Med Surge (Questions)

B

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? a) Bell's palsy b) trigeminal neuralgia c) migraine headache d) angina pectoris

C (current guidelines are to have a mammogram q 2 years until 74 yo)

A 70-year-old client asks the nurse if she needs to have a mammogram. Which is the nurse's best response? a) "Having a mammogram when you are older is less painful." b) "We need to consider your family history of breast cancer first." c) "The incidence of breast cancer increases with age." d) "It will be sufficient if you perform breast examinations monthly."

C

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6° F (38.1° C). Which outcome would be a priority for this client? a) prevention of urinary tract complications b) alleviation of nausea c) alleviation of pain d) maintenance of fluid and electrolyte balance

A (Sciatic nerve dmg) (Knee flexion would relieve) (Homans is for DVT)

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk? a) pain radiating down the posterior thigh b) back pain when the knees are flexed c) atrophy of the lower leg muscles d) Homans' sign

B

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a) Pallor, bradycardia, and reduced pulse pressure b) Pallor, tachycardia, and a sore tongue c) Sore tongue, dyspnea, and weight gain d) Angina pectoris, double vision, and anorexia

A (ABCs)

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention? a) Control the pain and support breathing and oxygenation. b) Decrease the anxiety and reduce the workload on the heart. c) Reduce the nausea and vomiting and stabilize the blood glucose. d) Monitor and manage potential complications.

C

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting a) 18 to 20 g of a simple carbohydrate. b) 25 to 30 g of a simple carbohydrate. c) 15 g of a simple carbohydrate. d) 2 to 5 g of a simple carbohydrate.

A

An oncology clinic nurse is reinforcing prevention measures for oropharyngeal infections to a client receiving chemotherapy. Which statement by the client indicates that teaching was successful? a) "I clean my teeth gently several times per day." b) "I replace my toothbrush every month." c) "I lubricate my lips with petroleum jelly." d) "I use an alcohol-based mouthwash every morning."

D

Following an emergency cholecystectomy, the client has a Jackson-Pratt drain with closed suction. After 4 hours, the drainage unit is full. What should the nurse do? a) Notify the surgeon. b) Remove the drain and suction unit. c) Check the dressing for bleeding. d) Empty the drainage unit.

B

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? a) every 4 hours, at specified times b) with each meal and snack c) in the morning and at bedtime d) three times daily between meals

B (a would be late menopause, c would be being childless)

Risk factors for the development of breast cancer include: a) early menopause (before age 40). b) early onset of menstruation. c) having had more than two children. d) breastfeeding.

D

The nurse caring for a client with an arteriovenous (AV) fistula notes that the fingers distal to the fistula are cold to the touch and the capillary refill time is greater than 3 seconds. What is the priority action by the nurse? a) Turn the client on the left side. b) Assess client's blood pressure. c) Keep arm elevated. d) Contact the healthcare provider.

D (suspect pinched/kinked catheter if blood can't be aspirated)

The nurse has been able to draw the daily blood specimen from a client's Hickman catheter only after requesting that the client raise the arms and cough. The client asks the nurse why this is necessary. The nurse should tell the client: a) "The catheter tends to collapse every time we exert pressure." b) "A fibrin sheath has grown over the tip of the catheter." c) "Your catheter probably is pinched between the clavicle and a rib." d) "The catheter may be lodged against a blood vessel wall."

A (indicates rupture)

What would be the priority treatment of a client who has reported severe lower right quadrant pain that has now resolved? a) preparation for emergency surgery b) initiation of antibiotic therapy c) referral for dietary revision d) modification of pain management strategies

B

When assessing a client with left-sided heart failure, the nurse expects to note a) jugular vein distention. b) air hunger. c) ascites. d) pitting edema of the legs.

C

Which action has the highest priority in the care of a client with chronic renal failure? a) Apply corticosteroid creams to relieve itching. b) Achieve pain control with analgesics. c) Maintain a low-sodium diet. d) Measure abdominal girth daily.

A (means binge eating)

Which dietary instruction would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? a) Avoid crash dieting. b) Restrict carbohydrate intake. c) Decrease sodium in the diet. d) Eat six small meals a day.

