MED -SURG

A nurse is providing discharge instructions to a male client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent the transmission of this sexually transmitted infection (STI)? A. "I will bring my sexual partner for treatment." B. "Now that I've had my first dose of medicine, I can resume sexual activity." C. "Once I have been treated, I don't have to use condoms anymore." D. "Once treatment is complete and I am free of symptoms, I don't have to return to the clinic."

A. "I will bring my sexual partner for treatment."

A nurse is teaching a client who has extensive deep partial- and full-thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes? A. Bacterial growth B. Scarring C. Skin graft size D. Pain

A. Bacterial growth

A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

A. Decreased albumin

A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at meal times C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking

A. Eat high-calorie foods first

A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? A. Grilled chicken B. Potato soup C. Fish sticks D. Baked ham

A. Grilled chicken

A nurse is assessing a client who has heart failure and is taking daily furosemide. The client's apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which of the following electrolyte imbalances? A. Hypokalemia B. Hypophosphatemia C. Hypercalcemia D. Hypermagnesemia

A. Hypokalemia

A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority? A. Initiate airborne precautions B. Administer antimicrobial therapy C. Tell the client that the infection will be communicable for 2-3 weeks from the start of medication therapy D. Teach the client about the manifestations of tuberculosis

A. Initiate airborne precautions

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A. Stridor

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider? A. Toes that are cold to the touch B. Serous drainage from the pin sites C. Blanching of the toenail beds with pressure D. Pink tissue around the fixator insertion sites

A. Toes that are cold to the touch

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? A "Place a warm compress on your forehead." B. "Darken the lights." C. "Light a scented candle." D. "Drink a caffeinated beverage."

B. "Darken the lights."

A nurse is teaching a client who has human immunodeficiency virus (HIV) about how the virus is transmitted. Which of the following statements should the nurse include the teaching? A. "HIV can be transmitted as soon as a person develops manifestations." B. "HIV can be transmitted to anyone who has had contact with infected blood." C. "HIV is transmitted through the respiratory route via droplets." D. "HIV is transmitted only during the active phase of the virus."

B. "HIV can be transmitted to anyone who has had contact with infected blood."

A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following client statements should the nurse provide further teaching? A. "I drink at least 2 L of fluid per day." B. "I prefer taking tub baths to showering." C. "I urinate before and after sexual relations." D. "I wipe from front to back after urinating."

B. "I prefer taking tub baths to showering."

A nurse is providing discharge teaching for a client who had a left total hip arthroplasty. Which of the following client statements indicates the teaching was effective? A. "I should expect swelling of the affected leg for several weeks." B. "I should not cross my legs at the ankles or knees." C. "I will inspect my hip incision every other day for redness." D. "I can bend over at the hip to pick up objects."

B. "I should not cross my legs at the ankles or knees."

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching? A. "I will ask my provider to change my contraception to an intrauterine device." B. "I will notify my doctor before I have dental procedures." C. "I will avoid using antiseptic mouthwash for oral care." D. "I will wear a mask when I go out in public."

B. "I will notify my doctor before I have dental procedures."

A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating which of the following? A. Confusion B. Arousal C. Orientation D. Attention

B. Arousal

A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is the top priority? A. Monitor intake and output. B. Administer antibiotics. C. Monitor respiratory status. D. Encourage fluid and food intake.

C. Monitor respiratory status.

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore IV catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist

B. Ensure an adequate airway

A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. Which of the following findings is a manifestation of bladder trauma? A. Stress incontinence B. Hematuria C. Pyuria D. Fever

B. Hematuria

A nurse is reviewing the laboratory report of a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which finding is the priority for the nurse to report to the provider? A. Hypocalcemia B. Hyperkalemia C. Anemia D. Hypoalbuminemia

B. Hyperkalemia

A nurse is planning a community health screening for a group of clients who are at risk for type 2 diabetes mellitus. Which of the following clients should the nurse include in the screening? A. Men who smoke B. Men and women who are obese C. Women who have hepatitis D. Men and women who consume high-protein and low-carbohydrate foods

B. Men and women who are obese

A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and hives 30 min after the infusion begins. Which of the following actions should the nurse take first? A. Maintain IV access with 0.9% sodium chloride B. Stop the infusion of blood C. Send the blood container and tubing to the blood bank D. Obtain a urine sample

B. Stop the infusion of blood

A nurse is conducting a home visit for an older adult client who has diabetes mellitus and takes regular insulin subcutaneously before each meal. The client appears disoriented and weak and has slurred speech. Which of the following conditions should the nurse consider first when responding to these manifestations? A. Dementia B. Hypoglycemia C. Infection D. Transient ischemic attack

B.Hypoglycemia

A nurse is teaching a client who has type 2 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. "I will apply moisturizer between my toes." B. "I will soak my feet daily." C. "I'll be sure to wear cotton socks every day." D. "I'll use a heating pad to warm my feet."

