medsurg 2 testb

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?

A 27-year-old client with a heart rate of 120 beats/min

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?

A 52-year-old in a tripod position using accessory muscles to breathe

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis?

A 74-year-old man who smokes and has a fractured pelvis

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first?

Administer oxygen via nasal cannula.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best?

Assess the clients culture more thoroughly.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?

Assess the clients gag reflex before giving any food or water.

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?

Assess the clients level of consciousness.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?

Assess the clients lung sounds.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?

Assess the clients oxygen saturation.

A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best

Assess the neurovascular status of the right leg.

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first?

Assess the pedal pulses.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?

Assist the client to choose a communication method.

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care?

Assistance with activities of daily living

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met?

Attends meetings of a book club

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first?

Client with a red, hot, swollen right wrist

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?

Collect the nasal drainage on a piece of filter paper.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best?

Consult with the provider about an x-ray.

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this clients plan of care?

Encourage range-of-motion exercises.

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?

How would you describe the pain that you are feeling?

A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?

Inability to initiate or maintain abduction of the affected arm at the shoulder

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?

Numbness in the extremity

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?

Obtain a prescription to culture the drainage.

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this clients pain?

Patient-controlled analgesia (PCA) pump with morphine

A phone triage nurse speaks with a client who has an arm cast. The client states, My arm feels really tight and puffy. How should the nurse respond?

Please come to the clinic today to have your arm checked by the provider.

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first?

Raise the arm above the level of the heart.

An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?

Remove the medical alert bracelet from the fractured arm.

A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?

Skeletal traction will assist in realigning your fractured bone.

A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, I dont want to live with only one leg. I should have died during the surgery. How should the nurse respond?

This is a big change for you. What support system do you have to help you cope?

A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention?

Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?

When the tube becomes disconnected from the drainage system

A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, The cast is loose enough to slide off. How should the nurse respond?

You need a new cast now that the swelling is decreased.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, What does this mean? How should the nurse respond?

Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke.

A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.)

a. Administer additional opioids as prescribed. b. Elevate the extremity on pillows. c. Apply ice to the fracture site.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.)

a. Alcohol b. Caffeine d. Carbonated beverages e. Vitamin D

When assessing gait, what features does the nurse inspect? (Select all that apply.)

a. Balance b. Ease of stride d. Length of stride e. Steadiness

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)

a. Edema Increased capillary permeability c. Unequal pulses Increased production of lactic acid d. Cyanosis Anaerobic metabolism

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. d. Re-position the client every 2 hours.

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

a. Encourage deep breathing and coughing. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins.

A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?

a. Immobilize the left arm.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.)

a. It leads to minimal blood loss. b. It allows for early ambulation. c. . It promotes healing.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)

a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)

a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage.

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)

a.22-year-old client with asthma c.Client with well-controlled diabetes d.Healthy 72-year-old client e.Client who is taking medication for hypertension

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?

airway patency

An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.)

b. Urinary output c. Blood pressure e. Skin color

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a few days ago and shows the nurse the results of what the client calls an allergy test, as shown below: What action by the nurse takes priority?

c.Immediately place the client on Airborne Precautions.

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client?

d. Ensure that the weights remain freely hanging at all times.

A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury?

d. Hematuria

27. A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the clients risk for infection?

d. Schedule for pin care to be provided every shift.

A nurse obtains the health history of a client with a fractured femur. Which factor identified in the clients history should the nurse recognize as an aspect that may impede healing of the fracture?

pagets disease

A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?

Assess for seafood or iodine allergy.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

Measure and compare cuff pressures.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.)

-Antibodies lead to inflammation. -It consists of an autoimmune process.

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

-Apply an abduction pillow to the clients legs. -Place pillows under the heels to keep them off the bed. -Take and record vital signs per unit/facility policy.

A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.)

-Bone changes lead to potential safety risks. -Osteoarthritis occurs due to cartilage degeneration. -Some muscle tissue atrophy occurs with aging.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.)

-Feltys syndrome -Joint deformity -weight loss

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best?

Assess neurovascular status in both legs.

A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?

21%

A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority?

Assess the clients cardiac and respiratory systems.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?