C

At a public health fair, a nurse teaches a group of women about breast cancer awareness. What is most important for the nurse to include in teaching about the warning signs of breast cancer? a) fever and erythema of the breast b) breast changes during menstruation c) nipple discharge and a breast nodule d) breast discomfort and multiple movable nodules

A (+ goosebumps, pounding h/a and sweating)

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for: a) sudden, severe hypertension b) bradycardia c) paralytic ileus d) hot, dry skin

A

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when the nurse notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) water-seal chamber b) collection chamber c) air-leak chamber d) suction control chamber

D (pv the brace from causing friction on skin. Cotton material absorbs perspiration)

After the nurse teaches a client about wearing a back brace after a spinal fusion, which statement indicates effective teaching? a) "I will apply lotion before putting on the brace." b) "I will be sure to pad the area around my iliac crest." c) "I can use baby powder under the brace to absorb perspiration." d) "I should wear a thin cotton undershirt under the brace."

D

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? a) pain b) altered level of consciousness c) fluid balance d) anaphylactic reaction

A

Which is a risk factor for testicular cancer? a) undescended testes b) sexual relations at an early age c) seminal vesiculitis d) epididymitis

A (r/t inflammation)

Which laboratory finding is expected when a client has diverticulitis? a) elevated white blood cell count b) elevated serum blood urea nitrogen concentration c) elevated red blood cell count d) decreased platelet count

D

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing a) pupillary changes. b) nuchal rigidity and Kernig's sign. c) motor loss in the legs that exceeds that in the arms. d) raccoon's eyes and Battle's sign.

C

A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is starting the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which client? a) client who had an ileal conduit 3 days ago b) middle-aged client who had a kidney transplant 3 days ago c) middle-aged stable client with bladder cancer awaiting surgery d) elderly client just admitted for an acute stroke

B

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time? a) evaluating vital signs frequently b) maintaining fluid and electrolyte balance c) preventing wound infections d) managing the child's pain

A (tracheal dev AWAY from affected side = tension pneumo = emergency)

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax? a) Sudden, sharp pain on the affected side. b) Tracheal deviation toward the affected side. c) Bradypnea and elevated blood pressure. d) Presence of crackles and wheezes.

C (pH close to normal indicates compensation - on high side of normal. CO2 low. HCO3 normal. The inverse indicates resp in nature)

During shift report, the nurse learns the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance is the client most likely experiencing? a) compensated metabolic acidosis b) compensated metabolic alkalosis c) compensated respiratory alkalosis d) uncompensated respiratory alkalosis

D (painless, moist ulcer w/ serous d/c that is very infectious)

The nurse is obtaining a health history from a client with a sexually transmitted disease. Which description from the client indicates the likelihood of syphilis? "In my genital area I have: a) ...a wart." b) ...itching." c) ...tender pimples." d) ...a moist ulcer."

D (called refractory hypoxemia)

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? a) severe, unexplained electrolyte imbalance b) elevated carbon dioxide level c) metabolic acidosis d) hypoxia not responsive to oxygen therapy

B

The nurse is assessing a client for potential subdural hematoma development after a head injury. Which manifestation does the nurse anticipate seeing first? a) bradycardia b) alteration in level of consciousness c) raccoon eyes and battle sign d) slurred speech

D

When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should: a) dress the client, explaining each step of the process as it is completed. b) encourage the client to wear clothing designed especially for people who have had a CVA. c) advise the client to ask for help when dressing. d) teach the client to put on clothing on the affected side first.

B

Which instruction would a nurse include in the discharge teaching for a client who has an ileal conduit? a) "Decrease your fluid intake." b) "Mucous in the pouch is expected." c) "It is only necessary to wear the appliance pouch at bedtime." d) "You can decrease fecal collection in the pouch by watching your diet."

A (obesity increases intra-abd pressure)

Which risk factor would most likely contribute to the development of a client's hiatal hernia? a) being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg) b) having a sedentary desk job c) being 40 years old d) using laxatives frequently

B

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a) abdominal pain or diarrhea b) light-headedness or paresthesia c) hallucinations or tinnitus d) nausea or vomiting

D

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values? a) decreased urine amylase level b) increased calcium level c) decreased glucose level d) increased serum amylase and lipase levels

A (is a bac infection of lower urinary tract via ascending urethral route)

A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis? a) Wash the perineum with warm water and soap, cleaning from front to back. b) Treat fungal infections such as athlete's foot immediately. c) Have a pneumonia immunization to prevent streptococcal infection. d) Treat skin lesions with antibiotics, and cover any open lesions.

