MED SURG FINAL EXAM :P
A nurse on a busy medical unit provides care for many client who requires indwelling urinary catheter at some points during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter are in which client? 1)A client whose diagnosis of chronic kidney disease required a fluid restriction. 2)A client who has Alzheimer disease and who is acutely agitated 3)A client who is on bedrest following a recent episode of venous thromboembolism. 4)A client who has decreased mobility following transmetatarsal amputation.
A client who has Alzheimer disease and who is acutely agitated
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? 1)Mono-Kellie hypothesis. 2)Glasgow Coma scale. 3)Cranial nerve function. 4)Mental status examination.
Glasgow Coma scale.
A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? 1)Insertion of an NG tube for decompression. 2)Administration of antiemetics. 3)Infusion of hypotonic IV solution. 4)Administration of proton pump inhibitors as prescribed
Insertion of an NG tube for decompression.
The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91% on room air. Which method of oxygen delivery is most appropriate for the client's needs? 1)Nasal canula 2)Non-rebreather mask 3)Venturi mask 4)Partial rebreather mask
Nasal canula
A client has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the client's level of anxiety. Which of the following actions is most likely to accomplish? 1)The nurse gauges the client's response to hypothetical outcomes. 2)The client is encouraged to express fears openly. 3)The nurse provides detailed and accurate information about the disease. 4)The nurse closely observes the client's body language.
The client is encouraged to express fears openly.
A patient discharged home two days ago with chronic pancreatitis reports the new onset of diarrhea after he resumed eating solid foods. What does the nurse suspect from this report? 1)The patient has developed exocrine pancreatic insufficiency. 2)The patient now requires home TPN feedings. 3)The symptoms suggest beta-cell autoimmune syndrome. 4)The patient has developed dumping syndrome.
The patient has developed exocrine pancreatic insufficiency.
A nurse is providing palliative care to a client with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nursing care? 1)To improve the client's and family's quality of life. 2)To support aggressive and innovative treatments for cure. 3)To provide physical support for the client. 4)To help the client develop a separate plan with each discipline of the health care team.
To improve the client's and family's quality of life.
A patient receiving chemotherapy has morning laboratory values just reported. The nurse notes a platelet count of 25,000. Which intervention is most important to teach this patient? 1)Use a soft-bristled toothbrush. 2)Avoid alcohol-based mouthwashes. 3)Take your temperature every 8 hours. 4)Don't get out of bed to avoid falling.
Use a soft-bristled toothbrush.
The nurse is assessing a patient having an apparent anaphylactic reaction to a medication. Which of the following clinical findings should the nurse consider as most serious? 1)Using of accessory muscle to breathe. 2)Flushing and diaphoresis of the skin. 3)Redness and itching of the skin. 4)Weakness and anxiety.
Using of accessory muscle to breathe.
priority change in major burn injury
change in hemodynamics
priority nursing intervention in parenteral nutrition infusion
start slow monitor blood glucose
Which of the following should be included in an interprofessional symptom management care plan for patients undergoing intravenous chemotherapy for a malignancy? Select all that apply. 1)Mucositis. 2)Neutropenia. 3)Thrombocytopenia. 4)Anemia. 5)Pruritus.
1)Mucositis. 2)Neutropenia. 3)Thrombocytopenia. 4)Anemia.
The highest priority for intervention during the first 30 minutes in treating an acute myocardial infarction including the following(s). SATA 1)Oxygen therapy 2)Morphine administration 3)Ondansetron (Zotran) 4)Nitroglycerin (NTG) 5)Aspirin (ASA) 6)CBC with differential 7)Furosemide ( Lasix)
1)Oxygen therapy 2)Morphine administration 4)Nitroglycerin (NTG) 5)Aspirin (ASA)
The nurse is caring for a patient who has been immobilized for three days following a perineal prostatectomy. The patient experiences a sudden of shortness of breath, sharp chest pain, and is coughing blood-tinged sputum. What are the nurse's best and first actions? 1)Elevate the head of bed, administer supplemental oxygen; perform a rapid respiratory assessment. 2)Assist the patient to cough to clear airway; If unsuccessful then perform nasotracheal suctioning; send the sputum specimen to the lab for culture and sensitivity. 3)Position patient in a supine, side-lying position; check urinary catheter for occlusion, assess for vasovagal reaction. 4)Administer morphine for chest pain, obtain 12 lead ECG; draw blood for complete blood count (CBC) and coagulation studies.
