NURSING 102 Med Surge Final Exam

1…. A nurse is reviewing the laboratory data of a client who has acute

pancreatitis. The nurse should expect to find an elevation of which of following

values?

Amylase

Rational

Amylase is an enzyme that changes complex sugars into simple sugars that can be

used by the body. It is produced by the pancreas and salivary glands and released

into the mouth, stomach, and intestines to aid in digestion. The amylase level of a

client who has acute pancreatitis usually increases within 12 to 24 hr and can

remain elevated for 2 to 3 days.

2…. A nurse in a clinic is interviewing a client who has a possible diagnosis of

endometriosis. Which of the following findings in the client's history should the

nurse recognize as consistent with a diagnosis of endometriosis?

Dysmenorrhea that is unresponsive to NSAIDs.

Rational

Endometriosis is a condition in which the type of tissue that lines the uterus

implants in locations outside the uterus. This typically causes pelvic pain around

the time of the menstrual period but can cause pain at other times in the cycle.

The discomfort is often unrelieved by the use of NSAIDs.

3…. A rehabilitation nurse is caring for a client who has had a spinal cord injury

that resulted in paraplegia. After a week on the unit, the nurse notes that the

client is withdrawn and increasingly resistant to rehabilitative efforts by the staff.

Which of the following actions should the nurse take?

Establish a plan of care with the client that sets attainable goals.

Rational

The nurse should develop a plan of care for this client with mutually set goals.

This action invests the client in the rehabilitation process, which encourages

feelings of ownership for it, and sees the goals as more attainable 

4….A nurse in a burn treatment center is caring for a client who is admitted with

severe burns to both lower extremities and is scheduled for an escharotomy. The

client's spouse asks the nurse what the procedure entails. Which of the following

nursing statements is appropriate?

Large incisions will be made in the eschar to improve circulation.

Rational

An escharotomy is a surgical incision made to release pressure and improve

circulation in a part of the body that has a deep burn and is experiencing

excessive swelling. Burn injuries that encircle a body part, such as an arm or the

chest, can cause swelling and tightness in the affected area, resulting in reduced

circulation. Making surgical incisions into the burned tissue allows the skin to

expand, reduces tightness and pressure, and improves circulation.

5….A nurse is caring for a client who has suspected cholecystitis. The nurse should

expect the client's urine to appear which of the following colors?

Dark and foamy

Rational

The nurse should expect the client to have dark and foamy urine, which indicates

the kidneys are filtering excess bilirubin from the blood.

6….A nurse is caring for an older adult client who has rheumatoid arthritis (RA)

and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests

should the nurse monitor to evaluate the effectiveness of this medication?

Erythrocyte sedimentation rate (ESR)

Rational

Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting

and monitoring tissue inflammation in clients with RA. As the disease improves

the ESR decreases.

7….A nurse is providing dietary teaching to a client who has a history of recurring

calcium oxalate kidney stones. Which of the following instructions should the

nurse include in the teaching?

Drink 3 L of fluid every day.

Rational

The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to

dilute the urine and reduce the risk for stone formation.

8….A nurse is assessing a client who has disseminated intravascular coagulation

(DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding

Rational

The nurse should expect excessive thrombosis and bleeding of mucous

membranes because both DIC impairs both coagulation and anticoagulation

pathways.

9….A nurse is caring for a middle adult client who has just received the diagnosis

of endometrial cancer. In taking a nursing history, which of the following

manifestations is likely to be reported by this client?

Postmenopausal bleeding

Rational

Endometrial cancer involves cancerous growth of the endometrium (lining of the

uterus). The most common manifestation of endometrial cancer is abnormal

uterine bleeding, including postmenopausal bleeding and bleeding between

normal periods in premenopausal women.

10…A nurse is giving a presentation to a community group about preventing

atherosclerosis. Which of the following should the nurse include as a modifiable

risk factor for this disorder? (Select all that apply.)

Hypercholesterolemia

Hypertension

Obesity

Smoking

11…A nurse is admitting a client who has active tuberculosis to a room on a

medical-surgical unit. Which of the following room assignments should the nurse

make for the client?

A room with air exhaust directly to the outdoor environment

Rational

A room with air exhaust directly to the outside environment eliminates

contamination of other client-care areas. This type of ventilation system is

referred to as an airborne infection isolation room