Custom:PN VATI Medical Surgical Re-evaluation Assessment

A nurse is assigned to care for a client suspected of having diabetes insipidus. The nurse should frequently check the client for the development of : A) hypotension B) polyphagia C) hyperglycemia D) bradycardia

A) hypotension

A nurse is reinforcing teaching for a client about using a metered-dose inhaler (MDI). Identify the sequence the client should follow. (Move the steps in order)

1) Inhale deeply and then exhale completeley 2) Place her lips firmly around the mouthpiece 3) Breathe in slowly over 2 to 3 seconds while pushing down on the canister. 4) Hold her breath for 10 secounds 5) Exhale slowly through pursed lips 6) Wait 30 to 60 seconds between each puff.

A nurse is evaluating a client who sustained severe burn injuries in a grease fire. The nurse shades in the diagram indicating to nurned surface area. What percentage of body surface area does the nurse estimate the client has burned? Left arm: 9% 1/2 of right arm: 4.5% Front torso: 18%

9 + 4.5 + 18 = 31.5%

A nurse is caring for a postthoracotomy client who has just returned from the operating room. Which of the following is the nurse's priority action? A) Administer oxygen via nasal cannula B) Monitor urinary output C) Measure urinary output D) Maintain IV access at a rate of 75 mL/hour

A) Administer oxygen via nasal cannula

A nurse in an emergency department is preparing to care for a client who is brought with multiple system trauma following a motor vehicle crash. Which of the following is the priority focus of care?

A) Airway protection.

A nurse is caring for a client who had an open reduction and internal fixation of a fractured femur. Which of the following findings has the highest pirority? A) Altered level of consciousness B) Oral temperature 37.7 C (100 F) C) Muscle spasms D) Headache

A) Altered level of consciousness

A nurse is caring for a client with Alzheimer's disease who is hospitalized for treatment of pneumonia. During the night shift, the client is found lcimbing into the bed of another client, who becomes upset and frightened. Which of the following actions should the nurse take? A) Asisst the client to his room B) Place the client in restraints temporarily C) Reprimand the client for invading the other client's privacy D) Ask the client to apologize to the other client.

A) Asisst the client to his room

A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first? A) Assess orthostatic blood pressure B) Explain the procedure for an upper GI series C) Administer pain medication D) Test hte emesis for blood

A) Assess orthostatic blood pressure

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first? A) Auscultate lung fields B) Assess pulse and respirations C) Assess characteristics of her sputum. D) Reinforce teaching to slowly exhale with purse lips.

A) Auscultate lung fields

A nurse is reinforcing dietary teaching for a client who has a history of recurring uric acid stones. The nurse should instruct the client that it is most important to avoid which of the following foods as part of a low-purine diet? A) Brown gravy B) Asparagus C) Turkey D) Whole grain bread

A) Brown gravy

A nurse notes a small section of bowel protruding from the abdominal incision of a postoperative client. Which of the following actions should the nurse perform first? A) Cover the client's wound with a moist sterile dressing B) Determine the client's pain level C) Check the client's vital signs D) Obtain a culture and sensitivity of the client's wound drainage.

A) Cover the client's wound with a moist sterile dressing

A nurse is collecting data from a client who has Paget's disease. Which of the following findings should the nurse expect? (Select all that apply). A) Cranial enlargement B) Skeletal pain C) Waddling gait D) Cold extremities E) Muscle weakness

A) Cranial enlargement B) Skeletal pain C) Waddling gait

A nurse is collecting data on a client who has renal failure for fluid volume increase. Which of the following assessment methods is most reliable? A) Daily weight B) Serum sodium C) Tissue turgor D) Intake and output

A) Daily weight

A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect? A) Denial B) Bargaining C) Acceptance D) Anger

A) Denial

A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first? A) Determine the client's usual pattern of activity. B) Assist the client to develop a healthy eating plan C) Encourage the client to join a support group. D) Provide the client with a list of signs and symptoms to report to the provider.

A) Determine the client's usual pattern of activity.

