Adult medical surgical B
A nurse is preparing an in-service presentation about the basics of hematology. Which of the following factors provides a stimulus for the production of RBC's?
Tissue Hypoxia
A nurse is providing discharge instructions to a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a mole's potential malignancy?
Ulceration
A nurse is caring for a client who is receiving TPN through a central line. which of the following actions should the nurse perform?
Weigh the client daily
A nurse is teaching a client who has HIV about early manifestations of AIDS. Which of the following statements should the nurse include in the teaching?
You can expect a persistent fever and swollen glands
A nurse is examining an ECG of a client who is having an acute myocardial infarction. The nurse should identify the elevated ST segments on the ECG indicate which of the following alterations?
Necrosis
A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect?
Paresthiasis of hands and feet
A nurse is caring for a client who has a brainstem injury. which of the following psychological functions should the nurse monitor?
Respiratory effort
A nurse is evaluating the lab values of a client who is in resuscitation phase following a major burn, which of the following lab findings should the nurse expect?
Sodium 132
A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. which of the following actions should the nurse take to assess for changes in the clients abdominal distention?
Take serial measurements of the abdomen with a tape measure
A charge nurse is observing a newly licensed nurse irrigate a clients ear, which is impacted with cerumen. which of the following actions requires the charge nurse to intervene?
Instilling 50ml of fluid with each irrigation
A nurse is teaching a client who has Chronic Kidney disease (CKD). Which of the following instuctions should the nurse take?
Limit fluid intake
A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of a hemolytic transfusion reaction.
Low back pain
The nurse is examining the ECG for a client who has frequent premature ventricular Contractions (PVC). Which of the following QRS changes should the nurse expect to see on a clients ECG?
Much greater amplitude then the usual QRS complexes
A nurse is caring for a client with a history of cirrhosis who has been admitted with the manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent excessive alcohol use?
Gamma-Glutamyl transferase (GGT)
A nurse is checking lab values to determine if a client with diabetes mellitus is adhering to the treatment plan. Which of the following tests should the nurse use to make this determination?
Glycosylated hemaglobin levels
A nurse is caring for a client who has acute lymphocytic leukemia and reports a fever, chills, fatigue, and pallor over the past week. When checking the clients lab results, Which of the following values should the nurse identify as contributing to the clients fatigue and pallor?
Hgb 6.5
A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?
Hx of Anorexia nervosa
A nurse is providing preoperative teaching for a client who is scheduled for total knee arthroplasty. which of the following statements by the client indicates an understanding of the teaching?
I should wear elastic stockings on both of my legs
The nurse is assessing the hematologic system of an older adult client. the nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder?
Absence of hair legs
A nurse is preparing a client for an EEG. When the client asks the nurse what this test does which of the following responses should the nurse provide?
An EEG records the electrical activity of your brain cells
A nurse is assessing a client who is in the early stages if hepatitis A which of the following manifestations should the nurse expect?
Anorexia
A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse "I am in so much pain" Which of the following actions should the nurse take first?
Ask the client to describe the characteristic of the pain.
A nurse is assisting a provider with performing a parecentesis on a client, which of the following actions should the nurse take?
Ask the client to empty his bladder before the procedure
A nurse is caring for a client who is 72 hr postoperative following an above the knee amputation. which of the following actions should the nurse take?
Assist the client into a prone position Q4
A nurse is planning care for a client who has acute mylogenious leukemia and a platelet count of 48,000. which of the following interventions should the nurse include?
Avoid IM injections
A nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. The nurse should explain which of the following options?
Begin annual mammograms at age 40
A nurse in a rehab center is performing an assessment for a client who is recovering from a left hemispheric stroke. which of the following findings should the nurse expect?
Difficulty with speech
A nurse is planning care for a client during a sickle cell crisis. which of the following interventions should the nurse include in the clients plan of care?
encourage increased fluid intake
A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. the nurse should instruct the client to monitor for which of the following adverse effects of this medication?
infection
A nurse is planning care for a client who has pernicious anemia. which of the following interventions should the nurse include in the plan?
initiates weakly injections of vitamin B12
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. which of the following actions should the nurse include in the clients plan of care?
offering the client a diet high in fluid in fiber
A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from the chemotherapy?
pancytopenia
A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger of the upper side wall of the cranium. the fracture is located on which of the following bones?
parietal
A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote client safety?
provide an obstacle- free path for ambulation
A nurse is providing discharge teaching to a client who is post-operative following a right mastectomy for breast cancer. the client will be discharged with 2 JP drains. which of the following pieces of information should the nurse include in the teaching?
the drain tubes are often removed the same time as the stitches
A nurse is providing preoperative teaching for a client who will undergo LASIK surgery. which of the following pieces of information should the nurse include?
you might need glasses after the surgery
