Med-surge 3
Surgery is the process of incursion into the body of a living organism with the intention to cure or treat a condition and prevent further damage. Med-surge 3 dwells more on the nurses' roles in matters surgery.
- 1.A client has very dry skin. Which is the best intervention for the nurse to teach the client?
- A.
Use antimicrobial soap so scratching won't cause infection
- B.
After you bathe, put lotion on before your skin dries completely
- C.
Avoid wearing stockings or other constricting clothing
- D.
Be sure to use lots of moisturizer several times a day
- 2.A client is going home with a surgical wound on the coccyx that is to heal by secondary intention. Which priority problem must the nurse address in the teaching plan?
- A.
Pain
- B.
Infection
- C.
Dehydration
- D.
Poor body image
- 3.Which client does the nurse assess to be at greatest risk for pressure ulcer development?
- A.
Client who requires assistance with ambulation
- B.
Incontinent client with limited mobility
- C.
Client who has pneumonia
- D.
Client with HTN on multiple medications
- 4.When getting a client up in a chair the nurse notices that the pressure relieving mattress overlay has deep butt, heel and scapulae imprints. What is the nurse's best action?
- A.
Turn the mattress overlay to the opposite side
- B.
Do nothing because this is expected
- C.
Apply a different pressure-relieving device
- D.
Reinforce the overlay
- 5.A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the periameter and the bone is exposed. Which is the nurse's best action?
- A.
Document as a stage III pressure ulcer and start antibiotics
- B.
Stage I pressure ulcer and apply a transparent dressing
- C.
Stage II pressure ulcer and start wet-to-dry dressing
- D.
Stage IV pressure ulcer and prep the client for debreidment
- 6.A client presents with a pressure ulcer on the ankle. Which is the first intervention that nurse implements?
- A.
Place the client and the instruct him to elevate his foot
- B.
Draw blood for albumin. prealbumin, and total protein
- C.
Assess the affected leg for pulses, skin color, and temperature
- D.
Option 4
- 7.Which finding puts a client at greatest risk for wound infection?
- A.
Coexisting medical conditions
- B.
Immune compromised status
- C.
Presence of a deep wound
- D.
Severely reddened skin
- 8.A client has a chronic wound that is being treated with a wound vac device. Which intervention by the nurse takes priorty?
- A.
Assess the vac every 2 hours for bleeding
- B.
Check the integrity of the dressing seal every 4 hours
- C.
Document the wound size with each dressing change
- D.
Provide pain meds as needed
- 9.Which statement made by the caregiver of a home care client indicates a need for clarification regarding pressure ulcer prevention and treatment?
- A.
He drinks nutritional supplement between meals to maintain his weight
- B.
I apply lotion to his arms and legs every evening because they so dry
- C.
I help him shift his position every hour hen he sits in the chair
- D.
I massage his tailbone every morning when he gets up because it is red
- 10.A client has been identified as being at risk for formation of pressure ulcers. Which dietary choices by then client indicate a good understanding of teaching related to this condition?
- A.
Low-fat, low cholesterol, high fiber, low carb
- B.
Vegetarian diet with nutritional supplements
- C.
High protein diet with vitamins and mineral supplements
- D.
Low-fat diet with whole grains and cereal and vitamin supplements
- 11.The nurse sees a client with which condition first to evaluate for wound infection?
- A.
Decrease in wound size
- B.
This serous wound drainage
- C.
Pending blood cultures
- D.
WBC of 23,000
- 12.An African-American woman had a breast biopsy 1 year ago. The incision site is elevated, dark, and protruding. What information does the nurse provide to the client?
- A.
A deep infection has probably become symptomatic
- B.
Chronic inflammatory changes have occured
- C.
The benign tumor has undergone malignant changes
- D.
A keloid has formed over the biopsy scar
- 13.The RN has assigned a client who has an open burn to a LPN. Which instruction is most important to provide?
- A.
Assess wounds for signs of infection
- B.
Chronic inflammatory changes have occurred in the skin
- C.
Wash hands on entering the clients room
- D.
Have the client cough and deep breathing
- 14.The nurse is teaching burn prevention to a community group. Which information shared by a member of the group causes the nurse greatest concern?
- A.
My hot water heater is set at about 120 degrees
- B.
I use a space heater when it gets below zero
- C.
I get chimney swept every other year
- D.
Sometimes I wake up and smoke at night
- 15.Which statement best exemplifies a client's understanding of rehab after a full-thickness burn injury?
- A.
My goal is to achieve the highest level of functioning that I can
- B.
I will eventually be able to perform all my former activities
- C.
I am fully recovered when all the wounds are closed
- D.
Full recovery from a major burn injury never recurs
- 16.A client is in the ED after being rescued from a house fire. After the initial assessment, the client develops a loud brassy cough. What is the priority intervention?
- A.
Allow the client to suck on small quantities of ice chips
- B.
Apply oxygen and continuous pulse ox
- C.
Request an antitussive med from the physician
- D.
Have the RT provide humidified room air
- 17.A client has burns on both legs. They are white and leather like. No blister or bleeding is present and the client describes a small amount of pain. How is this injury categorized?
- A.
Full thickness
- B.
Partial thickness deep
- C.
Superficial
- D.
Partial thickness superficial
- 18.A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first?
- A.
Measure abdominal girth and auscultate bowel sounds
- B.
Auscultate breath sounds over the trachea and main stem bronchi
- C.
Assess level of consciousness and pupillary reactions
- D.
Ascertain the time food or liquid was last consumed
- 19.On assessment, the nurse notes that a client has burns inside the mouth and is wheezing. Several hours later, then wheezing is no longer heard. What is the nurse's next action?
- A.
Gather appropriate equipment and prepare for intubation
- B.
Administer a laxative
- C.
Raise head of the bed to a semi-fowelrs
- D.
Document the findings and reassess in 1 hour
- 20.A client suffered a% total body surface area burn and was intubated. 12 hours later, bowel sounds were absent in all four quadrants. Which is the best action?
- A.
Re-position the client on the right side
- B.
Admin. a laxative
- C.
Prepare to insert NG tube
- D.
Document the finding
- 21.A client has experienced an electrical burn of the lower extremities. What is the priority assessment of this client?
- A.
Orientation to time, place and person
- B.
Heart rate, rhythm, and ECG
- C.
ROM of all extremities
- D.
Respiratory rate and pulse ox
- 22.A client who has had a full-thickness burn is being discharged. Which information is most important for the nurse to provide?
- A.
Learning to perform dressing changes
- B.
Joining a community reintegration program
- C.
Options available for scar removal
- D.
How to maintain home smoke detectors
- 23.A client with aphasia presents to the ED with a suspected brain attack. Which clinical manifestation leads the nurse to suspect that this client has had a thrombotic stroke?
- A.
Chest pain and nuchal
- B.
Sudden loss of motor coordination
- C.
Two episodes of speech difficulty in the last month
- D.
A grand mal seizure 2 months ago
- 24.The nurse is caring for an 80 y.o. who presented to the ED in coma. Which question does the nurse as the client's family to determine if the coma is related to a stroke.
- A.
Is any history of seizures among your mother's immediate family?
- B.
Did you mother complain of any weakness in her lower extremities
- C.
Does your mother drink any alcohol or take any meds?
- D.
How many hours does your mother usually sleep at night?
- 25.The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for?
- A.
Agrphia
- B.
Aphasia
- C.
Imparied olfaction
- D.
Impaired proprioception
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