A nurse is caring for a client who has end-stage renal disease and must limit protein intake. Which of the following foods should the nurse plan to include in the client's diet? A) Eggs B) Dried beans C) Nuts D) Green vegetables

A) Eggs

A nurse finds radioactive pellets on the surgical unit suite floor. Which of the following should be the nurse's priority action? A) Follow material safety data sheet (MSDS) instructions B) Place pellets in the biohazard area C) Contact environment services D) Notify the surgical department director.

A) Follow material safety data sheet (MSDS) instructions

A nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing intervention is the highest priority to assist in meeting this outcome? A) Maintain immobilization and alignment B) Provide optimal nutrition and hydration C) Promote independence in activities of daily living D) Provide relief from pain and discomfort

A) Maintain immobilizaton and alignment

A nurse is caring for a client whose throat culture is positive for group A streptococcus 24 hour after the rapid strep test (RST) was negative. Which of the following is the priority nursing action? A) Notify the client to return to the clinic for initiation of antibiotic therapy B) Ask the client to identify friends and family who have been in close contact C) Reinforce teaching regarding gargling with warm saline several times daily D) Instruct the client to take antipyretics as directed for elevated temperature

A) Notify the client to return to the clinic for initiation of antibiotic therapy

While admitting a client for a cardiac catheterization, the nurse asks the client about allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing intervention? A) Notify the provider of the client's allergy B) Attach a wrist band indicating the client's allergy C) Ask the client if any other foods cause such a reaction D) Notify dietary department of the client's allergy

A) Notify the provider of the client's allergy

A nurse assisting with the care of a client who is receiving treatment following a motor vehicle crash. Which of the following actions should the nurse take to determine the client's level of alertness? A) check the client's eye opening in response to verbal stimuli B) Check the client's pupillary response to light C) Check the client's motor response to nail bed pressure D) Check teh client's response to questions about place and time

A) check the client's eye opening in response to verbal stimuli

A nurse is reinforcing discharge instructions with a client who has hepatitis A. The nurse determines that the teaching is effective when the client makes which of the following statements? A) "I will not eat fried foods" B) "I will not donate blood" C) "I will refrain from internationaltravel" D)"I will not order a salad in a restaurant".

B) "I will not donate blood"

A nurse has been assigned to care for four clients. The nurse should observe which of the following clients for indication of Vitamin B6 deficiency? A) A client who has cystic fibrosis B) A client who has a chronic alcohol problem C) A client who take phenytoin (Dilantin) for a seizure disorder D) A client who is prescribed rifampin (Rifadin) for tuberculosis

B) A client who has a chronic alcohol problem

A nurse is planning possible interventions in the care for a client who may need for total parenteral nutrition (TPN). Which of the following clients should benefit form TPN? A) A client who has acute gastritis B) A client who has a complete bowel obstruction C) A client who has been vomiting for the past 4 hrs D) A client who has undergone a cholecystectomy

B) A client who has a complete bowel obstruction

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection? A) A client who has serosanguineous drainage from the wound B) A client who has swelling and tenderness around the wound C) A client who has urticaria and itching around the wound D) A client who has brown crusting over the wound

B) A client who has swelling and tenderness around the wound

A nurse in the emergency department is assisting with the care of a client who is comatose. The provider suspects ketoacidosis. Which of the following findings should the nurse expect? A) Malignant hypertension B) Acetone odor to breath C) Cheyne-Stokes breathing D) Blood glucose level below 40 mg/dL

B) Acetone odor to breath

A nurse collects data on a client who returned to the unit four hr ago following a partial colectomy. Which of the following conditions should the nurse attend to first? A) Change the moderately saturated dressing. B) Administer analgesic medication for incisional pain. C) Catheterize for a distended bladder. D) Cough and deep breathe client.

