Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam

Question 6

Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam. A client has a spinal cord injury, and the nursing problem is “Altered Mobility.” What is the priority nursing concern related to this diagnosis for the client?

• A) Addressing the client’s psychological adjustment to the injury
• B) Promoting independence in activities of daily living (ADLs)
• C) Preventing complications such as pressure ulcers and contractures
• D) Ensuring adequate nutrition and hydration for the client

Question 7

The nurse is providing education to a patient with a new diagnosis of hiatal hernia. Which of the following should the nurse include in the education?

• A) Eat large meals to prevent reflux
• B) Lie down immediately after eating to promote digestion
• C) Avoid foods that trigger heartburn, such as spicy or acidic foods
• D) Increase caffeine and carbonated beverages to aid digestion

Question 9

A patient with right upper quadrant pain is scheduled to undergo an abdominal ultrasound to assess for possible cholecystitis. The patient expresses concern about the diagnostic procedure. What is the nurse’s best response?

• A) “The ultrasound is a routine and painless procedure, do not worry.”
• B) “You should be more concerned about the results, not the procedure.”
• C) “It’s just a simple scan. You won’t feel anything.”
• D) “Could you tell me more about your concern so we can discuss it?”

Question 10

A client reports cramping pain in the calf while walking, which disappears after resting for several minutes. On assessment, the nurse notes shiny, thin skin and decreased hair growth on the lower legs. What is the most likely cause of these symptoms?

• A) Deep vein thrombosis (DVT)
• B) Insufficient blood flow to the leg muscles during activity (intermittent claudication)
• C) Chronic venous insufficiency
• D) Osteoarthritis of the knee

Question 11

A student nurse is discussing a condition of the heart with a more experienced nurse. The experienced nurse would see the need for further education if the student nurse said:

• A) “Myocardial infarction (MI) and angina are the same thing because they both involve chest pain.”
• B) “Atherosclerosis is the buildup of fatty deposits in the arteries, leading to reduced blood flow.”
• C) “Hypertension is a condition where blood pressure is consistently elevated above normal levels.”
• D) “Cardiogenic shock can result from severe heart failure and inadequate cardiac output.”

Question 12

The nurse is caring for a client admitted to the unit for a bowel obstruction. A nasogastric tube to low continuous suction has been in place for 48 hours. Upon reviewing the client’s lab values, the nurse notes hypokalemia. The nurse should assess the client for?

• A) Hypercalcemia
• B) Metabolic acidosis
• C) Metabolic alkalosis
• D) Respiratory alkalosis

Question 13

A client is being discharged home with an arm fracture after receiving care from an orthopedic nurse. What is an appropriate discharge instruction provided by the nurse to assist in the client’s recovery?

• A) Emphasize the importance of elevating the arm to decrease chances of swelling
• B) Encourage the client to return to regular activities
• C) Provide instructions on removing the cast at home to promote skin health
• D) Recommend the client perform regular exercises with the arm to speed up the healing process.

Question 14

A client has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is the client’s drug regimen most likely to consist of?

• A) Bismuth salts, antivirals, and histamine-2 (H2) antagonists
• B) H2 antagonists, antibiotics, and bicarbonate salts
• C) Bicarbonate salts, antibiotics, and ZES
• D) Antibiotics, proton pump inhibitors, and sucralfate

Question 15

The neurologic ICU nurse is admitting a client with increased intracranial pressure (ICP). How should the nurse best position the client to help reduce ICP?

• A) Supine with the head flat
• B) Prone with the head turned to the side
• C) Head of the bed elevated 30 degrees with the head and neck in neutral alignment
• D) High Fowler’s position with the neck flexed

Question 16

A nurse is caring for an elderly client in a long-term care facility. Which of the following signs and symptoms should the nurse be particularly vigilant for as potential indicators of dehydration in the elderly?

• A) Increased heart rate
• B) Increased urinary output
• C) Confusion and disorientation
• D) Flushed skin

Question 17

A nurse is reviewing the ABG results of a client. The ABG results show a pH of 7.29, PaCO2 of 60 mm Hg, and HCO3- of 26 mEq/L. Which of the following acid-base imbalances is most likely occurring in this client?

• A) Respiratory acidosis
• B) Respiratory alkalosis
• C) Metabolic acidosis
• D) Metabolic alkalosis

Question 18

A client with a cast is being discharged home, and the nurse has provided instructions on cast care, mobility, and signs of complications. The client is asked about the provided instructions and responds with confusion and uncertainty. What is the nurse’s most appropriate action in this situation?

• A) Assume that the client understood the instructions and allow them to go home.
• B) Repeat the instructions and ask the client to explain them back to ensure understanding.
• C) Provide a written handout with the instructions and have the client read it at home.
• D) Discharge the client home and inform the client’s primary care physician about the confusion.

Question 19

A nurse is providing health promotion education to a client diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the client to implement? Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.

• A) Keep the head of the bed lowered.
• B) Drink a cup of hot tea before bedtime.
• C) avoid oral intake for 2 hours prior to going to bed
• D) Eat a low-protein diet.

