Drinking a full glass of water when taking each dose
• Reducing the drug dosage when psoriasis symptoms decrease
• Reporting symptoms of infection to the prescriber immediately
• / 4