final medsurg 2

A client will undergo basal gastric acid secretion analysis. The client is taking several medications. Which types of drugs should the nurse withhold prior to the test? Select all that apply? Anticholinrgic Cardiac Glycoside Antacid Diuretic Corticosteroid

Anticholinrgic Antacid Corticosteroid

A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client? Acute pain Impaired mobility Difficulty swallowing Hematoma formation

Hematoma formation

After a gastroscopy, how does the nurse assess the client for the return of the gag reflex? Touching the pharynx with a tongue depressor Giving a small amount of water using an oral syringe Observing the client's swallowing ability Instructing the client to breathe deeply and cough gently

Touching the pharynx with a tongue depressor

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) pH 7.35, CO 2 47 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) pH 7.46, CO 2 30 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) pH 7.50, CO 2 50 mm Hg, HCO 3 - 22 mEq/L (22 mmol/L)

pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L)

A client with gastroesophageal reflux disease (GERD) receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? Select all that apply. Nizatidine Ranitidine Lansoprazole Famotidine Pantoprazole

Nizatidine Ranitidine Famotidine

The nurse observes a client starting to have seizures. After assessing the airway, what should be the highest priority of the nurse? Insert artificial airway Observe and record seizure activity Administer Diazepam Restrain the extremities to protect from injury

Observe and record seizure activity

A patient is admitted to the hospital with severe renal colic. The nurse's first priority in management of the patient is to administer opioids as prescribed obtain supplies for straining all urine encourage fluid intake of 3 to 4 liters per day keep the patient NPO in preparation for surger

administer opioids as prescribed

Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of Nasogastric suctioning Inflammation of the incision site Irritation of the bowel Impaired peristalsis

Impaired peristalsis

A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? A halo sign on the nasal drip pad Decreased blood pressure and urinary output A positive reading for glucose on a Test-tape strip Clear nasal drainage along with the bloody discharge

A halo sign on the nasal drip pad

Which medication should the nurse review first for a potential interaction in a client admitted to the hospital with a state of alkalosis? Warfarin Metformin Digoxin Ibuprofen

Digoxin

Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply. Edema Vertigo Ascites Palpitations Polyuria

Edema Ascites

Which assessment finding in a 35 year old client with an intracranial hematoma should concern the nurse? Hamstring pain when the hip and knee are flexed and then extended Curling of the toes when the bottom of the foot is stroked in upward motion Muscle aches and cramping, especially at night Cogwheel and lead pipe rigidity

Hamstring pain when the hip and knee are flexed and then extended

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. What should the nurse do to prepare the client for the procedure? Have the client to void Have the client not to eat or drink for 4 hours Give the client an analgesic Have the client turn to the lateral position.

Have the client to void

While a client with an abdominal aortic aneurysm is being prepared for surgery, the client complains of feeling light-headed. The client is pale and has a rapid pulse. What does the nurse conclude that the client's symptoms indicate? Hyperventilation Shock Anxiety Infection

Shock

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? An obese client with leg trauma A pregnant client with acute asthma A client with diabetes who has cholecystitis A client with pneumonia who is immunocompromised

An obese client with leg trauma

A client is prescribed ranitidine 150 mg daily to treat peptic ulcer disease (PUD). Which instruction would the nurse give to the client about when to take this medication? As needed With meals At bed time When indigestion occurs

At bed time

A primary healthcare provider prescribes atenolol 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to teach in the discharge planning? Drink alcohol beverages in moderation Avoid stopping medication abruptly Hold medicine if pulse rate is less than 70bpm Increase the dose if chest pain is present

Avoid stopping medication abruptly

Which information should be included in the teaching plan for the elderly client with peptic ulcer disease who is taking an antacid and sucralfate? Antacids should be taken 30 minutes before a meal. Sucralfate should be taken on an empty stomach one hour before meals. Sodium bicarbonate is an inexpensive over-the-counter antacid with few adverse effects. Sucralfate is prescribed for the long-term maintenance of peptic ulcer disease.

Sucralfate should be taken on an empty stomach one hour before meals.