Question 20

A client who has recently had a stroke is seeking guidance on how to prevent another stroke. What education should the nurse provide to the client?

• A) Encourage the client to increase sodium intake to maintain blood pressure.
• B) Recommend smoking cessation, a healthy diet, and medication compliance.
• C) Advise the client to avoid physical activity to prevent overexertion.
• D) Suggest discontinuing anticoagulant medications to reduce bleeding risk.

Question 21

The nurse is caring for a patient with a diagnosis of cirrhosis related to having chronic hepatitis B. The nurse notes that the patient has ascites and asterixis is present. What is the nurse’s most appropriate action?

• A) Ensure that the client’s sodium intake does not exceed recommended levels.
• B) Report this finding to the primary provider due to the possibility of hepatic encephalopathy.
• C) Inform the primary provider that the client should be assessed for alcoholic hepatitis.
• D) Implement interventions aimed at ensuring a calm and therapeutic care environment.

Question 22

A nurse is caring for a patient with metabolic alkalosis. Which of the following interventions should the nurse prioritize for this patient?

• A) Administer intravenous potassium supplements.
• B) Encourage increased fluid intake.
• C) Administer a diuretic medication.
• D) Monitor for signs of respiratory distress.

Question 23

A client with a brain tumor has begun to exhibit signs of cachexia. The nurse should subsequently prioritize which assessment?

• A) Assessment of peripheral nervous system
• B) Assessment of cranial nerve function
• C) Assessment of nutritional status
• D) Assessment of respiratory status

Question 24

The cardiac nurse is admitting a patient with a diagnosis of complete heart block. The nurse expects to see which of the following on the rhythm strip?

• A) more P waves than QRS waves
• B) absence of P waves
• C) multiple P waves before each QRS
• D) fewer P waves than QRS waves

Question 25

After a laparoscopic cholecystectomy, what is the nursing priority for the patient during the immediate postoperative period?

• A) Monitoring vital signs and assessment for bleeding
• B) Assisting with deep breathing exercises.
• C) Keeping the head of the bed elevated to decrease pain
• D) Administration of anticoagulants to prevent DVT

Question 31

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy, but questions the nurse about how his health will be impacted by the absence of an appendix. How should the nurse best respond?

• A) “Your appendix doesn’t play a major role, so you won’t notice any difference after recovery from your surgery.”
• B) “The surgeon will encourage you to limit fats in your diet.”
• C) “Your body will absorb slightly fewer nutrients from the foods that you eat, but you won’t notice thi.s”
• D) “Your intestine will adapt over time to the absence of your appendi.x”

Question 32

A client with a fractured femur has been placed in Buck’s traction. What should the nurse prioritize when assessing the client in Buck’s traction?

• A) Monitoring the client’s pain level and administering analgesics as needed.
• B) Ensuring proper alignment and functionality of the traction equipment.
• C) Assessing the client’s integumentary system
• D) Evaluating the client’s nutritional intake and maintaining a balanced diet.

Question 33

A client with suspected bacterial meningitis is admitted to the intensive care unit. What assessment finding would the nurse expect to see with bacterial meningitis?

• A) Pain upon ankle dorsiflexion of the foot
• B) Neck flexion produces flexion of the hips and knees
• C) Inability to stand with eyes closed and arms extended without swaying
• D) Numbness and tingling of the lower extremities

Question 34

A nurse is caring for a client on a medical-surgical unit on postoperative day 5. During routine assessments, the nurse monitors the client for signs of infection. Which finding is most indicative of an active infection?

• A) Presence of an indwelling urinary catheter
• B) Oral temperature of $99.0^\circ\text{F}$ ($37.2^\circ\text{C}$)
• C) Redness and warmth at the incision site with purulent drainage
• D) White blood cell count of $8,000/\text{mm}^3$

Question 35

A client with a new diagnosis of angina is prescribed nitroglycerin. Which statement by the client indicates that teaching about nitroglycerin was effective?

• A) “I should take nitroglycerin when I feel any pain.”
• B) “If I experience chest pain, I can take a dose of nitroglycerin and rest; I should call 911 if the pain persists after three doses.”
• C) “I should take nitroglycerin every day at the same time, even if I have no chest pain.”
• D) “I can drink alcohol while taking nitroglycerin to help relax my heart.”

Question 36

A client presents to the Emergency Department after being hit in the head and is diagnosed with a concussion. The client appears lethargic and less responsive. What is the nurse’s priority action in this situation?

• A) Provide the client with a quiet, dark room to sleep.
• B) Administer analgesics to relieve headache and discomfort.
• C) Contact the healthcare provider immediately for further assessment.
• D) Offer a meal or snack to help the client regain energy.

Question 37

The experienced nurse is educating a new nurse about the care of the client with hepatitis A. Which statement by the new nurse indicates a need for additional education?

• A) “I should reinforce good hand hygiene to prevent spreading the virus.”
• B) “Clients with hepatitis A may need to avoid alcohol and certain medications to protect the liver.”
• C) “I will place the client on strict airborne precautions to prevent transmission.”
• D) “I should teach the client that symptoms like fatigue and jaundice may persist for several weeks.”

