Med/Surg-Chapters 7, 33, and 61 Exam

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?

My shoes fit tighter by the end of the day.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?

Note the time of the clients first void and collect urine for 24 hours.

A nurse prepares to palpate a clients thyroid gland. which action should the nurse take when performing this assessment?

Place the client in a sitting position with the chin tucked down.

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?

Slurred speech and confusion.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?

A 45-year-old American Indian woman with diabetes mellitus.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?

A 58-year-old male who describes his pain as intense stabbing that spreads across his chest.

A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? ___________drops/min

31

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?

Allergies to iodine-based agents

A nurse cares for a client with excessive production of calcitonin. For which electrolyte imbalance should the nurse assess?

Calcium

A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply)

Can communicate his treatment preferences; Is oriented enough to understand information provided; Can evaluate and deliberate information.

A nurse assesses a client who is recovering from a myocardial infarction. The client's pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?

Compare the results with previous pulmonary artery pressure readings.

A nurse teaches a client's family members about signs and symptoms of approaching death. Which manifestations should the nurse include in this teaching? (Select all that apply)

Decreased appetite; Congestion and gurgling

A nurse cares for a client who is prescribed a drug that blocks a hormones receptor site. Which therapeutic effect should the nurse expect?

Decreased hormone activity

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?

Disorientation and confusion

A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this client's plan of care?

Do you want to be at home at the end of your life?

A nurse assesses clients who have endocrine disorders. Which assessment finding are paired correctly with the endocrine disorder? (Select all that apply)

Excessive thyroid-stimulating hormone= Increased bone formation; Excessive melanocyte-stimulating hormone= Darkening of the skin.

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply)

Fatigue despite adequate rest; Indigestion; Shortness of breath

A nurse assesses a client who is prescribed a medication that stimulates beta 1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?

Heart rate 50 bpm

A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply)

Hormones may travel long distances to get to their target tissues; Continued hormone activity requires continued production and secretion; Control of hormone activity is caused by negative feedback mechanisms.

A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this client's teaching?

Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?

I get short of breath when I climb stairs.

A nurse assesses a client diagnosed with adrenal hypofunction. Which client statement does the nurse correlate with this diagnosis?

I have a terrible craving for potato chips.

A nurse is caring for a dying client. The client's spouse states, I think he is choking to death. How should the nurse respond?

I will have another nurse assist me to turn your husband on his side.

A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?

Increased urine output

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?

Initiation of an external pacemaker

A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion?

Judaism: A person who is extremely ill and dying should not be left alone.

A nurse is caring for a client who is terminally ill. The client's spouse states, "I am concerned because he does not want to eat." How should the nurse respond?

Let him know that food is available if he wants it, but do not insist that he eat.

A nurse cares for a client who is prescribed MRI of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?

Notify the health care provider before scheduling the MRI.

A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?

Pain

A nurse cares for a client who is prescribed a serum catecholamine test. Which action should the nurse take when obtaining the sample?

Place the sample on ice and send to the laboratory immediately.

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in the client's pain management plan? (Select all that apply)

Play music that the client enjoys; Rub lavender lotion on the client's feet.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply)

Prepare for continuous blood pressure and pulse; Give the client nothing by mouth 3 to 6 hours before the procedure; Explain to the client that dobutamine will simulate exercise for this examination.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?

Pulse decreased from 100 bpm to 80 bpm.

A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death?

Respiratory rate

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply)

Serum potassium of 2.9 mEq/L; Expanding groin hematoma; Rhythm changes on the cardiac monitor.

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply)

Teach family members about physical signs of impending death; Encourage the management of adverse symptoms; Encourage reminiscence by both client and family members.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?

Tell me more about your concerns about the surgery.

A nurse discusses inpatient hospice with a client and the client's family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond?

The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.

A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, "Why do I need to collect urine for 24 hours instead of providing a random specimen?" How should the nurse respond?

This test will assess for a hormone secreted on a circadian rhythm.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)

Thrombophlebitis; Pulmonary embolism; cardiac tamponade

A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply)

Thyroid-stimulating hormone; Follicle-stimulating hormone; Growth hormone

A nurse reviews a client's lab results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.)

Total cholesterol: 280mg/dL; Triglycerides: 200mg/dL; Low-density lipoprotein cholesterol: 160mg/dL

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (audio)

atrial gallop S4.

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question?

Morphine 10mg sublingual every 6 hours PRN for pain level greater than 5

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?

Use pillows to elevate your head and chest while you are sleeping.

A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this clients teaching to decrease injury?

Walk around the neighborhood for daily exercise.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?

What do you understand about what happened to you?

A client tells the nurse that, even though it has been 4 months since her sister's death, she frequently finds herself crying uncontrollably. How should the nurse respond?

Your feelings are completely normal and may continue for a long time.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?

You should balance weight loss with consuming necessary nutrients.

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 bpm. Which action should the nurse take first?

Assess the client's medications.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?

Assess the color and temperature of the left leg.

After teaching a client about advance directives, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching?

An advance directive will specify what I want done when I can no longer make decisions about health care.

A nurse evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value the nurse assess first?

Anterior pituitary hormones

A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first?

Ask family members if they would like to spend time alone with the client.

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?

Heart rate of 120 bpm

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse's teaching?

I have some of her favorite hymns on a CD that I could bring for music therapy.

A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next?

Ask the UAP if he washed his hands afterward.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.)

Assess for allergies to iodine; Administer IV fluids; Assess BUN/Creatinine.

A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client?

How do you feel about yourself?

An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond?

I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death.

A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?

Increased pulse

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? (pic)

Location A

A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies and no significant health history. Which action should the nurse include in this clients plan of care?

Offer fluids every hour or two.