A patient with a head injury develops SIADH . Manifestations the nurse would expect to find include hypernatremia and edema muscle spasticity and hypertension low urine output and hyponatremia weight gain and decreased glomerular filtration rate

low urine output and hyponatremia

The nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram. Which clinical finding is most significant when assessing the left extremity before the arteriogram? Mottling of the leg Coolness of the leg Absence of pedal pulse Thickening of toe nail on left leg

Absence of pedal pulse

A client is diagnosed with emphysema. What long-term problem should the nurse monitor in this client? Localized tissue necrosis Carbon dioxide retention Increased respiratory rate Saturated hemoglobin molecules

Carbon dioxide retention

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? Offer soft-textured foods to reduce the digestive burden Offer low-cholesterol foods to avoid further formation of gallstones Increase protein intake to promote tissue healing and improve energy reserves Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

A client is admitted to the hospital with sudden onset of severe abdominal pain. Which ABG value should the nurse expect to see in the client? PaCO2 48 HCO3 18 pH 7.32 SaO290

HCO3 18

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? Risk for impairment of tissue integrity caused by paralysis Altered patterns of urinary elimination caused by tetraplegia Altered family and individual coping caused by the extent of trauma Ineffective airway clearance caused by high cervical spinal cord injury

Ineffective airway clearance caused by high cervical spinal cord injury

The healthcare provider prescribes isosorbide dinitrate 10 mg for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. How will the nurse respond? It prevents excessive blood clotting." It suppresses irritability in the ventricles." It improves oxygen supply to heart tissue." The inotropic action increases the force of contraction of the heart."

It improves oxygen supply to heart tissue."

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested medications and reports severe epigastric and abdominal pain. The client has absent bowel sounds, rigid abdomen, a pulse rate of 134, and shallow respirations of 32 per minute. The primary healthcare provider has been contacted. What should be the nurse's next priority? Keep the client nothing by mouth (NPO) Teach the client coughing and deep breathing Inquire whether any red or black stools have been noted Place the client in the supine position with the legs elevated

Keep the client nothing by mouth (NPO)

A client develops thrombophlebitis in the right calf. Bed rest is prescribed, and an IV of heparin is initiated. What drug action will the nurse include when describing the purpose of this drug to the client? Prevents extension of the clot Reduces the size of the thrombus Dissolves the blood clot in the vein Facilitates absorption of red blood cells

Prevents extension of the clot

The laboratory report of a client reveals the presence of 350 cells/mm 3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? Stage 1 Stage 2 Stage 3 Stage 4

Stage 2

You are teaching a patient with osteopenia. What is important to include in the teaching plan? Lose weight Stop smoking Eat a high protein diet Start swimming for exercise

Stop smoking

A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client makes which statement? Eliminating fluids with meals will prevent pain." I will increase my food intake to avoid an empty stomach." Taking an aspirin with milk will relieve my pain and coat my ulcer." Taking an antacid preparation will decrease pain due to gastric acid."

Taking an antacid preparation will decrease pain due to gastric acid."

The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? Azotemia Hypokalemia Metabolic alkalosis Respiratory Alkalosis

Azotemia

The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with pruitis Client with flushing Client with itching Client with wheezing

! Client with wheezing

Nursing care of a client with a fractured hip should include the assessment of pedal pulses. The nurse should assess for which important characteristics of the pedal pulses? Contractility and rate Color of skin and rhythm Amplitude and symmetry Local temperature and visible pulsation

Amplitude and symmetry

The nurse provides care for a Chinese client who is experiencing leg pain. The client states, "I don't want to take any medication that I may get addicted to." What is the best nursing intervention in this situation? Answer Give ibuprofen (Advil) to the client with hot tea Give morphine (Avinza) to the client with hot tea Give ibuprofen (Advil) to the client with cold water Postpone medication administration to the client

Answer Give ibuprofen (Advil) to the client with hot tea

What technique should a nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula? Apply a precut dressing around the insertion site with the flaps pointing upward. Replace the tube with a sterile obturator Use sterile cotton balls to cleanse the outer cannula Remove the tube after the high-volume, low-pressure cuff has been deflated.