1)Elevate the head of bed, administer supplemental oxygen; perform a rapid respiratory assessment.
A patient with ischemic brain attack (stroke) is susceptible to post-stroke complications. Which complications are sensitive to nursing care? Select all that apply. 1)Extremity contractures 2)Urinary tract infection 3)Carotid stenosis with cerebral ischemia 4)Impaired skin integrity
1)Extremity contractures 2)Urinary tract infection 4)Impaired skin integrity
A patient with ischemic brain attack (stroke) is susceptible to post-stroke complications. Which complications are sensitive to nursing care? Select all that apply. 1)Extremity contractures. 2)Urinary tract infection. 3)Carotid stenosis with cerebral ischemia. 4)Impaired skin integrity.
1)Extremity contractures. 2)Urinary tract infection. 4)Impaired skin integrity.
A client is 6-hour postoperative partial thyroidectomy for a malignant tumor. The nurse knows to carefully monitor for parathyroid involvement manifested as the following assessment findings. Select all that apply. 1)Flexion of wrist when blood pressure cuff is inflated. 2)Contraction of facial muscle upon tapping. 3)Prolonged QT interval. 4)Peaked T-wave.
1)Flexion of wrist when blood pressure cuff is inflated. 2)Contraction of facial muscle upon tapping. 3)Prolonged QT interval.
Which of the following should be included in an interprofessional symptom management care plan for patients undergoing intravenous chemotherapy for a malignancy? Select all that apply. 1)Mucositis 2)Neutropenia 3)Thrombocytopenia 4)Amenia 5)Pruritis
1)Mucositis 2)Neutropenia 3)Thrombocytopenia 4)Amenia
The nurse is caring for a client recovering from an ischemic stroke. What interventions address potential complications after an ischemic stroke? Select all that apply. 1)Providing frequent small meals rather than three larger meals. 2)Teaching the client to perform deep breathing and coughing exercise. 3)Keeping a urinary catheter in place for the full duration of recovering. 4)Limit intake of insoluble fiber, carbohydrates and simple sugars.
1)Providing frequent small meals rather than three larger meals. 3)Keeping a urinary catheter in place for the full duration of recovering.
The nurse caring for a client who is on the med-surgical unit post-operative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indication of infection? 1)Red, warm, tender incision site. 2)Presence of indwelling urinary catheter. 3)Rectal temperature is 99.50 F. 4)White blood cell (WBC) count is 8,000/mL
1)Red, warm, tender incision site.
When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needs C. Changes in brain activity during sleep and wakefulness D. Temporary changes in metabolism
A. Frustration around changes in function and communication
A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? 1)Prevent complications of immobility. 2)Maintain and improve cerebral tissue perfusion. 3)Relieve anxiety and pain. 4)Relieve sensory deprivation.
2)Maintain and improve cerebral tissue perfusion.
A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action? A. Instill the medication in the conjunctival sac. B. Maintain a supine position for 10 minutes after administration. C. Keep the eyes closed for 1 to 2 minutes after administration. D. Apply the medication evenly to the sclera
A. Instill the medication in the conjunctival sac.
A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse's care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client? A. Pneumonia, pulmonary embolism, and sepsis B. Cardiac tamponade, hypoxia, and malnutrition C. Oxygen toxicity in paralytic ileus and electrolyte imbalances D. Seizures, osteomyelitis, and urinary tract infections
A. Pneumonia, pulmonary embolism, and sepsis
Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2) C. Administering hypertonic intravenous (IV) solution D. Initiating early mobilization
A. Positioning the client to avoid intercranial pressure (ICP)
The nurse coming on shift on the medical unit is taking a report on four clients. What client does the nurse know is at greatest risk of developing ESKD? 1)A client with a history of polycystic kidney disease. 2)A client with diabetes mellitus and poorly controlled hypertension. 3)A client who is morbidly obese with a history of vascular disorders. 4)A client with severe chronic obstructive pulmonary disease.
A client with diabetes mellitus and poorly controlled hypertension.
