10/24 RN med-surg

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 The nurse should monitor for and report manifestations of compartment syndrome following internal fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch.

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. Infliximab

B. Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster.

A nurse in a provider's office is assessing a client who has GERD. When documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? A. Stair-climbing B. Bending over C. Sitting D. Walking

B. Bending over Gastroesophageal reflux symptoms are most evident with activities that increase intra-abdominal pressure (e.g. bending over, straining, lifting, and lying down).

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes

B. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.

A nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? A. Monitor visitors for manifestations of infection B. Remind the client to use an electric razor C. Encourage frequent rest periods D. Instruct the client to rinse mouth daily with normal saline

B. Remind the client to use an electric razor Thrombocytopenia is a decrease in the client's blood platelet count, which places the client at an increased risk of bleeding due to the blood's inability to clot. Therefore, the nurse should institute bleeding precautions, including the use of an electric razor.

A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse report to the provider? A. Allergy to egg products B. Vomiting and diarrhea for the last 6 hr C. Serum potassium of 3.6 mEq/L D. Serum creatinine of 1.2 mg/dL

B. Vomiting and diarrhea for the last 6 hr Vomiting and diarrhea for 6 hours deplete the client's fluid volume, which results in dehydration that can cause renal failure following a procedure that uses contrast dye. Therefore, the nurse should notify the provider.

A nurse is teaching a client who tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen through which of the following statements? a. "I will begin vacuuming once a week." B. "Carpeting the entire house will be very expensive, but it will be worth it." C. "I will put a mattress cover on my bed." D. "Installing curtains on the windows will help control the dust in my house."

C. "I will put a mattress cover on my bed." The nurse should instruct the client to apply a hypoallergenic mattress cover that can be zipped over her bed to control the amount of dust. The client should remove and machine-wash the mattress cover periodically.

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 When applying the urgent vs. non-urgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a risk to the client. The nurse might also use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status.

A nurse is caring for a client who recently had chemotherapy and now has myelosuppression. Which of the following interventions should the nurse initiate? (SATA) a. prohibit visitors from bringing fresh flowers and plants into the client's room b. encourage frequent visits from family and friends c. ensure thorough cleaning of the client's room and bathroom daily d. replace wound dressings every other day e. use dedicated equipment such as stethoscopes

a,c,e myelosuppressions is bone-marrow depression, which puts the client at a high risk of infection after chemotherapy. Fresh flowers and potted plants can introduce microorganisms into the client's immediate environment. Due to the client's high risk of infection, the nurse should make sure the housekeeping staff clean and sanitize the client's environment daily. In addition, the nurse should utilize single-use equipment as much as possible and keep reusable equipment (i.e. stethoscopes and blood pressure cuffs) in the client's room for dedicated use by the client only.

A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? a. absence of breath sounds b. expiratory wheezing c. inspiratory stridor d. rhonchi

a. absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A nurse is performing discharge teaching about ostomy care while at home for a client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? a. empty your ostomy pouch when it becomes half full b. place an aspirin in the ostomy pouch to eliminate odor c. change the ostomy appliance every week d. cleanse the site around the stoma with hydrogen peroxide and water

a. empty your ostomy pouch when it becomes half full The nurse should instruct the client to empty the ostomy pouch when it is 1/3 to 1/3 full. This prevents the ostomy from becoming too full of stool and gas and exploding.

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? a. offer the client a bedpan every 2 hr b. limit the client's daily fluid intake until he is no longer incontinent c. request a prescription for an indwelling catheter from the client's provdier d. ambulate the client to the bathroom every 30 min

a. offer the client a bedpan every 2 hr Following a stroke, the client might have bladder incontinence due to confusion, impaired sensation in response to bladder fullness, and decreased sphincter control. The nurse should encourage and assist the client to void every 2 hours while awake to promote bladder control. By offering a bedpan, the nurse promotes client safety

A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the client's breast cancer risk? (SATA) A. Increased breast density B. BMI of 32 C. Having given birth to 5 children D. Undergoing hormonal replacement therapy for 10 years E. Having 1-2 alcoholic drinks per week

b,d,e Women who have dense breast tissue are at an increased risk for developing breast cancer because they have more connective and glandular breast tissue. Postmenopausal obesity increases the risk of developing breast cancer. Hormone-related risks for developing breast cancer include the long-term use of oral contraceptives or hormone replacement therapy, early menarche, late menopause, and first pregnancy after 30 years of age.

A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? a. the client has active tuberculosis b. the client had an expsure to tuberculosis c. the nurse must re-evaluate the result in 24 hr d. the test is negative for tuberculosis

b. the client had an exposure to tuberculosis A Mantoux test is a skin test that determines exposure to tuberculosis. The nurse should look at the test site and palpate the area to determine if the injection site is raised and feels hard to the touch (induration). Then, the nurse should record the results in millimeters to represent the size of the raised bump. Redness alone does not determine a positive result.

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? a. platelets help the body fight infection b. platelets help break down the clots in the body c. platelets plug breaks in blood vessels d. platelets produce the molecules that carry oxygen

c. platelets plus breaks in blood vessels Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When an injury occurs to a blood vessel, platelets collect at the edge of the break and adhere to each other to plug the injured area and limit blood loss.

An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? a. monitor urinary output b. administer an osmotic diuretic c. provide supplemental oxygen d. initiate seizure precautions

c. provide supplemental oxygen The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical ventilation because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death.

A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this client? a. whole blood b. lactated ringers c. dextran 40 in 0.9% sodium chloride d. 0.45% sodium chloride

d. 0.45% sodium chloride The nurse should identify that 0.45% sodium chloride is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value <270 mOsm/L, which is less than the expected reference range of the osmolarity value for plasma and body fluid of 285 to 292 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid.

A home health nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following foods should the nurse include in the client's plan of care? a. soft-boiled eggs b. brie cheese made with unpasteurized milk c. cold deli-meat sandwiches d. backed chicken

d. baked chicken Well-cooked meats, including baked chicken, do not pose a threat to clients who have neutropenia and may be included in the client's dietary plan. For optimal safety, poultry should be cooked to an internal temperature of 74°C (165°F).

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? a. measuring heart rate b. palpating peripheral pulses c. observing sputum for blood d. confirming the gag reflex

d. confirming the gag reflex The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can maintain hydration and nutrition without risk

The nurse is teaching a client about prostate-specific antigen (PSA) test. Which of the following directions should the nurse provide? a. you should fast for 8 hours after the PSA test b. annual PSA screening should begin at age 40 c. expected PSA values will decrease as you get older d. you should not ejaculate for 24 hours prior to the PSA test

d. you should not ejaculate for 24 hours prior to the PSA test PSA is a glycoprotein manufactured in the prostate that is used to screen for prostate cancer. Ejaculation within 24 hours prior to the test can falsely elevate levels of PSA.