B (can indicate FVO. This med can impair renal fxn)

The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information about the client is most important to communicate to the health care provider? a) intermittent nausea b) a 3-kg weight gain over 2 days c) a temperature of 99°F (37.2°C) orally d) constant fatigue

D (tinea capitis)

The nurse is caring for an immune-compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems? a) Allow hair to air dry after shampooing. b) Wash hair with a dandruff-preventing shampoo. c) Keep hair length short and well trimmed. d) Avoid sharing combs and brushes.

D (Brachytherapy - Internal radiation so RN must use principles of time, distance and shielding) (Not C b/c radiation will have a cumulative effect)

Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer? a) female nurse with 10 years' experience who suspects she may be pregnant b) male nurse who has floated to this unit from the operating room c) male nurse who is also assigned to another client receiving brachytherapy d) female nurse with 3 years' experience working in oncology

C

Which progression would be expected in a pt with myasthenia gravis? a) muscle pain, difficulty speaking, headaches, and arthritic changes b) atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving c) muscle weakness, difficulty swallowing, double vision, and difficulty speaking d) muscle inflammation, choking when eating, nearsightedness, and painful joints

B (b/c it compresses spinal nerves)

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk? a) Homans' sign b) back pain when the knees are flexed c) pain radiating down the posterior thigh d) atrophy of the lower leg muscles

B

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? a) "Apply an antibacterial dressing to the incision daily." b) "Increase your fluid intake to 2 to 3 L per day." c) "Take your temperature every 4 hours." d) "Be aware that your urine will be cherry-red for 5 to 7 days."

C (decrease RF falls)

A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority? a) Use pillows to support the client's head. b) Assist the client to the restroom every hour. c) Instruct the client to remain in bed. d) Remind the client to ask for assistance when turning.

B (want to keep legs abducted to pv dislocation)

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan? a) performing passive range-of-motion (ROM) exercises on the client's legs once each shift b) keeping a pillow between the client's legs at all times c) turning the client from side to side every 2 hours d) maintaining the client in semi-Fowler's position

D (adduction = internal rotation)

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. How should the nurse respond to the client's concern? a) "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation." b) "Don't worry. Your new hip is very strong." c) "Use of a cushioned toilet seat helps to prevent dislocation." d) "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."

C

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: a) hypercalcemia. b) hypernatremia. c) hyperkalemia. d) hypokalemia.

A (indicates leak in system)

A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? a) Continuous bubbling in the water-seal chamber. b) Respiratory rate greater than 16 breaths/minute. c) Fluctuation of fluid in the water-seal chamber. d) Fluid in the chest tube.

D

A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? a) jugular vein distention b) right upper quadrant pain c) dependent edema d) bibasilar crackles

C

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to a) palpate the abdomen. b) insert a rectal tube. c) auscultate bowel sounds. d) change the client's position.

A

A client has a throbbing headache when nitroglycerin is taken for angina. What should the nurse instruct the client to do? a) Take acetaminophen or ibuprofen. b) Limit the frequency of using nitroglycerin. c) Take the nitroglycerin with a few glasses of water. d) Rest in a supine position to minimize the headache.

C

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? a) respiratory acidosis b) metabolic acidosis c) metabolic alkalosis d) respiratory alkalosis

A (indicates CSF leak) (normal for mild h/a to occur)

A client has just undergone a lumbar puncture (LP). Which finding should the nurse immediately report to the health care provider (HCP)? a) A moderate amount of serous fluid was noted on the lumbar dressing. b) The client is concerned about the test results. c) The client required analgesia for headache. d) The client's oral intake was 1,200 mL in the past 8 hours.

D

A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? a) crackles auscultated halfway up lungs, previously in bases b) PaO2 80 mm Hg c) blood pressure 140/80 mm Hg d) trace peripheral edema, previously +2

C (ABCs - decrease RF aspiration)

A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which action has the highest priority? a) Aspirate the PEG tube prior to each feeding. b) Flush the PEG tube with water before and after each feeding. c) Elevate the head of the bed during and after the PEG tube feedings. d) Cleanse the skin around the PEG tube site each shift.