A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A. Applying a protective eye shield at night B. Chewing on the affected side to prevent unilateral neglect C. Avoiding the use of analgesics whenever possible D. Avoiding brushing the teeth
A. Applying a protective eye shield at night
The nurse is assessing a client with a spinal cord injury that reports a severe headache with a rapid onset. The nurse knows that this could be a symptom of which complication of a spinal cord injury? A. Autonomic dysreflexia B. Spinal shock C. Retinal hemorrhage D. Myocardial infarction
A. Autonomic dysreflexia
A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common cause(s) of blindness and visual impairment among adults over the age of 40? Select all that apply. A. Diabetic retinopathy B. Trauma C. Macular degeneration D. Cytomegalovirus E. Glaucoma
A. Diabetic retinopathy C. Macular degeneration E. Glaucoma
A nurse suspects that an older adult client may be experiencing hearing loss. Which finding would support the nurse's suspicion? Select all that apply. A. Dropping of word endings B. Disinterest in conversations C. Social withdrawal D. Domination of conversations E. Quick decision making
A. Dropping of word endings B. Disinterest in conversations C. Social withdrawal D. Domination of conversations
A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months
A. Evidence of hemorrhagic stroke
A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this client? A. The hearing loss will likely resolve with time after the drug is discontinued. B. The client's hearing loss and tinnitus are irreversible at this point. C. The client's tinnitus is likely multifactorial, and not directly related to aspirin use. D. The client's tinnitus will abate as tolerance to aspirin develops.
A. The hearing loss will likely resolve with time after the drug is discontinued.
A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A. Urinary catheter use often leads to urinary tract infections (UTIs). B. Urinary function is permanently lost following an SCI. C. Urinary catheters should not remain in place for more than 7 days. D. Overuse of urinary catheters can exacerbate nerve damage.
A. Urinary catheter use often leads to urinary tract infections (UTIs).
The nurse is administering medication to a client through a feeding tube. Which action should the nurse take? 1)Flush the tube with 5 mL of water before administering medication. 2)Turn the tube feeding off for 1 hour before administering the medication. 3)Administer each medication separately. 4)Flush with 50 mL of water between each medication.
Administer each medication separately.
A patient who is ten days postoperative liver transplant is to be readmitted to the hospital. Only semi-private rooms are available. The most appropriate choice for a roommate would be a patient who has: 1)Angina. 2)Pneumonia. 3)Leg ulcer with cellulitis infection. 4)Hepatitis B
Angina
The post-anesthesia care unit (PACU) nurse has received a patient from surgery. What action by the nurse is a primary intervention to minimize the potential for a deep vein thrombosis (DVT)? 1)Reinforce the importance of smoking cessation to reduce risk. 2)Assess legs with each set of vital signs. 3)Apply the prescribed sequential compression device (SCD). 4)Teach the patient to report the onset of Homan's sign.
Apply the prescribed sequential compression device (SCD).
A client has become legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate? 1)Encourage the client to focus on use of other senses. 2)Assess and promote the client's coping skills during interactions with the client. 3)Emphasize that lifestyle will be unchanged once adaptation to vision loss has occurred. 4)Promote the client's hope for recovery.
Assess and promote the client's coping skills during interactions with the client.
While auscultating the heart of a patient admitted for complications following a myocardial infarction three weeks ago, the nurse notes the presence of a new S3 heart sounds. Based on this finding, what is the nurse's best action at this time? 1)Assess for symptoms of left-sided heart failure. 2)Call the MD. 3)Check the serum potassium level for presence of hypokalemia. 4)Prepare for placement of a 12-lead EKG.
Assess for symptoms of left-sided heart failure.
The nurse understands that the initial response to an acute hypoglycemic episode in a type-1 hospitalized adult diabetes includes the following cluster of actions. 1)Assess symptoms; check blood glucose; assess swallow safety; administer 15 grams carbohydrate orally; evaluate response in 15 minutes. 2)Obtain STAT venous lab draw for glucose; notify physician; have patient drink 8 oz. of orange juice; evaluate response in 20 minutes. 3)Evaluate neurological status; follow prescribed insulin overdose protocol; hang 10% dextrose and run at 40mL/hour. 4)Administer oxygen; check ABG for metabolic acidosis; administer 10% glucose by IV push.
