MEDSURG FINAL EXAM REVIEW

MEDSURG FINAL EXAM REVIEW

• Nurse in ED caring for a client who is having an acute asthma attack. How

can she tell the client in in respiratory distress (Select all)

A. 95 % O 2

• Wheezing
• Retraction of sternal muscles
• Pink mucous membranes
• Premature ventricular complexes (PVCs)
• Morning
• Newly admitted patient w/diagnosis of ascites. What order would the nurse

question?

• select all )
• High sodium
• Spironolactone
• Paracentesis
• Administration of salt-poor albumin
• Assisted ambulation
• A client is administered to the emergency department with several large

kidney stones.What is the nursing priority of this patient?

• Administer a Foley catheter
• Have the patient transferred to the ER to have the stones surgically

removed

• Administer hydrochlorothiazide
• Administer acetaminophen
• A student nurse is completing a pain assessment. The patient states that

the pain is located in his abdomen, and relieved by defecation. After 1 / 2

reviewing his chart she noticed the consistency of his stools also changed.What would the student suspect his diagnosis to be?

• Appendicitis
• Irritable bowel syndrome
• Irregular diet
• Abdominal hernia
• The nurse obtains a diet history from a pregnant 16 yr old girl. The girl tells

the nurse her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milkshake, fries and a salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on the data?

a. Altered nutrition: more than body requirements related to high-fat

diet

b. Knowledge deficit: nutrition in pregnancy

c. Altered nutrition: less that body requirements related to increased

nutritional demands of pregnancy

d. Risk for injury: fetal malnutrition related to poor maternal diet

• A boy was riding his bike to school when he hit the curb. He fell and hurt his

leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture to the right femur. Which of the following is the FIRST action the nurse should take

• check the pedal pulse and blanching sign in both legs
• immobilize the affected limb with a splint and ask him not to move
• make a thorough assessment of the circumstances surrounding the

accident

• put him in semi-fowler’s position for comfort
• A 65 year old patient with pneumonia is receiving gentamicin. It would be

most important for a nurse to monitor which of the following lab values in this patient

• Hemoglobin and Hematocrit

b. BUN and creatinine: cleared by kidneys, gentamicin is nephrotoxic

• Platelet count and clotting time
• Sodium and potassium
• To enhance the percutaneous absorption of nitroglycerin ointment, it

would be MOST important for the nurse to select a site that is

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