B) Administer analgesic medication for incisional pain. Rationale: Administer pain medication to establish comfort and then attend to the other reported condition.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A) Give morphine IV B) Administer oxygen therapy C) Start an IV infusion of lactated Ringer's D) Initiate cardiac monitoring

B) Administer oxygen therapy

A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture. Which of the following is the nurse's priority? A) Pain control B) Airway managment C) Oral hygiene D) Nutritional support

B) Airway managment

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first? A) Apply a tourniquet just above the wound B) Apply pressure directly at the wound C) Elevate the extremity D) Place the client in a modified Trendelenburg position

B) Apply pressure directly at the wound

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention? A) Insert an IV line B) Count the respiratory rate C) Administer oxygen D) Prepare equipment for intubation

B) Count the respiratory rate

A nurse is reinforcing teaching with a client who has ulcerative colitis and requires a low fiber diet. The nurse should instruct the client to avoid which of the following foods? A) Cooked carrots B) Dried apricots C) Ripe bananas D) White rice

B) Dried apricots

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following acitons hsould the nurse take? A) Elevate the foot of bed B) Elevate the head of the bed C) Apply the pelvic girdle D) Place the client in a supin position

B) Elevate the head of the bed

A nurse is caring for a client following the application of an aquatermia pad. Which of the following is the first indication that the client is experiencing a thermal injury to the application site? A) Blistering B) Erythema C) Edema D) Pain

B) Erythema

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following nursing actions is the priority at this time? A) Increase the oxygen flow to 3 L/min B) Evaluate the client's respiratory status C) Call emergency services for the client D) Have the client cough and expectorate secretions

B) Evaluate the client's respiratory status

A nurse is reinforcing teaching for a client regarding cancer prevention and plans to address the importance of foods high in antioxidants. Which of the following foods should the nurse include in the discussion? A) Cottage cheese B) Fresh berries C) Bran cereal D) Skim milk

B) Fresh berries

A nurse is caring for a client diagnosed with myasthenia gravis. Which of the following findings indicates the client is experiencing an advanced symptom of this disease? A) Confusion B) Incontinence C) Headache D) Hypertension

B) Incontinence

The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take? A) Add tap water as needed to the suction control chamber B) Maintain the drainage container below the level of the client's chest C) Empty the collection container every shift D) Clamp the chest tubes if it becomes disconnected

B) Maintain the drainage container below the level of the client's chest

A nurse is caring for a client who has COPD. Which of the following nursing actions is appropriate for the client?

B) Providing mouth care before meals

A nurse is caring for a client who has a respiratory rate of 7/min. Which of the following is an appropriate interpretation of the client's arterial blood gas ABG's? A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis

B) Respiratory acidosis

A nurse is reinforcing teaching to a client who wants to increase daily intake of omeg-3 type fatty acids. Which of the following foods should the nurse suggest the client increase? A) Blueberries B) Soybean oil C) Citrus fruits D) Green tea

B) Soybean oil

A nurse is caring for a client following a CT scan with dye who has an anaphylaxis reaction. Which of the following conditions requires a priority nursing response? A) Urticaria B) Stridor C) Tachypnea D) Angioedema

B) Stridor

A nurse is reinforcing health teaching regarding skin cancer to a group of clients. Which of the following should the nurse identify as the leading cause of skin cancer? A) Exposure to environmental pollutants B) Sun exposure C) Chronic irritation of nevi (moles) D) Scars from a severe burn

B) Sun exposure

A nurse is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency? A) Dry, red conjunctiva B) Swollen, bleeding gums C) Inflammation of the tongue D) Pale, brittle nales

B) Swollen, bleeding gums

A nurse is organizing at the beginning of her shift the plan of care for two clients. The first client who is one day post-operative from a partial bowel resection requires a complete dressing change, total parental nutririon administration, and is reporting pain at a level of 6 on a 10-point scale. The second client who has a newly inserted percutaneous gastrostomy tube requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? A) Weigh the client requiring a daily weight B) Take vital signs on both clients C) Administer pain medication to the client reporting pain D) Change the dressings.

B) Take vital signs on both clients

A nurse is reinforcing teaching for a middle-age client who is at high risk for osteoporosis and is taking a calcium supplement. Which of the following instructions should the nurse include? A) Take the calcium suplement on an empty stomach. B) Take vitamin D supplements. C) Take the calcium supplement with green tea. D) Take iron supplements

B) Take vitamin D supplements.