Question 38

A nurse is assessing a client for the presence of a Chvostek sign. What action should the nurse perform to elicit a Chvostek sign?

• A) Tap the client’s knee with a reflex hammer.
• B) Ask the client to touch their toes.
• C) Tap the client’s facial nerve near the ear.
• D) Instruct the client to take a deep breath.

Question 39

A nurse is caring for a patient receiving intravenous (IV) vancomycin. Which of the of the following nursing interventions is crucial when administering vancomycin?

• A) Administer the medication as a rapid IV bolus to ensure effectiveness.
• B) Monitor labs for signs of toxicity.
• C) Administer the medication with dairy products to enhance absorption.
• D) Mix vancomycin with other antibiotics for a synergistic effect.

Question 40

The nurse is working in the cardiac care unit. She notes the following dysrhythmia on the bedside monitor. The nurse calculates the ventricular rate at?

• A) 65
• B) 90
• C) 180
• D) 260

Question 41

The client’s labs indicate minimally elevated serum creatinine levels. What is the most appropriate nursing action in response to this finding?

• A) Increase the client’s fluid intake to flush out the excess creatinine.
• B) Monitor the client’s urine output and report any significant changes.
• C) Administer over-the-counter medications to lower creatinine levels.
• D) Advise the client to reduce protein intake in their diet.

Question 42

A new cardiac nurse is receiving education on understanding rhythm strips. To correctly identify the part of the rhythm strip that represents ventricular depolarization, the nurse should focus on which component of the ECG complex?

• A) The P-wave
• B) The QRS complex
• C) The T-wave
• D) The PR interval

Question 43

A nurse needs to assess the function of cranial nerve I in a client. What is the best way for the nurse to check the function of this cranial nerve?

• A) Test the client’s visual acuity by asking them to read a chart.
• B) Observe the client’s pupillary response to light.
• C) Have the client identify various common odors with their eyes closed.
• D) Evaluate the client’s ability to hear and discriminate sounds.

Question 44

An elderly client has fallen in their home, and the nurse is concerned about potential complications due to the client’s age. What complication is the nurse most concerned about in this elderly client?

• A) Minor abrasions and bruises.
• B) Fractures, particularly hip fractures.
• C) Mild discomfort and muscle strain.
• D) Superficial skin lacerations.

Question 51

Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam. A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens’ center. What non-modifiable risk factor for stroke should the nurse cite?

• A) Gender
• B) Recent weight gain
• C) Advanced age
• D) Smoking

Question 52

A public health nurse is assisting with a health fair and providing education on the link between smoking and the risk for coronary artery disease (CAD). What should be the nurse’s primary focus in this educational effort?

• A) Describing the benefits of nicotine replacement therapy
• B) Explaining the impact of smoking on lung health
• C) Emphasizing the importance of smoking cessation for CAD prevention
• D) Discussing the risks of passive smoking (secondhand smoke)

Question 53

A client who has experienced a myocardial infarction asks the nurse what it means and whether there is damage to their heart. The nurse’s best response is:

• A) “A myocardial infarction is a brief disruption of blood flow to the heart, and it typically doesn’t cause any lasting damage.”
• B) “A heart attack, or myocardial infarction, occurs when there is permanent damage to the heart muscle due to a lack of blood supply.”
• C) “A myocardial infarction is a common occurrence, and there is often no need to be concerned about any heart damage.”
• D) “A heart attack is when your heart temporarily stops beating, but it usually resumes normal function without any damage.”

Question 54

A nurse is caring for a client with hypocalcemia. Which of the following clinical manifestations should the nurse expect to assess?

• A) Hyperactive deep tendon reflexes, muscle cramps, and tetany
• B) Lethargy, constipation, and hypotonia
• C) Flushed skin, hypotension, and bradycardia
• D) Bradykinesia, decreased deep tendon reflexes, and muscle weakness

Question 55

A client with a recent diagnosis of cerebrovascular disease is admitted to the unit and exhibits difficulty copying a figure drawn by the nurse. The client is diagnosed with visual receptive aphasia. When explaining to the client’s family, the nurse should clarify that the brain region primarily involved in visual receptive aphasia is: Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.

• A) The frontal lobe
• B) The temporal lobe
• C) The parietal lobe
• D) The occipital lobe

Question 56

A client with elevated LDL (low-density lipoprotein) cholesterol levels and lowered HDL (high-density lipoprotein) cholesterol levels is receiving education on the risk of coronary artery disease (CAD). Which statement made by the client indicates an understanding of the risk of CAD?

• A) “My high LDL cholesterol puts me at a lower risk for CAD.”
• B) “Lowering my HDL cholesterol will reduce my risk of CAD.”
• C) “I should monitor my cholesterol levels regularly to manage CAD risk.”
• D) “Elevated cholesterol levels have no impact on my risk of CAD.”

Question 57

A client with a C6 spinal cord injury is at risk for autonomic dysreflexia. When educating the client about autonomic dysreflexia, which information should the nurse prioritize for this client?

