Med-Surg Final Exam
Flumazenil
A nurse administered midazolam IV bolus to a client before a procedure. The client's blood pressure is 86/40 mm Hg, and the heart rate is 134/min. Which of the following IV medications should the nurse administer.
Use cotton-tipped application to obtain fluid from the lesion, Place the specimen tube on ice after obtaining sample.
A nurse in a clinic is preparing to obtain a skin specimen from a client who has suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply)
Superficial thickness
A nurse in a provider's office is assessing a pt who has a sever sunburn. Which of the following classifications should the nurse use to document the burn?
Head tilt, chin lift
A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway?
Cyanosis, Paradoxical chest movement, Dyspnea, cyanosis
A nurse in the emergency department is assessing a patient who sustained multiple rub fractures and has flail chest. Which of the following findings should the nurse expect? (Select all that apply)
Remove wet clothing, Apply warm blankets, Use rapid rewarming water of 40 degrees to 42C degrees (104-108 F), Infuse warmed IV fluids
A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take.
Wheezing, Tachycardia, Retraction of sternal muscles
A nurse in the emergency department is caring for a patient who is experiencing an acute asthma attack. Which of the following assessment indicates that the respiratory status is declining? (Select all that apply)
Decreased skin turgor, concentrated urine, low-grade fever, tachypnea
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings should the nurse identify as manifestations of fluid volume deficit?
Dyspnea, Edema, Hypertension, and Weakness
A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5lb) in 48 hr. Which of the following manifestations of fluid volume excess should the nurse expect (Select all that apply).
Diabetic ketoacidosis
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance?
Tachycardia
A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse expect.
Deviation of trachea, Pleuritic pain, Tachypnea
A nurse is assessing a patient following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply)
Environmental allergies
A nurse is assessing a patient who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma
Pleural friction rub, Petechiae, Tachycardia
A nurse is assessing a patient who has pulmonary embolism. Which of the following manifestation should the nurse expect? (Select all that apply)
Tap lightly on the pt's neck
A nurse is assessing a pt for Chvostek's sign. Which of the following techniques should the nurse use to perform this test?
Temperature 36.1C (97F), Hyperkalemia, Hyponatremia
A nurse is assessing a pt who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hrs ago. Which of the following are common findings during this phase?
Creatine 2.8 mg/dL, Blood glucose 235 mg/dL, WBC 17,850/mm3
A nurse is assessing a pt's laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all the apply)
Assess oxygen saturation
A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to pt during the induction of anesthesia. Which of the following is the priority nursing action?
Monitor orthostatic hypotension
A nurse is caring for a client in a long-term care facility who has become week, confused, and experienced dizziness when standing. The pt's temperature is 38.3 C ( 100.9 F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of the following action should the nurse take?
Place the client in a lateral position.
A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following action should the nurse perform first?
Hyponatremia
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
Anorexia
A nurse is caring for a client who has contact dermatitis and has new prescription for diphenhydramine. For which of the following adverse effect should the nurse monitor?
Inhalation injury
A nurse is caring for a client who has sustained burns over 35% of total body surface area. The pt's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the pt has which of the following?
Assess bowel sounds
A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first?
A patient who has a BMI of 30, A patient who has a chronic atrial fibrillation, A patient who has a fractured femur
A nurse is caring for a group of patients. Which of the following patients are at risk for a pulmonary embolism? (Select all that apply)
Beta 2 agonist
A nurse is caring for a patient 2 hours after admission. The patient has a SaO2 of 91%, exhibits audible wheezes, and is using accessory muscle when breathing. Which of the following classes of medication should the nurse expect to administer?
Respitory Acidosis
A nurse is caring for a patient in respiratory distress. An ABG has been obtained. The pH is 7.33 is 47 mmHg and HCO3 is 24 mEq/L. Interpret the ABG
Metabolic Alkalosis.
A nurse is caring for a patient in respiratory distress. An ABG has been obtained. The pH is 7.47, PCO2 is 42 mmHg and HCO3 is 27 mEq/L. Interpret the ABG
Respiratory Alkalosis.
A nurse is caring for a patient in respiratory distress. An ABG has been obtained. The pH is 7.48, PCO2 is 33, and HCO3 is24 mEq/L. Interpret the ABG.
"It allows preset pressure delivered during spontaneous ventilation."
A nurse is caring for a patient receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statement by the nurse indicated an understanding of PSV?
Watch for any changes in vision.
A nurse is caring for a patient who has a new diagnosis of tuberculosis and has been places on a multimedication regimen. Which of the following instruction should the nurse give the patient related to ethambutol.
Venturi Mask
A nurse is caring for a patient who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the patient?
Instill activated charcoal, Perform a gastric lavage with aspiration, and infuse IV fluids.
A nurse is caring for a patient who has ingested a toxic agent. Which of the following actions should the nurse plan to take?
Administer oxygen therapy, Perform a sputum culture, Administer antibiotics, Instruct the patient to obtain a yearly influenza vaccination.
A nurse is caring for a patient who has pneumonia. Assessment findings include temperature 37.8 degrees C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions.
Assess breath sounds every 4 hr.
A nurse is caring for a patient who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
Obtain baseline vital signs and oxygen saturation.
A nurse is caring for a patient who, upon awakening, was disoriented to person, place, and time. The patient reports chill and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?
Provide airway support
A nurse is caring for a pt who develops a systemic toxic reaction following regional block. Which of the following actions should the nurse take?