Assess symptoms; check blood glucose; assess swallow safety; administer 15 grams carbohydrate orally; evaluate response in 15 minutes.
A patient on chemotherapy has a total WBC count of 2.8 mm3. Based on this laboratory finding, which of the following should the nurse include as a priority in the patient care plan? 1)Assess temperature every 4 hours. 2)Monitor hourly urine output. 3)Assess for bleeding gums. 4)Prepare to administer prophylactic IV antibiotics 124hours.
Assess temperature every 4 hours.
The nurse is caring for a client who has returned to post-surgical suite after postanesthetic recovery from a nephrectomy. The nurse's most recent assessment reveals increased sedation, shortness of breath, hypotension, and low urine output over the last 2 hours. What is the nurse's best response? 1)Assess the client for signs of bleeding and inform the primary care provider. 2)Perform a full neurological assessment and notify the primary provider. 3)Increase the frequency of taking vital signs, monitor pain, and notify the provider. 4)Palpate the client's torso bilateraly for flank pain and notify the provider.
Assess the client for signs of bleeding and inform the primary care provider.
The nurse is obtaining a health history for a patient admitted to the hospital after experiencing a brain attack. Which disorder does the nurse identify as a predisposing factor for an embolic ischemic stroke? 1)Atrial fibrillation. 2)Psychotropics drug use. 3)Seizure. 4)Pressure injury.
Atrial fibrillation.
The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath
B. Alteration in level of consciousness (LOC)
A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client's status? A. The client's level of knowledge about preceding events B. An assessment of the client's current level of consciousness C. An assessment of the client's lowest verbal and physical response to stimuli D. An in-depth and real-time neurological assessment of the client's condition
B. An assessment of the client's current level of consciousness
The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. A. Absence of pain response B. Apnea C. Coma D. Absence of brain stem reflexes E. Absence of deep tendon reflexes
B. Apnea C. Coma D. Absence of brain stem reflexes
A client has become legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is mostappropriate? A. Encourage the client to focus on use of other senses. B. Assess and promote the client's coping skills during interactions with the client. C. Emphasize that lifestyle will be unchanged once adaptation to vision loss has occurred. D. Promote the client's hope for recovery.
B. Assess and promote the client's coping skills during interactions with the client.
An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake. C. Assess the client's surgical history. D. Encourage the client to take fiber supplements.
B. Assess the client's food and fluid intake.
A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice. B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's discharge E. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.
B. Assist the client out of bed and into the chair for meals. C. Instruct the client to tuck his/her chin towards their chest when swallowing.
The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block
B. Atrial fibrillation
When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck
B. Elevation of the head of the bed
A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client should be kept in a prone position until otherwise ordered. What should the nurse do? A. Clarify the order with the surgeon. B. Follow the order because this bed position is correct. C. Reposition the client after the first dressing change. D. Ask the client to lie in a semi-Fowler position.
B. Follow the order because this bed position is correct.
A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client? A. Generously flush the affected eye with a dilute antibiotic solution. B. Generously flush the affected eye with normal saline or water. C. Apply a patch to the affected eye. D. Apply direct pressure to the affected eye.
B. Generously flush the affected eye with normal saline or water.
A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Have a colleague follow the client closely with a wheelchair. C. Avoid mobilizing the client in the early morning or late evening. D. Ensure that the client's family members do not participate in mobilization.
B. Have a colleague follow the client closely with a wheelchair.
The nurse is planning the care of a client who is adapting to the use of a hearing aid for the first time. What is the mostsignificant challenge this client is likely to experience? A. Regulating the tone and volume B. Learning to cope with amplification of background noise C. Constant irritation of the external auditory canal D. Challenges in keeping the hearing aid clean while minimizing exposure to moisture
B. Learning to cope with amplification of background noise
A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.
B. Maintain and improve cerebral tissue perfusion.
A patient with chronic renal failure is maintained on hemodialysis three times per week. His wife calls the triage nurse the day before his scheduled dialysis with the following symptoms for her husband: •shortness of breath at rest and rapid breathing •inability to lie flat in bed to sleep •confusion and increasing lethargy • 2-pound weight gain since the day before What instructions should the triage nurse give? 1)Bring the patient for emergency hemodialysis. 2)Restrict fluid to no more than 3 litters till the next hemodialysis schedule. 3)Take an extra dose of prescribed furosemide ( Lasix). 4)Take the patient's blood pressure and heart rate and call back for the results.