Apply a precut dressing around the insertion site with the flaps pointing upward.

A client is admitted with a head injury after being in a motor vehicle crash. After noting the presence of clear drainage from the left ear the nurse should suspect which underlying problem commonly associated with this finding? Linear skull fracture Basilar skull fracture Subdural hematoma Epidural hematoma

Basilar skull fracture

A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin? Hypertension Headaches Bradycardia Junctional Tachycardia

Bradycardia

Which instruction should the nurse give to a client with multiple sclerosis who has urinary retension? Run water whenever you experience difficulty initiating urination Decrease your fluid intake to prevent urgency Drink caffeinated beverage to promote the ability to form urine Catheterize your bladder according to the schedule we discussed.

Catheterize your bladder according to the schedule we discussed.

What is the primary responsibility of a nurse when caring for a client with a chest tube attached to a three-chamber underwater-seal drainage system? Ensure maintenance of the closed system Maintain mechanical suction to the system Encourage the client to deep breathe and cough Keep the client in the dorsal recumbent position

Ensure maintenance of the closed system

A client with arthritis increases the dose of ibuprofen to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What findings does the nurse expect to identify when performing an admission assessment? Select all that apply. Melena Clay-colored stools Tachycardia Constipation Painful bowel movements

Melena Tachycardia

A client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement? Turning on the television for diversion Calling the primary healthcare provider for another analgesic prescription Placing the prescribed as-needed warm, wet compress on the elbow Informing the client gently to wait until the pump reactivates to get more medication

Placing the prescribed as-needed warm, wet compress on the elbow

The nurses teaches a client that which factor might increase the risk of developing an exacerbation of Systemic Lupus Erythematous (SLE) ? Pregnancy Hypotension Fever GI upset

Pregnancy

Vasogenic cerebral odema increases intracranial pressure by shifting fluid in gray matter altering endothelial lining of cerebral capillaries leaking molecules from the intracellular fluid to the capillaries altering the osmotic gradient flow into the intravascular component

altering endothelial lining of cerebral capillaries

The most common early symptom of a spinal cord tumor is urinary incontinence back pain that worsens with activities paralysis below the level of involvement impaired sensation of pain, temperature, and light touch

back pain that worsens with activities

The nurse teaches the patient that the best time to take corticosteroids for the replacement purpose is once a day at bedtime every other day on awakening on arising and in the late afternoon at consistent intervals every 6 to 8 hours

on arising and in the late afternoon

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? Xanax Morphine Aspirin Nitroglycerin

Aspirin

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is administer codeine for pain relief controlling fever with prescribed medicines and cooling techniques keeping room dark and minimizing environmental stimuli maintaing strict bed rest and elevating head of bed

controlling fever with prescribed medicines and cooling techniques

A client who is receiving a cardiac glycoside, a diuretic, and a vasodilator has been placed on bed rest. The client's apical pulse rate is 44 beats per minute. The nurse concludes that the decreased heart rate most likely is a result of which drug? Diuretic Vasodilator Bed rest regimen Cardiac Glycoside

Cardiac Glycoside

What is the priority action for the nurse to take if the patient with type 2 diabetes complaints of blurred vision and irritability? Call the Physician Administer Insulin as ordered Check patients blood glucose level Assess for other neurologic symptoms

Check patients blood glucose level

A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention? Maintain client in bed rest Maintain the client's lower extremities in extension Check vitals signs every 15 minutes Administer prescribed oxygen

Check vitals signs every 15 minutes

A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history? Cystitis as an adult Pleurisy as an adult Childhood strep throat Childhood German Measles

Childhood strep throat

While providing a community education on prevention of peripheral arterial disease (PAD) the nurse should include which major risk factors? Select all that apply . Dysrhythmias Low protein intake Exposure to cool weather Cigarette smoking Hypertension

Cigarette smoking Hypertension

A client is admitted to the hospital for surgery for a laparoscopic cholecystectomy. To monitor the flow of bile to the gastrointestinal tract, what symptom should the nurse assess? Color of stool Presence of peristalsis Bleeding at the operative site Presence of cholesterol intolerance