Infuse iced IV fluids, Provide 100% oxygen, Place a cooling blanket on the pt, Administer IV dantrolene
A nurse is caring for a pt who develops malignant hyperthermia. Which of the following actions should the nurse take? (Select all the apply)
ECG changes
A nurse is caring for a pt who has a blood potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations?
Three tap water enemas
A nurse is caring for a pt who has a blood sodium level 133mEq/L and blood potassium level of 3.4mEq/L. The nurse should recognize which of the following treatments can result in these laboratory findings
Pale Skin, Elevated blood pressure
A nurse is caring for a pt who is experiencing respiratory distress. Which of the following early manifestation of hypoxemia should the nurse recognize? (Select all that apply)
Inform the surgeon of the elevated temperature
A nurse is caring for a pt who is schedules for an exploratory laparotomy. The pt's temperature is 39C (102.2F) orally. Which of the following actions should the nurse take?
Place the head of the bed flat
A nurse is caring for a pt who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take?
Tzanck smear report
A nurse is caring for pt who has suspected viral skin lesion. Which of the following laboratory findings should the nurse expect to review to confirm this diagnosis?
"There are portable oxygen delivery systems that you can take with you."
A nurse is discharging a patient who has COPD. The patient is concerned about not being able to leave the house due to the need for staying on continuous oxygen. Which of the following responses should the nurse make?
Calcium
A nurse is educating a pt on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following laboratory values should the nurse monitor?
Apply warm compresses to the affected area.
A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include?
"I will take in a deep breath and hold it before exhaling."
A nurse is instructing a patient on the use of an incentive spirometer. Which of the following statements by the patient indicates an understanding of the teaching?
Client who has dysphagia, Client who has AIDS, Client who has a closed head injury and is receiving mechanical ventilation, Client who has myasthenia gravis.
A nurse is monitoring a group of patients for increased risk for developing pneumonia. Which of the following patients should the nurse expect to be at risk
Encourage use of the incentive spirometer every 2hr., Instruct the pt to splint the incision when coughing and deep breathing, Reposition the pt every 2hr., Assist with early ambulation.
A nurse is planning care for a pt to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)
Limit visitor in the pt's room, Increase protein intake, Restrict fresh flowers in the room.
A nurse is planning care for an adult client who sustained sever burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply)
Hypokalemia, Fluid Retention, Black Tarry stools.
A nurse is preparing to administer an initial dose of prednisone to a patient who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply)
Intravenous
A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of the body 24 hrs. ago. The nurse should plan to use which of the following routes to administer the medication?
"I should apply an antibiotic ointment to the area"
A nurse is providing discharge instructions to a pt who has a skin biopsy with sutures. The nurse should identify that which of the following client statements indicated that the teaching has been effective?
"I can have an increase in my heart rate while taking this medication"
A nurse is providing discharge teaching to a patient who has COPD and a new prescription for albuterol. Which of the following statements by the patient indicates an understanding of the teaching?
"I will take my medication with meals"
A nurse is providing discharge teaching to a patient who has a new prescription for prednisone for asthma. Which of the following patient statements indicates understandings?
Apply an occlusive dressing after application, Wear gloves after application to lesions on the hands, avoid applying in skin folds
A nurse is providing information about a new prescription for corticosteroid cream to a pt who has mild psoriasis. Which of the following instructions should the nurse include? (Select all the apply)
Persistent cough, fatigue, night sweats, purulent sputum
A nurse is providing information about tuberculosis to a group of patients at a local community center. Which of the following manifestations should the nurse include? (Select all that apply)
Take your medication with a sip of water before surgery, Splint the abdominal incision with a pillow when coughing and deep breathing, Anti-embolism stockings are applied before surgery.
A nurse is providing preoperative teaching to a pt who is to have abdominal surgery. Which of the following statements should the nurse make? (Select all that apply)
"Apply the topical medication for up to 2 weeks after the fungal lesions are gone."
A nurse is providing teaching to a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include?
Place the child in a bath with colloidal oatmeal.
A nurse is providing teaching to the guardian of a child who has contact dermatitis. Which of the following information should the nurse include?
"I take this medication to prevent asthma attacks"
A nurse is reinforcing teaching with a patient on the purpose of taking a bronchodilator. Which of the following patient statement indicates understanding?
"Notify your provider if you experience a productive cough."
A nurse is reviewing discharge instruction for a patient who has COPD and experienced a pneumothorax. Which of the following statements should the nurse include?
Administer oxygen therapy
A nurse is reviewing prescriptions for a patient who has acute dyspnea and diaphoresis. The patient states, "I am anxious and unable to get enough air." Vital signs are HR 117/min, respirations 38/min, temperature 38.4 degree C (101.2 degree F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority?
Administer IV epinephrine
A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency?
A patient who experienced acute drug toxicity. A patient who has dysphagia. A patient following coronary artery bypass graft surgery.
A nurse is reviewing the health records of five patients. Which of the following patients are at risk for developing acute respiratory syndrome? (Select all that apply)
"I should wash my hands after blowing my nose to prevent spreading the virus"
A nurse is teaching a group of patients about influenza. Which of the following patient statements, indicates an understanding of the teaching?
"You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."
A nurse is teaching a patient who has tuberculosis. Which of the following statements should the nurse include?
Administer a psoralen medication before the treatment
A nurse is teaching a pt who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include in the teaching?
Ensure the pt understands information about the procedure, witness the pt signing the informed consent form, determine if the pt is capable of understanding the reason for the procedure.
A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following action should the nurse take? (Select all that apply)
Clients who reports right calf pain and shortness of breath
A nurse on a medical- surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients?
Remove the nail polish on fingers and toes
A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take?