• A) Encouraging active range of motion exercises to prevent dysreflexia.
• B) Recommending regular use of over-the-counter analgesics for pain relief.
• C) Instructing the client to maintain a seated position to minimize symptoms.
• D) Emphasizing the importance of monitoring blood pressure and recognizing early signs.

Question 58

A nurse is caring for a patient who has a history of chronic obstructive pulmonary disease (COPD). The nurse assesses the patient and notes shallow, rapid respirations, and a decreased level of consciousness. Which acid-base imbalance is most likely occurring in this patient?

• A) Respiratory alkalosis
• B) Metabolic acidosis
• C) Respiratory acidosis
• D) Metabolic alkalosis

Question 59

A client is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows which procedure will be involved?

• A) Angiography
• B) Myelography
• C) Paracentesis
• D) Arthrocentesis

Question 60

A nurse is caring for a patient diagnosed with hypermagnesemia. Which of the following clinical manifestations should the nurse expect to assess in this patient?

• A) Hypertension and tachycardia
• B) Hyperactive deep tendon reflexes
• C) Muscle weakness and diminished deep tendon reflexes
• D) Metabolic acidosis

Question 61

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?

• A) To decrease cerebral edema
• B) To prevent seizure activity that is common following a TIA
• C) To remove atherosclerotic plaques blocking cerebral flow
• D) To determine the cause of the TIA

Question 62

The nurse is planning the care for a client recently diagnosed with a cerebellar tumor. Given the client’s tumor location, which complication should the nurse implement measures to prevent?

• A) Imbalance and falls
• B) Auditory hallucinations
• C) Respiratory depression
• D) Problems with fluctuating blood pressure

Question 63

A client who has undergone abdominal surgery is non-compliant with wearing compression stockings, and the client’s family asks the nurse why it matters. What is the most appropriate response by the nurse?

• A) “The stockings are purely for comfort and have no impact on the recovery process.”
• B) “Wearing the stockings helps reduce the risk of blood clots, which can be a serious postoperative complication.”
• C) “The stockings are mainly for aesthetic purposes to improve the appearance of the legs.”
• D) “The stockings promote quicker wound healing and reduce the risk of infection.”

Question 64

A nurse is developing a plan of care for a client admitted to the emergency department (ED) with an open fracture of the radius. Which nursing problem should the nurse identify as the highest priority?

• A) Risk for infection
• B) Risk for ineffective role performance Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.
• C) Acute pain
• D) Impaired physical mobility

Question 65

A client with a recent below-the-knee amputation is being discharged from the hospital. The nurse should primarily assess for which outcome to ensure a successful transition to home care and rehabilitation?

• A) Complete independence in all self-care activities
• B) Absence of phantom limb pain
• C) Dietary instructions
• D) Maintenance of limb integrity and use of assistive devices

Question 66

The community health nurse is performing a home visit to an older client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused and has dry mucous membranes. When asked about fluid intake, the client states, “I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom.” What would be the nurse’s best response?

• A) “I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup.”
• B) “Limiting your fluids can create imbalances that can result in confusion. Maybe we need to adjust the timing of your fluids.”
• C) “It is normal to be a little confused following surgery, and it is safe not to urinate at night.”
• D) “If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.”

Question 67

A nurse is providing education to a client on the use of compression stockings to treat venous insufficiency. What should the nurse prioritize when providing instructions to the client?

• A) Demonstrating how to properly apply and when to apply and remove the compression stockings.
• B) Discussing the importance of elevating the legs during periods of rest.
• C) Emphasizing the need to wear the stockings during the night and remove them in the morning.
• D) Explaining the costs associated with compression stockings.

Question 68

As an ICU nurse, during your assessment of a client, you observe decerebrate posturing. How should the nurse appropriately document this finding in the client’s medical record?

• A) “The client exhibited rigid extension of all extremities and abnormal posturing.”
• B) “The client displayed signs of spastic paralysis in both upper and lower limbs.”
• C) “The client’s arms and legs were flaccid, with an inability to move voluntarily.”
• D) “The client showed signs of ataxia and loss of coordination in the extremities.”

Question 69

When assessing a client with Parkinson’s disease, what does the nurse expect to find as a common clinical manifestation of this condition?

• A) Rapid, coordinated muscle movements.
• B) Intermittent periods of tremors and muscle spasms.
• C) Slowness of movement (bradykinesia) and muscle rigidity.
• D) Excessive salivation and overactive reflexes.

Question 70

A nurse is providing dietary education to a client with osteomalacia. Which breakfast option would be the best choice for this client?

• A) Scrambled eggs with cereal and milk and an orange.
• B) Pancakes with maple syrup and a side of bacon.
• C) Oatmeal and a banana.
• D) Greek yogurt with fresh berries and a sprinkle of chopped nuts.

Question 71

The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client’s blood pressure is 88/50 mm Hg, the pulse is 110. The nurse documents that the client’s skin is cool, moist, and pale. What is the client showing signs of?

• A) Hypothermia
• B) Hypovolemic shock
• C) Neurogenic shock
• D) Malignant hyperthermia

Question 72

A client with a head injury is becoming more agitated, restless, and at risk for self-injury. What is the best nursing intervention to prevent injury and ensure the client’s safety? Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.