Bring the patient for emergency hemodialysis
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures
C. Bleeding
A nurse is assessing reflexes in a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding? A. Rigidity B. Flaccidity C. Clonus D. Ataxia
C. Clonus
The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation
C. Depression
A client is receiving education about an upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that the client may experience which of the following adverse effects associated with this procedure? A. Persistent feelings of hunger and thirst B. Constipation or bowel incontinence C. Diarrhea and feelings of fullness D. Gastric reflux and belching
C. Diarrhea and feelings of fullness
A 6-month-old infant is brought to the ED by the parents for inconsolable crying and pulling at the right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear? A. Yellowish-white B. Pink C. Gray D. Bluish-white
C. Gray
A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? A. Risk for impaired skin integrity related to immobility and sensory loss B. Impaired physical mobility related to loss of motor function C. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously
C. Ineffective breathing patterns related to weakness of the intercostal muscles
The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment? A. Decreased muscle tone B. Flaccid paralysis C. Loss of voluntary control of movement D. Slow reflexes
C. Loss of voluntary control of movement
The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A. Maintaining the client's functional independence B. Providing health education C. Monitoring neurologic status closely D. Promoting mobility
C. Monitoring neurologic status closely
When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A. Palpate trapezius muscle while client shrugs shoulders against resistance. B. Administer the whisper or watch tick test. C. Observe for facial movement symmetry, such as a smile. D. Note any hoarseness in the client's voice.
C. Observe for facial movement symmetry, such as a smile
When administering a client's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A. Ensure that the client is well hydrated at all times. B. Encourage self-administration of eye drops. C. Occlude the puncta after applying the medication. D. Position the client supine before administering eye drops.
C. Occlude the puncta after applying the medication.
A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Epidural hemorrhage B. Hypertensive emergency C. Spinal shock D. Hypovolemia
C. Spinal shock
The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge
C. Take antihypertensive medication as prescribed.
Following a motorcycle accidence, an adolescent client is brought to the emergency department (ED). What physical assessment findings related to the ear should be reported by the nurse immediately? 1)The malleus can be visualized during otoscopic examination. 2)The tympanic membrane is pearly gray. 3)Tenderness is reported by the client when the mastoid area is palpated. 4)Clear, watery fluid is draining from the client's ear canal.
Clear, watery fluid is draining from the client's ear canal.
A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? Consume high-residue, high-fiber foods. Limit physical activity in order to promote bowel peristalsis. Use glycerin suppositories on a regular basis. Resist to urge to defecate until the urge become intense.
Consume high-residue, high-fiber foods.
The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis? A. "Client exhibits increased muscle tone." B. "Client demonstrates normal muscle structure with no evidence of atrophy." C. "Client demonstrates hyperactive deep tendon reflexes." D. "Client demonstrates an absence of deep tendon reflexes."
D. "Client demonstrates an absence of deep tendon reflexes."
The nurse is discharging a client home after mastoid surgery. What should the nurse include in discharge teaching? A. "Try to induce a sneeze every 4 hours to equalize pressure." B. "Be sure to exercise to reduce fatigue." C. "Avoid sleeping in a side-lying position." D. "Don't blow your nose for 2 to 3 weeks."
D. "Don't blow your nose for 2 to 3 weeks."
The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye? A. 30 seconds B. 1 minute C. 3 minutes D. 5 minutes
D. 5 minutes
A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment
D. Absolute bed rest in a quiet, non stimulating environment
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A. Rinsing the ears with normal saline after swimming B. Avoiding loud environmental noises C. Instilling antibiotic ointments on a regular basis D. Avoiding the use of cotton swabs
D. Avoiding the use of cotton swabs
Following a motorcycle accidence, an adolescent client is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A. The malleus can be visualized during otoscopic examination. B. The tympanic membrane is pearly gray. C. Tenderness is reported by the client when the mastoid area is palpated. D. Clear, watery fluid is draining from the client's ear.
