College Exams & Notes

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QUESTION #1
Medical-Surgical Exam 4 Med-Surg
The nurse is assessing a client who is suspected of having psoriasis. Which of the following findings is most characteristic of this condition?
A Pruritic wheals that appear and disappear rapidly.
B Thick, erythematous plaques covered with silvery scales.
C Vesicular lesions with clear fluid that rupture easily.
D Painful ulcerations with irregular borders.

Explanations

A
This finding is characteristic of urticaria (hives) rather than psoriasis.
B
Psoriasis typically presents with raised, red plaques covered with silvery white scales, commonly found on the scalp, elbows, and knees.
C
Vesicles are more characteristic of conditions such as herpes infections or contact dermatitis, not psoriasis.
D
Ulcerations are not typical of psoriasis and may indicate other skin disorders such as vascular ulcers or severe infections.
QUESTION #2
Medical-Surgical Exam 4 Med-Surg
The nurse is caring for a client who has an infected wound and requires blood cultures. Which of the following nursing actions is most important to ensure accurate test results?
A Draw blood from the extremity closest to the infected wound.
B Cleanse the venipuncture site using sterile technique prior to specimen collection.
C Collect both blood culture specimens from the same venipuncture site.
D Obtain the blood specimens after the first dose of antibiotics is administered.

Explanations

A
Blood cultures should not specifically be drawn from the infected area because contamination may occur.
B
Proper skin antisepsis prevents contamination of the sample with skin bacteria, ensuring accurate culture results.
C
Blood cultures should be obtained from two separate sites to improve accuracy and help identify contamination.
D
Blood cultures should be collected before antibiotics are given to avoid false negative results.
QUESTION #3
Medical-Surgical Exam 4 Med-Surg
The nurse is teaching a client about the treatment of scabies. The client has been prescribed permethrin 5% cream. Which of the following client statements indicates a correct understanding of the prescribed therapy?
A “I should apply the medication from my neck down and leave it on as directed.”
B “I do not need to wash my clothes or bedding after treatment.”
C “Once the itching stops, I can stop using the medication.”
D “I will apply the medication only to the areas that are itching.”

Explanations

A
Permethrin cream should be applied to the entire body from the neck down and left on for the prescribed time, usually 8–14 hours, to kill mites and eggs.
B
Clothing, bedding, and towels should be washed in hot water to prevent reinfestation.
C
Treatment must be completed as prescribed because itching may persist even after the mites are eliminated.
D
The medication must be applied to the entire body surface (neck down), not only symptomatic areas, because mites may be present elsewhere.
QUESTION #4
Medical-Surgical Exam 4 Med-Surg
The nurse is caring for a client who has cellulitis of the arm. Which of the following findings indicates the client may be developing a complication?
A Clear drainage from a small blister near the area.
B Localized warmth and erythema at the affected site.
C Mild tenderness upon palpation of the affected arm.
D Red streaking extending proximally from the infection site.

Explanations

A
Blistering with clear fluid can occur with inflammation and does not necessarily indicate a serious complication.
B
Warmth and redness are expected findings with cellulitis due to localized inflammation.
C
Pain or tenderness is common in cellulitis and does not alone indicate worsening infection.
D
Red streaks suggest lymphangitis, indicating the infection is spreading through the lymphatic system and requires immediate medical attention.
QUESTION #5
Medical-Surgical Exam 4 Med-Surg
The nurse is performing a skin assessment on a client who is bedridden. The nurse notes a small wound over the client’s sacral area that is shallow and has a pink wound bed. Which classification of pressure injury does the nurse identify this client is experiencing?
A Stage 1.
B Stage 2.
C Stage 3.
D Stage 4.

Explanations

A
Stage 1 pressure injuries present as intact skin with nonblanchable redness and no open wound.
B
Stage 2 pressure injuries involve partial thickness skin loss with a shallow open wound and a pink or red wound bed.
C
Stage 3 injuries involve full thickness skin loss with visible subcutaneous tissue but no exposure of muscle or bone.
D
Stage 4 pressure injuries involve full thickness tissue loss with exposed muscle, bone, or supporting structures.
QUESTION #6
Medical-Surgical Exam 4 Med-Surg
The nurse is caring for a client who has cellulitis. Which of the following findings should the nurse report to the primary health care provider (PHCP) immediately?
A The client is fever free for 8 hours.
B The nurse notes the lack of purulent drainage.
C The wound is painful to touch.
D The wound has increased in size past the outlined areas.