• A) Administer a sedative medication to calm the client.
• B) Apply physical restraints to immobilize the client.
• C) Provide a quiet and calm environment with close supervision.
• D) Allow the client to walk around the hospital to get some agitation out.

Question 73

A client with a casted leg reports severe pain, and prescribed pain medication has been administered without providing relief. The pain has intensified, and the nurse suspects the client may be experiencing a complication related to the cast. Which condition should the nurse be most concerned about in this situation?

• A) Allergic reaction to the pain medication
• B) Fracture at the casted site
• C) Pressure ulcer under the cast
• D) Compartment syndrome

Question 74

A nurse is developing a plan of care for a client with a long bone fracture who is awaiting surgical repair. Which intervention is most important for the nurse to include in the care plan at this time?

• A) Encourage active range-of-motion exercises of the injured extremity
• B) Maintain proper immobilization and alignment of the affected limb
• C) Apply continuous heat to the fracture site to reduce pain
• D) Encourage weight-bearing as tolerated on the injured limb

Question 75

The nurse is caring for a client who has had a dysrhythmic event. What change in status may indicate to the nurse a decrease in cardiac output?

• A) Increased blood pressure
• B) Bounding peripheral pulses
• C) Changes in level of consciousness
• D) Skin flushing

Question 76

While assessing pain discrimination, a client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. How does the nurse then proceed with the examination?

• A) Touch the pin on the same area of the left hand.
• B) Touch the pin on the right forearm.
• C) Touch the pin on the right upper arm.
• D) Touch the right hand with a drop of cold water.

Question 77

A client is at risk for cardiogenic embolic stroke due to a cardiac condition. The nurse anticipates that this client may have dysrhythmia that can contribute to the formation of emboli.

• A) Atrial fibrillation (AFib).
• B) Sinus bradycardia.
• C) First-degree heart block.
• D) Ventricular tachycardia (VTach).

Question 78

A client with Parkinson’s disease is at risk of dysphagia, and a swallow assessment has been performed. What is the best way to meet the nutritional needs of this client while ensuring safe swallowing?

• A) Encourage the client to consume thin liquids and pureed foods for easy swallowing.
• B) Administer medications that increase saliva production to aid in swallowing.
• C) Provide the client with a diet of regular textures without any dietary modifications.
• D) Offer a modified texture diet, such as thickened liquids and soft, moist foods.

Question 79

A nurse is assessing a client on postoperative day one following foot surgery to repair a fractured metatarsal bone. During the assessment, the nurse notes that the surgical site shows mild swelling, is well-circumscribed, and shows no signs of infection or altered circulation. The client is experiencing pain at the surgical site. What is the expected intervention at this stage?

• A) Call the MD for a PRN dose of a stronger pain medication.
• B) Administer pain meds as ordered, document the findings, and continue to monitor the surgical site.
• C) Notify the surgeon immediately about the mild swelling.
• D) Perform a wound dressing change to check for any drainage or infection.

Question 80

A nurse is providing education to a client who has been newly diagnosed with gout. The nurse should recognize the need for additional teaching when the client makes which statement? Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.

• A) “I should limit my intake of foods high in purines, like organ meats and anchovies.”
• B) “I can continue consuming alcohol, especially beer, as it doesn’t affect gout.”
• C) “Staying well-hydrated and drinking plenty of water is important in managing gout.”
• D) “Gout is a buildup of uric acid in the joints.”

Question 81

The nurse is caring for a client admitted to the hospital with an exacerbation of multiple sclerosis. To ensure the client’s safety, which nursing action should be performed when preparing the room?

• A) Pad the bed rails
• B) Maintain bedrest
• C) Ensure suction apparatus/oxygen is at the bedside
• D) Provide three large meals daily

Question 82

A client with a fractured femur is being treated with skeletal traction and has been identified as being at risk for impaired tissue perfusion related to deep vein thrombosis (DVT). Which nursing intervention is most appropriate to reduce this risk?

• A) Encourage massage of the affected extremity
• B) Perform frequent neurovascular and circulatory assessments of the affected limb
• C) Apply continuous heat to the affected leg
• D) Maintain the client on strict bed rest without movementPurdue Global NU144 Medical Surgical Nursing II Unit 10 Exam

Question 83

A nurse is admitting a patient to the critical care unit with complaints of shortness of breath, dizziness, and palpitations. The nurse applies the cardiac monitor and sees the following dysrhythmia. The nurse knows the top priority related to this dysrhythmia is?

• A) Education on eating protein
• B) Controlling the ventricular rate
• C) Obtaining arterial blood gasses
• D) Administration of IV atropine

Question 90

The nurse is providing care for a client who is unconscious. What nursing intervention takes the highest priority?

• A) Maintaining accurate records of intake and output
• B) Maintaining a patent airway
• C) Inserting a nasogastric(NG)tube ASAP
• D) Providing appropriate pain control

Question 91

A client with hepatic encephalopathy is experiencing frequent bowel movements after starting lactulose. The client states refusal to the next dose. Why is it important for the client to continue taking this medication as prescribed?