D. Clear, watery fluid is draining from the client's ear.
A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A. Inability to use a wheelchair B. Unable to swallow liquid and solid food C. Incontinent in bowel movements D. Requires full assistance for elimination
D. Requires full assistance for elimination
A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? A. Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B. Eyeglasses or magnifying lenses C. Corticosteroid eye drops D. Surgical intervention
D. Surgical intervention
A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion. B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.
D. The client's urinary catheter became occluded.
A nurse is caring for a client who is exhibiting ventricular tachycardia. Because the client is pulseless and unconscious, the nurse should prepare for what intervention? 1)Defibrillation, CPR. 2)ECG monitoring. 3)Implantation of a cardioverter defibrillator. 4)Angioplasty.
Defibrillation, CPR.
A patient who is four days postoperative resection of the stomach and pylorus (Billroth 1 procedure) resumes eating. The nurse observes for the complication of dumping syndrome. What cluster of symptoms represents the early symptoms of this complication occurring 30 minutes after eating? 1)Dizziness, tachycardia, abdominal cramps. 2)Confusion, bradycardia, tremor. 3)Hypertension, altered LOC, periumbilical pain. 4)LLQ pain, confusion, metabolic acidosis
Dizziness, tachycardia, abdominal cramps.
A client with advanced venous insufficiency is confined to bedrest following orthopedic surgery. How can the nurse best prevent skin breakdown in the client's lower extremities? 1)Ensure the client's heels are supported and protected. 2)Closely monitor client's serum albumin and prealbumin. 3)Perform gently massage on client's extremities. 4)Perform passive range of motion exercise one per shift.
Ensure the client's heels are supported and protected.
You have been teaching the patient with new onset of SIADH about the disorder. Which of the following statementst by the patient best indicatets that he correctly understands how to manage this disease? I should limit my sodium intake to 2 grams daily I should report constipation or fatigue to the doctor I should drink at least 3000cc or 10 glasses of water daily I should limit my fluid intake to approximately 800cc or 4 glasses of water daily
I should limit my fluid intake to approximately 800cc or 4 glasses of water daily
A nurse is preparing a plan of care for a client with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? 1)Disturbed body image. 2)Impaired skin integrity. 3)Nausea. 4)Risk for deficient fluid volume.
Impaired skin integrity.
A nurse is planning discharged education for an 81-year-old client with mild short-term memory loss. The discharged education will include how to perform basic wound care for the venous ulcer on the client's lower leg. When planning the necessary health education for this client, the nurse should take which action? 1)Set long-term goals with the client. 2)Provide a list of useful websites to supplement learning. 3)Keep visual cues to a minimum to enhance the client's focus. 4)Keep teaching period short.
Keep teaching period short.
A client is recovering in the hospital following a gastrectomy. The nurse notes that the client has become increasingly difficult to engage and has had several angry outbursts at the staff members in recent days. The nurses attempts at therapeutic dialouge have been rebuffed. What is the nurse's most appropriate action? Ask the client's primary provider to liaise between the nurse and the client Delegate care of the client to a colleague Limit contact with the clientt in order to provide privacy Make appropriate referrals to services that provide psychosocial support
Make appropriate referrals to services that provide psychosocial support
A nurse is caring for a client who has a diagnosis of gastrointestinal (GI) bleed. During shift assessment, the nurse finds the client is tachycardiac and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of consciousness, what would be a priority nursing action for this client? 1)Place the client in a prone position. 2)Provide the client with ice water to slow any GI bleeding. 3)Prepare for the insertion of an GI tube. 4)Notify health care provider
Notify health care provider
You are monitoring a patient during the first eight hours postoperatively following surgery for an ileostomy. You note a change in the appearance of the ileostomy stoma, which now appears very dark red to purple in color on one half of the stoma. What is your best action at this time? 1)Notify the surgeon. 2)Replace the ostomy pouch with one that has a larger opening around the stoma. 3)Evaluate the patient's pulse oximetry and provide supplemental oxygen by cannula. 4)Evaluate the patient's blood pressure and heart rate for hypotension and bradycardia.
Notify the surgeon.
