MED-SURG PART A

1. A nurse is reinforcing discharge teaching about wound care with a family member of a

client who is postoperative. Which of the following should the nurse include in the teaching?

a) Administer an analgesic following wound care. (The nurse should remind the family

member to administer an analgesic prior to wound care to prevent discomfort.)

b) Irrigate the wound with povidone iodine. (The nurse should remind the family member to

irrigate the wound with 0.9% sodium chloride.)

c) Cleanse the wound with a cotton-tipped applicator. (The nurse should remind the family

member to avoid using a cotton-tipped applicator to cleanse the wound because the fibers

can become embedded in the wound, cause infection, and delay wound healing.)

d) Report purulent drainage to the provider. (The nurse should remind the family member to

report signs of infection, including purulent drainage.)

2. A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client,

which of the following findings should the nurse expect?

a) Flaccid neck (The nurse should recognize that nuchal rigidity, rather than a flaccid neck,

is a manifestation of meningitis.)

b) Stooped posture with shuffling gait (The nurse should recognize that a stooped posture

with shuffling gait is a manifestation of Parkinson's disease, not a manifestation of

meningitis.)

c) Red macular rash (The nurse should expect to find a red macular rash, sometimes called a

petechial rash, which is a manifestation of meningococcal meningitis.)

d) Masklike facial expression (The nurse should recognize that a masklike expression is a

manifestation of Parkinson's disease, not a manifestation of meningitis.)

3. A nurse is contributing to the plan of care for an older adult client who is at risk for

osteoporosis. Which of the following interventions should the nurse include to prevent bone

loss?

a) Increase fluid intake. (Fluid intake is beneficial for general health and wellness, and it

helps to treat some disorders. Caffeine and alcohol intake can increase the client's risk of

developing osteoporosis. However, fluid intake does not prevent bone loss.)

b) Encourage range-of-motion exercises. (Range-of-motion exercises are beneficial for

general health and wellness, and they help to maintain flexibility and prevent

contractures. However, range-of-motion exercises do not prevent bone loss.)

c) Massage bony prominences. (Massaging bony prominences should be avoided because it

can traumatize deep tissues.)

d) Encourage weight-bearing exercises. (Weight-bearing exercises, such as walking, can

maintain bone mass by reducing bone demineralization, thus helping to prevent

osteoporosis.)

4. A nurse is collecting data from a client and notices several skin lesion. Which of the

following findings should the nurse report as possible melanoma?

a) Scaly patches (The nurse should report scaly patches as possible basal or squamous cell

carcinoma.

b) Silvery white plaques (The nurse should report silvery white plaques as possible

psoriasis.)

c) Irregular borders (The nurse should report irregular borders of a skin lesion to the

provider because it can indicate malignant melanoma.)

d) Raised edges (The nurse should report raised edges of a skin lesion as possible basal cell

carcinoma.)

5. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client

following a partial gastrectomy for ulcers. Which of the following information should the

nurse include in the teaching?

a) Avoid liquids at mealtimes. (The nurse should remind the client to avoid drinking liquids

at mealtimes to prevent the food from emptying into the small bowel too quickly.)

b) Exclude eating starchy vegetables. (The nurse should remind the client to include starchy

vegetables in the meal plan to slow gastric emptying.)

c) Avoid eating high-protein meals. (The nurse should remind the client to eat high-protein

meals to help slow gastric emptying.)

d) Plan to increase intake of sweetened fruits. (The nurse should remind the client to

exclude sweetened fruits from the diet to help slow gastric emptying.)