• A) To prevent dehydration
• B) To lower ammonia levels and improve brain function
• C) To increase nutrient absorption
• D) To relieve constipation

Question 92

A client is scheduled to have a hysterectomy without oophorectomy. Which statement made by the client indicates an understanding of the procedure?

• A) “I know they’ll be removing my uterus and my ovaries.”
• B) “After the surgery, I won’t have my uterus, but my ovaries will still be there.”
• C) “I’m getting a hysterectomy, so they’ll remove my fallopian tubes and cervix.”
• D) “The surgery is just for my fallopian tubes and won’t affect my uterus or ovaries.”

Question 93

A client with a recent diagnosis of cerebrovascular disease is admitted to the unit and demonstrates difficulty copying a figure drawn by the nurse. The nurse suspects injury to the occipital lobe. Which additional assessment finding would most strongly support occipital lobe involvement?

• A) Difficulty understanding spoken language
• B) Impaired coordination and balance
• C) Loss of visual fields or difficulty interpreting visual stimuli
• D) Inability to perform purposeful movements on command

Question 94

A nurse is caring for a group of patients. Which of the following patients is most likely to have an acid-base imbalance?

• A) A young adult with a history of regular exercise.
• B) An elderly patient with a respiratory condition who uses a home oxygen concentrator.
• C) A pregnant woman in her third trimester.
• D) A child with a gastrointestinal infection and severe vomiting and diarrhea.

Question 95

A nurse is caring for a client who is prescribed diuretic medication for the management of heart failure. What nursing actions should be prioritized to reduce the client’s risk for electrolyte disturbances while on diuretics?

• A) Encourage the client to limit fluid intake to minimize the diuretic effect.
• B) Monitor the client’s blood pressure and heart rate regularly.
• C) Educate the client on the importance of maintaining a low-sodium diet.
• D) Monitor the client’s serum electrolyte levels as ordered.

Question 96

A nurse is caring for a client suspected of having Guillain-Barré syndrome. The nurse is aware that this condition often follows which of the following precedents?

• A) Recent weight loss or change in appetite.
• B) A history of recurrent migraines or tension headaches.
• C) A recent respiratory or gastrointestinal infection.
• D) Family history of autoimmune diseases.

Question 97

A nurse is caring for a patient with an IV line in place. The nurse assesses the patient’s IV site and notes the presence of redness, warmth, swelling, and tenderness along the vein. The nurse suspects IV phlebitis. What is the most appropriate nursing action?

• A) Administer pain medication to relieve discomfort.
• B) Document the findings and continue to monitor the site.
• C) Discontinue the IV line and establish a new one in a different location.
• D) Apply a warm compress to the site to reduce redness and swelling.

Question 98

A client with traumatic brain injury has developed increased intracranial pressure (ICP), resulting in increased brain stem compression and potential brain stem damage. What is a clinical manifestation that indicates significant brain stem damage in this client?

• A) Altered level of consciousness, such as confusion or disorientation.
• B) Pupils that are equal in size, non-reactive to light, and fixed (unresponsive).
• C) Muscle weakness and flaccid paralysis in the extremities.
• D) Rapid, shallow breathing and respiratory alkalosis.Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam

Question 99

A client presents to the Emergency Department with indications of a hemorrhagic stroke. What is the most critical nursing action for the client in this situation?

• A) Administer thrombolytic therapy to dissolve the blood clot.
• B) Elevate the head of the bed to 30 degrees and monitor vital signs.
• C) Prepare the client for an urgent ultrasound to assess the extent of brain damage.
• D) Provide a diet high in protein

Question 100

The school nurse has been called to the football field where a player is immobile on the field after landing awkwardly on his head. While awaiting the ambulance, what important action should the nurse take?

• A) Ensure the player is not moved
• B) Obtain the player’s vital signs and assess skin
• C) Perform an assessment of the player’s range of motion
• D) Assist the player up and into a vehicle for safety

Question 101

The nurse is taking the health history of a new client who reports pain in the left lower leg and foot when walking, which is relieved with rest. On assessment, the nurse notes the left lower leg is slightly edematous and hairless. When planning this client’s care, the nurse should most likely address which health problem?

• A) Deep vein thrombosis (DVT)
• B) Peripheral arterial disease (PAD)
• C) Chronic venous insufficiency
• D) Lymphedema

Question 102

The nurse is educating a client who is being started on metoprolol. Which of the following statements made by the client indicates a need for further education?

• A) “I will be sure to report difficulty breathing.”
• B) “I will notify my doctor if blood pressure is low.”
• C) “I only need to take my blood pressure routinely for one week.”
• D) “I should get up from a chair or my bed slowly.”

Question 103

A nurse is providing education on osteomyelitis in a community setting. The nurse understands which participant is at the highest risk for the development of osteomyelitis?

• A) A teenager with a recent sprained ankle
• B) An adult with a history of rheumatoid arthritis
• C) An older adult with diabetes and who has had an open foot ulcer
• D) A young adult with a history of seasonal allergies

Question 104

A nurse is providing preoperative education to a client scheduled for coronary artery bypass graft (CABG) surgery. The nurse teaches the client to perform leg and foot exercises after surgery. What is the primary purpose of teaching these exercises?