A client admitted to the hospital reports flank pain, nausea, and vomiting for 24 hr. Which of the following would be a priority nursing action? A) Monitor intake and output B) Strain the urine C) Administer pain medication D) Administer an antiemetic

C) Administer pain medication

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching? A) Resting in a supine position B) Elevating arms while performing ADLs C) Breathing in through the nose and out through pursed lips. D) Increasing oxygen delivery to 5 L/min during times of distress.

C) Breathing in through the nose and out through pursed lips.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions hsould the nurse perform first? A) obtain a throat culture specimen B) Perform a complete blood count C) Check the client's temperature D) Administer an oral analgesics

C) Check the client's temperature

A nurse is teaching a client who is at risk for iron-deficiency anemia about optimizing her dietary intake of iron. The nurse should explain that which of the following sources of iron is easiest for the body to absorb? A) Spinach B) Cantaloupe C) Chicken D) Lentils

C) Chicken

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is the nurse's monitoring priority? A) Palpating peripheral pulses B) Auscultating heart sounds C) Confirming the gag reflex D) Measuring blood pressure

C) Confirming the gag reflex

A nurse is caring for an older adult client diagnosed with colon cancer. The client asks the nurse several questions about his treatment plan. Which of teh following nursing actions is appropriate? A) Tell the client to have his daughter call the provider to ask what options he plans to recommend. B) Assure the client that the provider will tell him what is planned. C) Help the client write down questions to ask his provider D) Provide the client with various sources of information about colon cancer.

C) Help the client write down questions to ask his provider

A nurse is caring for a client who is receiving a unit of packed RBC's. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the clietn is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations? A) Urticaria B) Muscle pain C) Hypotension D) Distended neck veins

C) Hypotension

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use? A) Slow B) Not palpable C) Irregular D) Bounding

C) Irregular

A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decoricate posturing. Which of the following findings should the nurse expect to observe? A) Extension of the extremities B) Pronation of the hands C) Plantar flexion of the legs D) External rotation of the lower extremities.

C) Plantar flexion of the legs

A community health nurse is assisting with planning an immunization clinic for older adult clients. The nurse should advise the clients to receive an influenza vaccine A) only if they are in a high-risk group B) every 10 yrs C) annually D) if the clietn has never had influenza

C) annually

A nurse is reinforcing teaching for a client discharged from the hospital after treatment for poor circulation in the lower extremities. Which of the following statements by the client indicates a need for further teaching? A) "I will avoid crossing my legs at the knees." B) "I will use a thermometer to check the temperature of the bath water." C) "I will wear shoes instead of sandals." D) "I will wear stockings wiht elastic tops."

D) "I will wear stockings wiht elastic tops."

A nurse is reinforcing teaching about preventing long-term complications of retinopathy and neuropathy with an older adult client who has diabetes mellitus. Which of the following actions is the most important for the nurse to include in the teaching? A) "Plan to have an eye examination once per year." B) "Examine your feet carefully every day". C) "Wear closed toed shoes daily." D) "Maintain stable blood glucose levels."

D) "Maintain stable blood glucose levels."

A nurse is assisting with the care of a client who was admitted to the emergency department with reports of chest pain and severe epigastric distress. The nurse should anticipate that in the presence of an acute myocardial infarction the client's creatinine kinase-MB (CK-MB) is expected to peak how many hours after the onset of chest pain? A) 1 hr B) 4 hr C) 12 hr D) 24 hr

D) 24 hr Peaks 18 to 24 hr after the onset of chest pain when acute myocardial infarction occurs

A nurse is caring for a client in a body cast. Which of the following is the priority action the nurse should recommend for inclusion in the plan of care? A) Auscultate lung sounds B) Palpate peripheral pulses C) Monitor urinary output D) Assess the abdomen

D) Assess the abdomen

A nurse is caring for a client who had a mastectomy and returns to the surgical unit immediately following surgery. Which of the following is the priority action by the nurse? A) Observe the surgical drains B) Elevate the head of the bed 30 degrees C) Assess the dressing for bleeding D) Assess vital signs on the client's non-affected arm.