B (delivers highest FiO2)

A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations? a) face tent b) nonrebreather mask c) nasal cannula d) simple mask

C (s/s of fat embolism) (next would do contact MD)

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? a) Elevate the affected extremity. b) Contact the nursing supervisor. c) Administer oxygen. d) Contact the physician.

D (SOB r/t retained secretions, wheezing r/t resp infl... will have productive cough and fever)

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) sore throat and abdominal pain b) nonproductive cough and normal temperature c) hemoptysis and dysuria d) dyspnea and wheezing

A

A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and their family to expect which common symptom that typically resolves spontaneously? a) depression b) ankle edema c) memory lapses d) dizziness

C (swelling of surgical site may obstruct airway)

A client is returned to the hospital room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? a) automated vital signs machine b) humidifier c) tracheostomy set d) cardiac monitor

B

A client with a history of Addison's disease is experiencing weakness and headache. The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which solution would the nurse expect to administer? a) I.V. total parenteral nutrition and insulin coverage b) I.V. normal saline and glucocorticoids c) I.V. lactated Ringer's solution and packed cells d) I.V. 5% dextrose and dopamine

D (uses contrast dye)

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? a) Administer a sedative as ordered. b) Immobilize the neck before the client is moved onto a stretcher. c) Place a cap over the client's head. d) Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

C

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it a) is a respiratory depressant. b) is a respiratory stimulant. c) may induce bronchospasm. d) inhibits the cough reflex.

D

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? a) Contact the health care provider (HCP). b) Auscultate the lungs to detect abnormal breath sounds. c) Encourage the client to cough and deep breathe. d) Elevate the head of the bed 30 to 45 degrees.

C (indicates internal bleeding = RF hemorrhage)

A nurse is assessing a client who has a history of a bleeding peptic ulcer. What assessment findings should the nurse report immediately? a) abdominal cramping; slow, regular pulse; warm, pale skin b) warm, dry skin; hypotension; bounding, regular pulse c) abdominal distension; cool, clammy skin; weak, thready pulse d) strong, irregular pulse; lower abdominal pain; cool, dry skin

B (increased stiffness in AM)

A client with osteoarthritis asks for information concerning activity and exercise. When assisting the client, which concept should be included? a) Exercising in the evening before going to bed is beneficial. b) Exercising at least 1 hour after awakening allows the client to participate in exercise after some of the morning-related stiffness has subsided. c) The time of day when exercise is performed isn't important. d) Exercising immediately upon awakening allows the client to participate in activities when they have the greatest amount of energy.

D (C is hypothyroidism)

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? a) bradycardia, thirst, and anxiety b) polyuria, polydipsia, and polyphagia c) dry skin, bradycardia, and somnolence d) sweating, tremors, and tachycardia

D (secondary to diffuse osteoporosis and osteolytic lesions)

A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for a) chronic liver failure. b) acute heart failure. c) hypoxemia. d) pathologic bone fractures.

B

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition? a) hematuria b) massive proteinuria c) increased serum albumin level d) weight loss

B (abduction is AWAY from midline, Adduction is TOWARD midline)

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document? a) Adduction b) Abduction

A (pulmon edema = bilateral crackles)

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. What is the likely cause of these assessment findings? a) Bronchial edema and constriction have worsened. b) The asthma attack has resolved, and airflow is restored. c) The administered albuterol (salbutamol) has been effective. d) The client has developed acute pulmonary edema.

A (b/c of reduced aldosterone secretion)

A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see? a) serum potassium level of 6.8 mEq/L (6.8 mmol/L) b) blood urea nitrogen (BUN) level of 2.3 mg/dl (0.1 mmol/L) c) serum sodium level of 156 mEq/L (156 mmol/L) d) serum glucose level of 236 mg/dl (13.1 mmol/L)

C, E

A nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, the nurse correctly identifies which ECG changes associated with an evolving MI? Select all that apply. a) notched T-wave b) presence of a U-wave c) T-wave inversion d) prolonged PR-interval e) ST-segment elevation

A (could indicate complication perforation... others are expected s/s)

A nurse is performing focused assessment on a client admitted with a paralytic ileus. Which finding requires further action? a) client requesting another blanket and "feeling cold" b) abdominal distension and a client feeling "bloated" c) client reporting breath that smells like feces d) noting a lack of bowel movement since admission