• A) To increase muscle mass during postoperative recovery
• B) To promote venous circulation and reduce the risk of venous thromboembolism
• C) To prevent pressure injuries to the sacrum and heels
• D) To improve the client’s level of consciousness following anesthesia

Question 105

The nurse is assessing a patient who had a hemicolectomy and colostomy created 24 hours ago. The nurse notes that the stoma is pallor in color. Which of the following is the nurse’s priority action?

• A) Contact the provider to have the client’s hemoglobin checked
• B) Document these expected findings
• C) Contact the provider and report potential blood flow compromise
• D) Cleanse the stoma with alcohol or chlorhexidine

Question 106

The nurse is analyzing a rhythm strip. What component of the rhythm strip corresponds to atrial depolarization?

• A) P wave
• B) T wave
• C) QRS
• D) U wave Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.

Question 107

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client’s vital signs and level of consciousness, what would be a priority nursing action for this client?

• A) Place the client in a prone position.
• B) Provide the client with ice water to slow any GI bleeding. Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.
• C) Prepare for discharge to home.
• D) Notify the health care provider.

Question 108

A client is brought to the Emergency Room (ER) with a loss of function and sensation, and the healthcare provider suspects spinal cord compression. As the nurse, you anticipate educating the client and their family about what type of test to confirm this diagnosis?Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam

• A) Electrocardiogram (ECG)
• B) Magnetic Resonance Imaging (MRI)
• C) Lumbar Puncture (LP)
• D) A plethora of lab tests

Question 109

While caring for a client in the acute medical/surgical unit, a nurse notices that a family member of the client has a facial droop and slurred speech. What priority action would the nurse take?

• A) Advise them to go home and call their PCP
• B) Wheel them down to the ER ASAP
• C) Call a code
• D) Tell the family member to get into the bed so the nurse can care for the situation

Question 110

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client’s PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious when administering oxygen?

• A) The client’s calcium will rise dramatically due to pituitary stimulation.
• B) Oxygen will increase the client’s intracranial pressure and create confusion.
• C) Oxygen may cause the client to hyperventilate and become acidotic.
• D) Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.

Question 111

A client’s most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the client’s dietary intake of potassium. What should the nurse recommend?

• A) Apples
• B) Fish
• C) Rice
• D) Bananas

Question 112

A nurse is caring for a client who had a hemorrhagic stroke. Which nursing intervention is the highest priority for this client?

• A) Administering anticoagulant medications as prescribed.
• B) Monitoring vital signs and neurological status frequently.
• C) Assisting with physical therapy to promote mobility.
• D) Providing a diet high in sodium to maintain blood pressure.

Question 113

A nurse is caring for a client diagnosed with sciatica. What is the nurse’s appropriate recommendation for treatment to alleviate symptoms of sciatica?

• A) Encourage bed rest for an extended period to alleviate pain.
• B) Suggest applying heat to the affected area for immediate relief.
• C) Advise the client to maintain physical activity within the limits of pain.
• D) Narcotics for pain relief.

Question 114

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse’s primary assessment focus?

• A) Cardiac and respiratory status
• B) Seizure activity
• C) Pain
• D) Fluid and electrolyte balance

Question 115

Which statement by a student indicates a need for further teaching?

• A) “The atrioventricular (AV) node is responsible for initiating the electrical impulse in the heart.”
• B) “The bundle of His conducts the electrical impulse from the atria to the ventricles.”
• C) “The Purkinje fibers distribute the electrical impulse to the ventricles, causing them to contract.”
• D) “The sinoatrial (SA) node, located in the right atrium, initiates the heartbeat.”

Question 116

A client is preparing for a hemicolectomy, and the nurse has provided education on incision splinting and leg exercises for postoperative care. Which client comment indicates a good understanding of the teaching?

• A) “I won’t need to worry about my incision since it’s covered.”
• B) “I’ll keep my hand over the incision while coughing and moving.”
• C) “I’ll be sure to keep my legs still and not do any exercises.”
• D) “I’ll remember to hold a pillow over my incision when I cough or sneeze.”

Question 117

The nursing educator is describing the kidneys’ role in metabolic acidosis to a group of nursing students. What should the educator emphasize regarding the kidney’s role in this condition?

• A) The kidneys excrete excess bicarbonate to reduce blood pH.
• B) The kidneys excrete bicarbonate to increase blood pH.
• C) The kidneys excrete hydrogen ions and conserve bicarbonate to restore balance.
• D) The kidneys retain hydrogen ions to lower blood pH.

Question 118

A spouse expresses concern to the nurse that their partner may have Parkinson’s disease. What description of the partner’s symptoms would be expected in this situation?

• A) “My partner has been experiencing rapid, involuntary muscle contractions.”
• B) “My partner has been having difficulty swallowing and choking while eating.”
• C) “My partner’s memory and cognitive function have been deteriorating rapidly.”
• D) “My partner has been showing resting tremors and muscle stiffness.”