Notify the Rapid Response Team.

6. The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system?

red marrow

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?

Arrange a home safety evaluation.

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?

Ask about medications the client is currently taking.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?

Ask the client about fear of falling.

A client is distressed at body changes related to kyphosis. What response by the nurse is best?

Ask the client to explain more about these feelings.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees. What action by the nurse is best?

Assess the client for the presence of subcutaneous nodules or Bakers cysts.

A client is admitted with a large draining wound on the leg. What action does the nurse take first?

Obtain cultures of the leg wound.

A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain?

Occupation and hobbies

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?

Acetaminophen

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?

Administer pain medication and encourage the client to take deep breaths.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?

Administer preoperative antibiotic as ordered.

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?

Antibiotics started before admission

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.)

-Grab bars to reach high items -Long-handled bath scrub brush -Toothbrush with built-up handle

A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate?

. Bending forward from the hips

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?

Apply water-soluble ointment to nares and lips.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?

Applying suction while inserting the catheter

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)

Applying water-soluble lip balm to the clients lips Reminding the client to cough and deep breathe often

A client has a metastatic bone tumor. What action by the nurse takes priority?

Handle the affected extremity with caution.

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?

Have adequate help to transfer the client.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate?

Have you been taking glucosamine supplements?

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management?

I will not sit with my legs crossed.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?

Ice packs

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?

Notify the surgeon or anesthesia provider immediately.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first?

Do you experience shortness of breath with basic activities?

A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first?

Document the findings.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate?

Drink 1 to 2 liters of water each day.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?

Ensure that a consent for transfusion is on the chart.

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best?

Ensure the client gets 15 minutes of sun exposure daily.

What information does the nurse teach a womens group about osteoporosis?

For 5 years after menopause you lose 2% of bone mass yearly.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations?

Increased pulmonary pressure creating a higher workload on the right side of the heart

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct?

Inspect the clients distal finger joints.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?

Intact skin behind the ears

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?

Lose weight if needed.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?

Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching?

Make sure you clean the humidifier to prevent infection.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best?

Notify the provider immediately.

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best?

Older people often have vague symptoms, so an x-ray is essential.

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first?

Post-microvascular bone transfer client whose distal leg is cool and pale

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide oral care every 4 hours.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?

Providing a verbal hand-off report to the facility

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?

Raise the lower siderail on the affected side.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?

Severe osteoporosis

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?

Share any thoughts and feelings that cause you to limit social activities.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?

Stay with the client and have someone else call the provider immediately.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse?

Storing the CPM machine under the bed after removal

A nurse is providing education to a community womens group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)

Strengthening exercises are important.d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

Which teaching point is most important for the client with bacterial pharyngitis?

Take all antibiotics as directed.

A hospitalized clients strength of the upper extremities is rated at 3. What does the nurse understand about this clients ability to perform activities of daily living (ADLs)?

The client is able to perform ADLs but not lift some items.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching?

The client places his or her hands on his or her abdomen.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

The trachea is deviated toward the opposite side of the neck.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?

This is normal after surgery. What types of food do you like to eat?

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?

Traction weights are resting on the floor

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?

Tying a square knot at the back of the neck

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?

Use an abduction pillow.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?

Use aseptic technique for dressing changes.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?

Validate that informed consent has been given by the client.

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjgrens syndrome?

Visual acuity

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. d. Use a vibrating positive expiratory pressure device.

A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best? (Select all that apply.)

a. Assess the daily serum calcium level. b. Consult the provider about a loop diuretic. d. Instruct the client to call for help out of bed.

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this clients teaching? (Select all that apply.)

a. Avoid drinking fluids just before and during meals.b. Rest before meals if you have dyspnea. c. Have about six small meals a day.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.)

a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Remove all throw rugs throughout the house. d. Use a shower chair while taking a shower.

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)

a. Cognition. b. Dexterity d. Range of motion e. Vision

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)

a. Create a communication system d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.)

a. Draining sinus tracts c. Presence of foot ulcers

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.)

b. Do you have any difficulty sleeping? c. How long does it take to perform your morning routine? e. Have you lost any weight lately?