medsurg midterm

A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?

"Exercise, keep your blood sugar in check, and manage your stress."

A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response?

"Hypertension greatly increases your risk of stroke and heart disease."

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly?

"I flush my tube with water before and after each of my medications."

A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement?

"TIA is a warning sign. Let's talk about lowering your risks."

A telemetry monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?

"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

The nurse is teaching the client to instill eye drops. Which statement is correct?

"Wash your hands before and after instilling eye drops and do not touch the tip of the bottle."

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

4.0

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A room with air exhaust directly to the outdoor environment

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Alteration in level of consciousness (LOC)

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

Amylase

Which particular area(s) should be examined to assess peripheral edema?

Ankles and feet

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?

Arterial Blood Gas (ABG)

Which type of chest configuration is typical of a client with COPD?

Barrel chest

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma?

Bilateral wheezes

The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate?

Blurred or cloudy vision

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Brain CT scan or MRI

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Check the catheter tubing for kinks or twisting.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs.

A clinic nurse is caring for a client who has just been diagnosed with chronic obstructive pulmonary disease (COPD). The client asks the nurse what he could have done to minimize the risk of contracting this disease. What should the nurse describe as the most significant risk factor?

Cigarette smoking

A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess?

Diuretics

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Encourage fluid intake at and between meals.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

Encouraging the client to drink 2 to 3 L of water daily

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Establish the ability to communicate effectively.

The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse's best explanation?

In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output.

A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should:

Instruct the patient to breathe into a paper bag.

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside?

Intubation tray and suction apparatus

The nurse is developing a teaching plan for a client diagnosed with hypertension. What would be important for the nurse to emphasize as part of the plan of care?

Limit intake of dietary sodium

A client is being treated for renal calculi and suspected hydronephrosis. Which measure should the nurse take to help maintain a record of the kidneys' function?

Monitor the client's intake and output.

A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first:

Oxygen therapy through a non-rebreather mask

A client the nurse is caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury.

Your client is status post total laryngectomy and cannot talk. What intervention should you make to help this client communicate?

Provide alternative methods of communication

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Reduce the client's intake of protein.

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?pH 7.22PaCO2 68 mm HgBase excess -2PaO2 78 mm HgSaturation 80%Bicarbonate 26 mEq/L

Respiratory acidosis

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Review the client's electrolyte values.

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Risk for aspiration

A client is admitted from the emergency department with complaints of severe abdominal pain and an elevated white blood cell count. The physician diagnoses appendicitis. The nurse knows the client is at greatest risk for:

Rupture of the appendix

A client who has an altered level of consciousness is receiving a tube feeding. Clients receiving tube feeding should be placed in which position?

Semi-Fowler's or higher

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

Sputum culture for acid-fast bacillus

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Tachycardia

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through tasks one step at a time.

Which outcome indicates effective client teaching to prevent constipation?

The client reports engaging in a regular exercise regimen.

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

The client who has a nasogastric (NG) tube to suction

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

The client who has gastroenteritis and is febrile.

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?

Tugging on the affected ear lobe

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

Turn the client to the side during a seizure and do not restrain movements

The nurse who teaches a client about preventing recurrent urinary tract infections would include which statement?

Void immediately after sexual intercourse.

Which term refers to chest pain brought on by physical or emotional stress and relieved by rest or medication?

angina pectoris

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke?

being obese

The nurse is collecting a stool specimen from a patient. What characteristic of the stool indicates to the nurse that the patient may have an upper GI bleed?

black and tarry

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

blood

Medical management of cardiac failure uses similar methodology whether it is right-sided or left-sided. Measures such as dietary modification, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. The primary goal in the medical management of heart failure is to reduce:

cardiac workload

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

genetics

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

heart rate

A client has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the client's discharge education accordingly. What preventive measure should the nurse encourage the client to adopt?

increasing fluid intake

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

orthopnea

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency?

vitamin B12

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

weakness

The most accurate indicator of fluid loss or gain in an acutely ill client is:

weight