A patient with Crohn's disease has undergone abdominal imaging studies that demonstrated the presence of multiple strictures in the small intestine. Based on this finding, for which of the following initial complications should the nurse assess? 1)Obstruction. 2)Peritonitis. 3)GI bleeding. 4)Malabsorption.
Obstruction.
Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? 1)Peritonitis 2)Gastritis 3)Gastroesophageal reflux 4)Acute pancreatitis
Peritonitis
Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? 1)Peritonitis. 2)Gastritis. 3)Gastroesophageal reflux. 4)Acute pancreatitis.
Peritonitis.
A nurse has a client with a spinal cord injury and is tailoring the care plan to prevent the major cause of death for this client. The nurse's care plan includes assisted coughing techniques, applied sequential compression device, and prevented pressure injuries. Which are the most likely possible causes of death for this client? 1)Pneumonia, pulmonary embolism, and sepsis 2)Cardiac toxicity, paralytic ileus, and electrolyte imbalance 3)Seizure, osteomyelitis, and urinary tract infection 4)Cardiac tamponade, hypoxia, malnutrition
Pneumonia, pulmonary embolism, and sepsis
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? 1)Provide a board of commonly used needs and phrases. 2)Speak in a loud and deliberate voice to the client. 3)Help the client complete his or her sentences as needed. 4)Have the client speak to loved ones on the phone daily.
Provide a board of commonly used needs and phrases.
A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments? 1)Reviewing the client's creatinine and BUN levels. 2)Monitoring the client's neutrophil levels. 3)Assessing the client for signs of impaired liver function. 4)Monitoring the client's level of consciousness and behavior.
Reviewing the client's creatinine and BUN levels.
After a sudden decline in cognition, a 77-year-old client who has been diagnosed with vascular dementia is receiving care at home. To reduce this client's risk of future infarcts, which action should the nurse most strongly encourage? 1)Activity limitation and falls reduction efforts. 2)Adequate nutrition and fluid intake. 3)Rigorous control of the client's blood pressure and lipid levels. 4)Use of mobility aids to promote independence.
Rigorous control of the client's blood pressure and lipid levels.
A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? Imbalanced nutrition: Less than body requirements related to decreased oral intake Risk for infection related to possible rupture of appendix Constipation related to decreased bowel motility and decreased fluid intake Chronic pain related to appendicitis.
Risk for infection related to possible rupture of appendix
You are monitoring care for a patient diagnosed with active pulmonary tuberculosis (TB) who has been taking the prescribed doses of isoniazid, rifampin, pyrazinamide, and ethambutol. Which finding best indicates the antibiotic drug therapy is effective? 1)Sputum culture coverts to negative. 2)The tuberculin test is negative. 3)Intrapleural cavity is no longer visible on the chest X-Ray. 4)Patient is afebrile and no longer experience coughing.
Sputum culture coverts to negative.
The nurse is caring for a 78-year-old client who has had an outpatient cholecystectomy. The nurse is getting the client up for the first walk postoperatively. To decrease the potential of orthostatic hypotension and consequent falls, what should the nurse have the client do? 1)Stand upright for 2 to 3 minutes prior to ambulating. 2)Sit in a chair for 10 minutes prior to ambulating. 3)Drink plenty of fluid to increase circulating blood volume. 4)Perform range-of-motion exercises for each joint.
Stand upright for 2 to 3 minutes prior to ambulating.
You are working the night shift and have just received handoff report. Which of the following patients should you see first on your initial rounds? 1)The 72-year-old male with left-sided heart failure and has developed a new non-productive cough, crackles, and confusion. 2)The 52-year-old female who is experiencing abdominal cramping 30 minutes into peritoneal dialysis. 3)The 70-year-old male who is on a continuous bladder irrigation (CBI) after a transurethral resection of the prostate yesterday and reports bladder spasms. 4)The 37-year-old female admitted yesterday with a diagnosis of cellulitis of the left leg and is now experiencing redness, increasing warmth, and pain in the left leg.
The 72-year-old male with left-sided heart failure and has developed a new non-productive cough, crackles, and confusion.
a patient hospitalized for worsening renal failure suddenly becomes restless and agitated. Your assessment reveals tachycardia, hypertension and crackles bilaterally scattered through the lung fields. What do these symptoms suggest?
developing pulmonary edema