A

A registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel are caring for a group of clients. The RN asks the assistive personnel to check the pulse oximetry level of a client who underwent a laminectomy. The assistive personnel reports that the pulse oximetry reading is 89% on room air. The client has a prescription for oxygen at 2 L/min for a pulse oximetry level below 92%. The RN is currently assessing a postoperative client who just returned from the postanesthesia care unit. How will the RN proceed? a) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. b) Ask the assistive personnel to notify the provider of the low pulse oximetry level. c) Complete the assessment of the new client before attending to the client who underwent laminectomy. d) Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the provider.

A (decorticate = cerebral dysfunction... both r/t increased ICP)

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates a) dysfunction in the brain stem. b) dysfunction in the spinal column. c) dysfunction in the cerebrum. d) risk for increased intracranial pressure.

B (causes twisting motion)

After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching? a) drying the dishes b) sweeping the front porch c) making the bed walking from side to side d) sitting outside on firm cushions

A (ABCs)

After receiving the shift report, a registered nurse in the cardiac step-down unit must prioritize the client care assignment. The nurse has an ancillary staff member available to help care for the clients. Which of these clients should the registered nurse assess first? a) the client with heart failure who is having some difficulty breathing b) the anxious client who was diagnosed with an acute myocardial infarction (MI) 2 days ago, and was transferred from the coronary care unit today c) the coronary bypass client asking for pain medication for "11 of 10" pain in the donor site d) the client admitted during the previous shift with new-onset controlled atrial fibrillation, who has a call light on

D

Which signs and symptoms accompany a diagnosis of pericarditis? a) low urine output secondary to left ventricular dysfunction b) pitting edema, chest discomfort, and nonspecific ST-segment elevation c) lethargy, anorexia, and heart failure d) fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

D (other RF = blood transfusion, past tx chronic hemodialysis, born to mom with hep C, drug use, needlestick injuries)

The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan? The client: a) has a history of exercise-induced asthma. b) is a scientist and is frequently exposed to multiple chemicals. c) traveled to Central America recently and ate uncooked vegetables. d) has a known history of sexually transmitted disease.

B, C, E, F

The nurse is carrying out the plan of care for this client after the craniotomy. Which action(s) should the nurse take? Select all that apply. a) Report a narrowing pulse pressure to the neurosurgeon. b) Monitor the level of consciousness. c) Administer dexamethasone as prescribed. d) Position the client supine, with the head turned to the nonoperated side. e) Maintain the head of the bed at 30 degrees. f) Pad the side rails of the bed. g) Report an ICP of 9 mm Hg to the neurosurgeon.

D

The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch, and pedal pulses are palpable +1. What should the nurse instruct the client to do? a) Increase the length of time for walking. b) Include more potassium in the diet. c) Perform leg circles and ankle pumps. d) Seek consultation from the health care provider.

B, C, D, E, F (Addison's dx = do not produce enough steroids from adrenal cortex. Will need lifelong steroid replacement. Dental work, infections and surgery require a change in dosage)

The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply. a) Addison's disease will resolve over a few weeks, requiring no further treatment. b) Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations. c) Fatigue, weakness, dizziness, and mood changes need to be reported to the health care provider (HCP). d) A medical identification bracelet should be worn. e) Family members need to be informed about the warning signals of adrenal crisis. f) Dental work or surgery will require adjustment of daily medication.

A, B, D

The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease. What should the nurse instruct the client to do? Select all that apply. a) Avoid a diet high in fatty foods. b) Avoid beverages that contain caffeine. c) Eat three meals a day, with the largest meal being at dinner in the evening. d) Avoid all alcoholic beverages. e) Lie down after consuming each meal for 30 min. f) Use over-the-counter (OTC) antisecretory agents rather than prescriptions.

C (s/s = chest pain, cyanosis, SOB, high HR and RR, etc)

Which sign indicates that a client with a fracture of the right femur may be developing a fat embolus? a) muscle spasms in the right thigh b) numbness in the right leg c) acute respiratory distress syndrome d) migraine-like headaches

C (remember ABCDs)

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects a) actinic keratoses. b) squamous cell carcinoma. c) melanoma. d) basal cell carcinoma.