Color of stool

A nurse is caring for a client with severe gastritis who vomited a large amount of blood. A lavage is prescribed by the healthcare provider. Which response does the nurse expect when using a room temperature irrigating solution? Coagulation of blood Neutralization of acids Stimulation of vagus nerve Constriction of blood vessels

Constriction of blood vessels

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority? Increase left ventricular filling and improve cardiac output Decrease oxygen needs of the vital organs and prevent cardiac dysrhythmias Decrease the workload on the heart and promote maximum coronary artery filling Increase venous return to the right atrium and increase pulmonary arterial blood flow

Decrease the workload on the heart and promote maximum coronary artery filling

A circulating nurse in the operating room learns of being HIV positive. What should this nurse do regarding participation in exposure-prone procedures? Adhere to standard precautions at all times Avoid handling equipment used in direct client care Disinfect all equipment used for non-invasive procedures Discuss procedures that can be performed with a review panel

Discuss procedures that can be performed with a review panel

A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? High blood flow to the brain Normal Intracranial pressure Impaired blood flow to the brain Adequate autoregulation of blood flow

Impaired blood flow to the brain

The laboratory report of a Patient with celiac disease reveals that the patient has anemia. What does the nurse suspect as the most likely causes of the anemia? Select all that apply. Lack of gluten in the diet Inadequate caloric intake Absence of intrinsic factor Correct! Incomplete absorption of iron Incomplete absorption of folic acid

Incomplete absorption of folic acid

The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority? Assisting the client in eating and drinking Maintaining fluid balance in the client Providing adequate oxygenation for the client Encouraging the client to perform breathing exercise

Providing adequate oxygenation for the client

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Permit the development of positive pressure between the layers of the pleura Provide access for the instillation of medication into the pleural space

Remove the air that is present in the intrapleural space

Which assessment finding by the nurse warrants further investigation to determine if the client has rheumatoid arthritis(RA)? Negative family history Reports prolonged morning stiffness lasting for 1 hour Occasional use of NSAIDs for aches and pains Reports of pain with movement

Reports prolonged morning stiffness lasting for 1 hour

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? Tonic spasms of the legs Curling in a fetal position Arching of the neck and back Resistance to flexion of the neck

Resistance to flexion of the neck

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding? Passage of flatus Rise of formula in the tube Rapid infloe of the feeding Tenderness in epigastric area.

Rise of formula in the tube

A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply. Preventing constipation Screening of blood donors Avoiding shellfish in the diet Limiting hepatotoxic drug therapy Maintaining a monogamous sexual relationship

Screening of blood donors Maintaining a monogamous sexual relationship

One month after abdominal surgery, a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse should maintain the client in what position? Supine Semi Fowlers Right Sim A position that client prefers

Semi Fowlers

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. The test involves the administration of a contrast medium. Clients should have their hydration levels assessed. Clients are instructed to lie still on a hard table. Clients are served shellfish before the test. A client's serum creatinine level is evaluated after the test.

The test involves the administration of a contrast medium. Clients should have their hydration levels assessed. Clients are instructed to lie still on a hard table.

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason identified by the nurse for suctioning the client? Humidified oxygen is saturated with fluid. The tracheostomy tube interferes with effective coughing. The inner cannula of the tracheostomy tube irritates the mucosa. The weaning process increases the amount of respiratory secretions.

The tracheostomy tube interferes with effective coughing.

The home health nurse concludes that more teaching is needed after making which observations during the first home visit to a client discharged home after a stroke? A commode is observed at the bedside A package of psyllium is on the kitchen counter Hand weights are next to the couch There is a small rug at the side of the bed

There is a small rug at the side of the bed

The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient? Administer IV mannitol (Osmitrol). Ventilator use to hyperoxygenate the patient Use strict aseptic technique with dressing changes. Be aware of changes in ICP related to leaking CSF.

Use strict aseptic technique with dressing changes

A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? Oral Hydroxyurea Vitamin B12 injections Oral iron supplements Erythropoietin injections

Vitamin B12 injections