C. "I'll be sure to wear cotton socks every day."

A nurse is providing teaching about nutrients to a client. Which of the following statements should the nurse include? A. "Carbohydrates transport nutrients throughout the body." B. "Fats prevent ketosis." C. "Protein builds and repairs body tissue." D. "Carbohydrates help regulate body temperature."

C. "Protein builds and repairs body tissue."

A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? A. "If the test is positive, it means you have an active case of tuberculosis." B. "If the test is positive, you should have another tuberculin skin test in 3 weeks." C. "You must return to the clinic to have the test read in 2 or 3 days." D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

C. "You must return to the clinic to have the test read in 2 or 3 days."

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that his abdomen is distended. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter B. Administer pain medication to the client C. Change the client's position D. Place the drainage bag above the client's abdomen

C. Change the client's position

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? A. Onion soup and salad B. Vegetarian wrap with potato chips C. Grilled chicken salad with fresh tomatoes D. Chicken bouillon and crackers

C. Grilled chicken salad with fresh tomatoes

A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils

C. Level of consciousness

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

C. Night sweats

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings indicates that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food

C. Rigid abdomen

A nurse is assessing a client's skeletal system. The nurse should be in which of the following positions to screen the client for scoliosis? A. Standing beside the client, who is lying on the examination table B. Facing the client, who is sitting in a chair C. Standing behind the client, who is bent over at the waist D. Standing at the client's side, while the client leans back

C. Standing behind the client, who is bent over at the waist

A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site, and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first? A. Take a photograph of the peripheral IV site B. Obtain and record the client's vital signs C. Stop the infusion D. Identify all medications administered through the IV site for the past 24 hr

C. Stop the infusion

A nurse is caring for a client who has just returned from the surgical suite following a right nephrectomy. Which of the following indicates that the client is meeting a successful short-term goal following this procedure? A. The client requests pain medication upon arrival from surgery. B. A chest X-ray shows consolidation in the right lower lobe. C. Urinary output is 35 to 50 mL/hr consistently. D. The client has slight abdominal distention.

C. Urinary output is 35 to 50 mL/hr consistently.

A nurse is providing postoperative teaching about the management of dumping syndrome to a client who had a partial gastrectomy. Which of the following instructions should the nurse include in the teaching? A. "Consume at least 4 oz of fluid with meals." B. "Take a short walk after each meal." C. "Use honey to flavor foods such as cereal." D. "Eat protein with each meal."

D. "Eat protein with each meal."

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following pieces of information should the nurse include in the teaching? A. A TIA can cause irreversible hemiparesis. B. A TIA can be the result of cerebral bleeding. C. A TIA can cause cerebral edema. D. A TIA can precede an ischemic stroke.

D. A TIA can precede an ischemic stroke.

A nurse is caring for a client who is recovering at home after inpatient treatment for burn injuries. To increase the protein density of the client's meals, which of the following recommendations should the nurse make to the client's caregiver? A. Use sour cream instead of plain yogurt B. Add honey to cooked cereals C. Use salad dressing in place of mayonnaise D. Add chopped hard-boiled eggs to soups and casseroles

D. Add chopped hard-boiled eggs to soups and casseroles

A nurse is caring for a client who has regular occupational exposure to sunlight and presents for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose C. A raised, circumscribed lesion on the face that contains yellow-white purulent material D. An irregularly shaped brown lesion with light blue areas on the neck

D. An irregularly shaped brown lesion with light blue areas on the neck

A nurse is caring for a client who is postoperative following a laparotomy. The client has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings indicates that the client is developing a postoperative complication? A. Pain scale score of 5 out of 10 B. Urine output of 65 mL/hr C. 20 mL of bright red drainage from the drain D. Pulse oximetry of 85%

D. Pulse oximetry of 85%

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? A. Elevate the client's feet and legs B. Administer epinephrine C. Infuse 0.9% sodium chloride D. Stop the medication infusion

D. Stop the medication infusion

A nurse is planning a presentation for a group of older adults at a community center about risk factors for cancer. Which of the following factors increases the risk of developing cancer after age 60? A. High-protein diet B. Insufficient calcium intake C. Declining muscle mass D. Weakened immune responses

D. Weakened immune responses