D) Assess vital signs on the client's non-affected arm.

A nurse is caring for a client in skeletal traction who reports pain at the pin insertion site. Which of the following should be the initial nursing action? A) NOtify the client's provider B) Provide pin care to the insertion site C) Medicate the client with an analgesic, as prescribed D) Check the pin site for signs of drainage or inflammation

D) Check the pin site for signs of drainage or inflammation

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse report? A) Bradycardia B) Bradypnea C) Pallor D) Cyanosis

D) Cyanosis

A nurse is caring for a client who has been prescribed a potassium wasting diuretic medication. Which recommendation should the nurse make for change in the diet? A) Increase consumption of citrus fruits and strawberries B) Decrease amount of fluids containing caffeine C) Avoid milk and milk products D) Encourage oranges, bananas, and whole grain breads

D) Encourage oranges, bananas, and whole grain breads

A nurse is reinforcing teaching to the family of a client who has multiple myeloma and is admitted to the unit with a WBC count of 2,200/mm3. Which of the following food items brought by the family should the nurse prohibit from being given to the client? A) Fried chicken B) Bagels C) A factory-sealed box of chocolates D) Fresh fruit basket

D) Fresh fruit basket

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? A) Malnourishment related to NPO status and dysphagia B) Impaired verbal communication related to the tracheostomy C) High risk for infection related to surgical incisions D) Ineffective airway clearance related to thick, copious secretions

D) Ineffective airway clearance related to thick, copious secretions

A nurse is planning to care for a client who has acute dysphagia. Which of the following is appropriate to include in the plan of care? A) Use of a straw t oconsume liquids B) Encourage large bites C) Place the client in semi-Fowlers position during meals. D) Instruct the client to tilt head forward when swallowing

D) Instruct the client to tilt head forward when swallowing

A nurse is collecting data form a client who has a short arm cast for a fractured wrist. Which of the following findings indicated impaired venous return in the affected arm? A) A bounding distal pulse B) Auscultation of lungs revealing wheezing C) Fever D) Pain unrelieved by opioid analgesic

D) Pain unrelieved by opioid analgesic

A nurse is monitoring a client who has a spinal cord injury and suspects autonomic dysreflexia. Which of teh following actions should the nurse implement first? A) Check the client for a fecal impaction B) Ensure the room temperature is warm C) Check the client's bladder for distention D) Place the client in a sitting position

D) Place the client in a sitting position

A nurse is caring for a client with a spinal cord injury at level C-8 who is admitted for comprehensive rehabilitation. Which of the following long-term goals is appropriate with regard to the client's mobility? A) Walk with leg braces and crutches B) Drive an electric wheelchair with a hand-control device C) Drive an electric wheelchair equipped with a chin-control device D) Propel a wheelchair equipped with knobs on the wheels

D) Propel a wheelchair equipped with knobs on the wheels

A nurse is assisting with the plan of care for a client who has viral hepatitis. Which of the following acitons should the nurse include in the plan? A) Provide a low calorie diet B) Adminsiter acetaminphen for pain. C) Encourage eating three large meals daily D) Provide periods of rest

D) Provide periods of rest

A nurse is caring for a client who has primary open-angle glaucoma. The client questions the nurse about the purpose of the tonometry ecamination. The nurse should explain that this test is used to A) evaluate peripheral vision B) identify the width of the angle between the iris and cornea. C) inspect the optic disc for signs of degeneration. D) measure intraocular pressure

D) measure intraocular pressure

A nurse is assessing a client who is African-American and who is jaundice. Which of the following areas are the most reliable for the nurse to inspect? A) Palms of hands B) Hard palate C) Sclera D) Nail beds

Hard palate

A nurse is admitting a client with suspected appendicitis. Identify where the nurse should palpate to monitor for pain at McBurney's point. (Selectable areas / Hot spots)

Right lower quadrant O O X O

A nurse is monitoring a client's peripheral circulation. Identify where the nurse will palpate to check the posterior tibial pulse.

The posterior tibial pulse is located on the inner ankle one third of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm (1 inch) higher where it runs behind the medial malleolus.