Medsurg 2 Final Exam Latest Update 2024-2025 Actual Exam 120 Questions and 100% Correct Answers Guaranteed A+
A 12-year-old client comes to the emergency department (ED) after being bitten by a scorpion at a local petting zoo. Which action does the nurse perform first?
- Administers a tetanus shot
- Applies an ice pack to the sting site
- Assesses the client's vital signs
- Calls the poison control center - CORRECT ANSWER: C. Assesses the client's vital
signs
A 37-year-old male is admitted with a severely abscessed tooth, BP 90/42, HR 136, RR 28, SpO2 90% on room air, T 38.7 degrees C. The nurse suspects sepsis from the
tooth. The priority intervention by the nurse would be to:
- Administer prescribed antibiotics prior to blood cultures
- Initiate intravenous fluid resuscitation
- Obtain a complete chemistry for laboratory analysis
- Insert an indwelling urinary catheter - CORRECT ANSWER: B. Initiate intravenous
fluid resuscitation
A 6-foot, 6-inch tall 38-year-old man is being mechanically ventilated at a tidal volume of 500 mL and a respiratory rate of 16 breaths per minute. His most recent arterial blood gas (ABG) results are: pH = 7.33; Pao2 = 85 mm Hg; Paco2 = 55 mm Hg. What is the nurse's interpretation of these results?
- Ventilation is adequate to maintain oxygenation
- Ventilation is excessive; respiratory alkalosis is present 1 / 4
- Ventilation is inadequate; respiratory acidosis is present
- Ventilation status cannot be determined from the information presented - CORRECT
ANSWER: C. Ventilation is inadequate; respiratory acidosis is present
A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route?
- The drug will be effective more quickly than if given IM or subcutaneously
- It is less likely to interfere with the client's breathing and oxygenation
- The danger of an overdose during fluid remobilization is reduced
- The client has delayed gastric emptying - CORRECT ANSWER: C. The danger of an
overdose during fluid remobilization is reduced
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
D. Insert a nasogastric tube - CORRECT ANSWER: A. Provide supplemental oxygen
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
D. Assess the level of consciousness - CORRECT ANSWER: B. Assess and maintain
the client's airway
- / 4
A client who has a pulmonary embolism and a venous thromboembolism is to be started on oral warfarin (Coumadin) while still receiving intravenous heparin. What is the nurse's best action?
- Administer the medications as prescribed
- Remind the prescriber that two anticoagulants should not be administered
- Hold the dose of wwarfarin until the client's partial thromboplastin time is the same as
- Monitor the client for clinical manifestations of internal or external bleeding at least
concurrently
the control value
every 2 hours - CORRECT ANSWER: A. Administer the medications as prescribed
A client who has been receiving heparin subcutaneously for 10 days has all of the following laboratory blood test values. Which value does the nurse report immediately to the prescriber?
- Activated partial thromboplastin time 1.5
- International normalized ratio 1.7
- Red blood cells 4.2 million/mm3
D. Platelets 20,000/mm3 - CORRECT ANSWER: D. Platelets 20,000/mm3
A client with bacteremia associated with a bacterial skin infection is receiving clindamycin (Cleocin) intravenously (IV). Which assessment finding indicates the need for immediate action by the nurse?
- Blood pressure is 88/40 mm Hg
- White blood cell count is 15,000/mm3
- Oral temperature is 101 degrees F (38.3 degrees C)
D. Heart rate is 102 beats/min. - CORRECT ANSWER:
- / 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 ANSWER: B. "Avoid wearing pantyhose or nylon stockings for more than 2 hours at a time."
A golfer who is caught in a thunderstorm is struck by lightening. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially?
- Applies a dressing over the skin burn where the lightening entered
- Instructs everyone not to touch the victim to avoid being hurt
- Moves victim to a more secure area
- Palpates to check for the presence of a pulse - CORRECT ANSWER: D. Palpates to
check for the presence of a pulse
A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take?(Select all that apply)
- Scrape the site with a wooden tongue depressor
- Puncture the crusted area with a sterile needle
- Swab the crusted area with a sterile cotton-tipped applicator
- Place cotton-tipped applicator in culturette tube
- Place culturette tube in ice - CORRECT ANSWER: B. Puncture the crusted area with
- Place cotton-tipped applicator in culturette tube
- / 4
a sterile needle