Explanations

A
Absence of fever may indicate improvement and does not require urgent provider notification.
B
Lack of drainage is not concerning and may indicate that the infection is not worsening.
C
Tenderness is a common finding with cellulitis and does not necessarily indicate deterioration.
D
Expanding redness or swelling beyond the marked borders indicates the infection is spreading and requires immediate provider notification.
QUESTION #7
Medical-Surgical Exam 4 Med-Surg
The nurse is caring for a client who is postoperative following major abdominal surgery. The nurse notices the client has developed a fever and notes purulent drainage from the surgical incision. Which of the following is the most appropriate initial action for the nurse to take?
A Place the client in a private room to prevent the spread of infection.
B Change the surgical dressing and document the findings in the chart.
C Administer an antipyretic medication to reduce the fever.
D Notify the primary health care provider (PHCP) about the client’s condition.

Explanations

A
Surgical site infections typically do not require isolation because they are not usually transmitted person to person.
B
Dressing changes and documentation are appropriate but do not address the need for medical evaluation of a suspected surgical site infection.
C
Treating the fever may provide comfort but does not address the underlying infection.
D
Fever and purulent drainage indicate a possible surgical site infection, requiring prompt provider notification for evaluation and treatment such as cultures or antibiotics.
QUESTION #8
Medical-Surgical Exam 4 Med-Surg
The nurse is preparing to administer an intramuscular (IM) injection to a client. Which of the following actions reflects the principles of aseptic technique?
A The nurse touches the needle hub with their non-sterile gloves while preparing the injection.
B The nurse performs hand hygiene before and after administering the injection but fails to clean the top of the vial before withdrawing the medication.
C The nurse cleans the injection site with an alcohol swab and allows it to dry completely before administering the injection.
D The nurse reuses the same syringe for multiple clients to conserve supplies.

Explanations

A
Touching the needle hub contaminates the sterile part of the syringe and violates aseptic technique.
B
The vial stopper must be disinfected to prevent introducing microorganisms into the medication.
C
Allowing the antiseptic to dry ensures effective skin disinfection and reduces the risk of introducing microorganisms during injection.
D
Syringes and needles are single use items, and reusing them violates infection control standards and risks disease transmission.
QUESTION #9
Medical-Surgical Exam 4 Med-Surg
The nurse is preparing to perform a sterile dressing change on a client with a surgical wound. Which of the following actions demonstrates proper adherence to sterile technique?
A The nurse adjusts their hair and touches their face before donning sterile gloves.
B The nurse leans over the sterile field to inspect the wound more closely.
C The nurse opens the sterile dressing kit and places it on the client’s bedside table.
D The nurse ensures that all instruments used during the procedure are sterilized and kept within the sterile field.

Explanations

A
Touching the face or hair contaminates the hands and requires hand hygiene before sterile gloves are applied.
B
Leaning over a sterile field can contaminate it through contact or falling microorganisms from clothing or skin
C
The bedside table may not be a sterile or properly prepared surface for maintaining a sterile field.
D
Maintaining sterile instruments within the sterile field prevents contamination and demonstrates correct sterile technique.
QUESTION #10
Medical-Surgical Exam 4 Med-Surg
The nurse is planning care for a client who has acute glomerulonephritis. The client has developed hypertension and significant edema. Which of the following nursing interventions should the nurse prioritize?
A Implement a diet high in protein and potassium to support healing.
B Administer prescribed "drying" medications like antihistamines to reduce edema.
C Monitor the client’s daily weight and record accurate intake and output (I&O).
D Encourage a fluid intake of at least 3,000 mL per day to flush the kidneys.

Explanations

A
Clients with glomerulonephritis may require restricted protein and potassium, especially if kidney function is impaired.
B
Antihistamines do not treat edema related to kidney disease or fluid retention.
C
Daily weight and strict I&O monitoring are essential to evaluate fluid retention and kidney function, especially when edema and hypertension are present.
D
Excess fluid intake can worsen edema and hypertension in glomerulonephritis.
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