Question 119

A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting “coffee-ground” like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled?

• A) Within 24 hours or so
• B) Within the next week
• C) Without delay
• D) As soon as all the day’s elective surgeries have been completed

Question 120

A nurse is caring for a patient who is experiencing hypoventilation. The patient’s blood gas analysis reveals a pH of 7.55, PaCO2 of 31 mm Hg, and HCO3- of 24 mEq/L. Which of the following acid-base imbalances is most likely occurring in this patient?

• A) Respiratory acidosis
• B) Respiratory alkalosis
• C) Metabolic acidosis
• D) Metabolic alkalosis

Question 121

A physician orders an infusion of Aminophylline 44 mg/hour. The pharmacy sends Aminophylline 1 gram in 250 mL. How many milliliters per hour should the nurse set the infusion pump to deliver the ordered dose?

• A) 1 mL/hour
• B) 111 mL/minute
• C) .11 mL/hour
• D) 11 mL/hour

Question 134

A client who had surgery five days ago presents with signs that may indicate a surgical site infection. Which clinical manifestations should the nurse prioritize when assessing for signs of infection on post-op day 5? Select all that apply.

• [Answer] A) fever of 101 degrees Fahrenheit
• [Answer] B) increased redness at the surgical site
• [Answer] C) increased warmth at the surgical site
• D) constipation
• [Answer] E) Purulent drainage at the surgical site
• F) Lack of discomfort at the surgical site

Question 135

The nurse is giving a patient with a new diagnosis of atrial fibrillation education regarding the objectives of management of the dysrhythmia? Which of the following are considered top priorities in the management of atrial fibrillation? Select all that apply.

• [Answer] A) Controlling the ventricular rate
• B) The use of diuretic medications
• [Answer] C) Stroke prevention
• D) The use of ACE inhibitors
• E) Self-administration of Lovenox
• F) Increasing activity level

Question 136

When reviewing an older client’s medical record, which findings lead the nurse to perform a nutrition assessment? Select all that apply.

• [Answer] A) Random blood sugar level of 218 mg/dl
• B) Cholecystectomy 4 years ago
• [Answer] C) Inability to afford healthcare needs
• [Answer] D) Widow/Widower status
• [Answer] E) unexplained weight loss of 25 pounds in the last 2 months
• F) weight gain of 5 pounds over the last 2 years

Question 137

The nurse is educating a group of senior citizens at a community center about the clinical manifestations of osteoporosis. Which of the following should the nurse include in the education? Select all that apply.

• [Answer] A) Loss of height over time
• [Answer] B) Back pain related to vertebral compression fractures
• [Answer] C) Increased risk for bone fractures with minimal trauma
• D) Joint swelling and redness
• [Answer] E) Kyphosis (curvature of the upper spine)
• F) Muscle spasticity

Question 138

A nurse is caring for a group of older adult patients and is assessing them for the risk of dehydration. Which of the following factors or findings are indicative of potential dehydration risk in older adults? Select all that apply.

• [Answer] A) Decreased thirst sensation
• [Answer] B) Fear of falls
• [Answer] C) Taking diuretic medications
• D) Weight gain
• [Answer] E) Dry, mucous mucosa
• F) non-tenting skin turgor

Question 139

The student nurse is preparing a teaching plan for a client being discharged with a new diagnosis of heart failure. What should the student include in the teaching plan? Select all that apply.

• [Answer] A) Need for careful monitoring for cardiac symptoms/weight
• [Answer] B) Need for carefully regulated exercise
• [Answer] C) Need for dietary modifications
• D) Need to avoid all exercise
• E) Need for increased fluid intake
• F) need for a diet high in potassium-rich foods

Question 140

A nurse is assessing a group of patients for fluid and electrolyte imbalances. Which of the following findings are indicative of potential fluid and electrolyte imbalances? Select all that apply.

• [Answer] A) BP and HR changes
• [Answer] B) Dry mucous membranes
• [Answer] C) Muscle cramps or weakness
• D) Non-tenting skin
• E) Homeostasis
• [Answer] F) Edema in the ankles

Question 149

Mrs. Linda Thompson, a 57-year-old with a history of hypertension and GERD, was admitted to the PACU after an elective laparoscopic cholecystectomy. Home medications include lisinopril 10 mg daily and omeprazole 20 mg daily. She is drowsy but arousable, breathing spontaneously, and on continuous monitoring. Vital signs: BP 130/78 mmHg, HR 102 bpm, RR 14, SpO2 94% on 2L nasal cannula, and temp 98.2°F. Airway is patent, lung sounds are diminished at the bases, surgical dressing is dry and intact, and she reports pain 6/10.

Step 5: Take Action

Current situation: After implementing interventions, Mrs. Thompson’s BP improves to 102/64 mmHg and heart rate decreases to 110 bpm. She is awake, alert, and still slightly pale.

Which action should the nurse take first? (Select 1) Purdue Global NU144 Medical Surgical Nursing II Unit 10 Exam.

• A) Reassess vital signs in 30 minutes
• B) Notify the surgeon of her condition
• C) Encourage ambulation
• D) Provide pain medication