D

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? a) D-dimer, red blood cell count, and partial thromboplastin time b) thrombin time, fibrinogen, and hemoglobin level c) platelet count, red blood cell count, and hemoglobin d) platelet count, prothrombin time, and partial thromboplastin time

D (r/t ATH)

A client presents to the clinic for a follow-up visit for hospitalization due to uncontrolled diabetes. Which of the following assessment findings indicates a complication of diabetes mellitus? a) Hemoglobin of 9 g/dL (90 g/L) b) Inflamed, painful joints c) Pale yellow urine d) Blood pressure of 160/100 mm Hg

C

A nurse is explaining the use of ceftriaxone and doxycycline to a client with gonorrhea. The client asks the nurse the reason for two antibiotics. What is the nurse's best response? a) "Gonorrhea is resistant to treatment, so taking more than one antibiotic improves treatment success." b) "The combination of these two antibiotics reduces the risk of a reoccurring gonorrhea infection." c) "Often people infected with gonorrhea are also infected with chlamydia, which requires a different antibiotic." d) "This combination of medications will eradicate the gonorrhea infection faster than a single antibiotic."

A

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? a) The dressing should keep the wound moist. b) The wet-to-damp dressing should be tightly packed into the wound. c) The dressing should be allowed to dry out before removal. d) A plastic sheet-type dressing should cover the wet dressing.

B (normal urine pH = 4.5-8) (normal urine specific gravity is 1.002-1.035)

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? a) specific gravity of 1.03 b) urine pH of 3.0 c) absence of protein d) absence of glucose

A (pleural effusion - collection of fluid b/t layers of lung = decreased chest wall movement on that side)

The nurse is performing a respiratory assessment on a client who has a pleural effusion. Which breath sound is expected for this client? a) decreased breath sounds on the affected side b) normal bronchial breath sounds c) hyperresonance on percussion d) wheezing on auscultation

B (a is hyperplasia, c is anaplasia and d is metaplasia)

A client has an abnormal result on a Papanicolaou test. The client asks the nurse what dysplasia means. Which definition should the nurse provide? a) increase in the number of normal cells in a normal arrangement in a tissue or an organ b) alteration in the size, shape, and organization of differentiated cells c) presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin d) replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found

B (note the cause was high voltage - mess with the heart's electrical system)

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? a) Monitor urine output once a shift. b) A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. c) Initiate an antibiotic within 3 hours of the injury. d) Infuse dextrose and water at 50 mL per hour to avoid overload of the circulatory system

D

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem? a) a hemolytic reaction to mismatched blood b) a hemolytic reaction to Rh-incompatible blood c) a hemolytic reaction caused by bacterial contamination of donor blood d) a hemolytic allergic reaction caused by an antigen reaction

B (HOB should be elevated 30 degrees at least to pv aspiration and neck swelling)

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention? a) Foley catheter bag containing 500 ml of amber urine b) the client lying in a lateral position, with the head of bed flat c) a piggyback infusion of levofloxacin d) serosanguineous drainage on the dressing

B (A is incorrect b/c doesn't fix root cause)

The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which statement by the client indicates that the client understands the teaching? a) "I should take antihistamines to decrease the itching I'm experiencing." b) "It's safe to apply a non-perfumed lotion to my skin." c) "A heating pad, set on the lowest setting, will help decrease my discomfort." d) "I can apply an over-the-counter cortisone ointment to relieve the dryness."

D (r/t diuresis) (would have met acidosis, not alkalosis) (Elevated ketones and acetone is DKA)

A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? a) elevated serum acetone level b) serum ketone bodies c) serum alkalosis d) below-normal serum potassium level

C

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect? a) aortic regurgitation b) complete heart block c) pericardial tamponade d) left-sided heart failure

B (reduces amt of fecal material in GI tract and decreases stimulation)

Which is an appropriate nursing goal for the client who has ulcerative colitis? The client: a) maintains a daily record of intake and output. b) verbalizes the importance of small, frequent feedings. c) uses a heating pad to decrease abdominal cramping. d) accepts that a colostomy is inevitable at some time in his life.

B

A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis? a) no increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test b) a decreased TSH level c) an increase in the TSH level after 30 minutes during the TSH stimulation test d) below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay