Med surg exam 1

An adult client is experiencing hospitalization for the first time. What are the appropriate actions by the nurse to help promote the safety of the client? Select all that apply. A. Maintain a clutter-free client environment B. Keep the client's area well lighted during the night C. Assure the side rails are in up position when client is in the bed D. Examine equipment carefully before using it for client care E. Reorient the client to surroundings whenever necessary 1 A, D, E 2 A, B, D, E 3 A, B, E 4 B, C, D, E

1

Mrs. R. has developed an abscess following abdominal surgery and her food intake has been decreasing over the past 2 weeks. Which of the following laboratory findings may suggest the need for nutritional support? 1 Low serum albumin levels 2 Low random blood glucose levels 3 Increased white blood cells 4 Proteinuria

1

What should the nurse do to prepare the unconscious patient for oral care? 1 Use small amounts of water and suction device 2 Place the patient in high Fowler's position 3 Place the patient in the supine position with the head lowered 4 Place the patient in the Fowler's position with the head turned to the side

1

A client is on a full liquid diet following gastric surgery. Which food brought to the client by a family member indicates to the nurse that dietary teaching is effective? 1 Homemade clam chowder with potatoes 2 Custard 3 Soft cake 4 Chopped vegetables

2

A female patient asks the nurse why she urinates more frequently as she is getting older. Which of the following is the nurse's best response? 1 "As you age, you have increased blood flow to your kidneys." 2 "Your bladder capacity decreases with age." 3 "The number of filtering units in your kidneys increase with age." 4 "It is your body's natural way of keeping the genital tract lubricated as you age."

2

An older adult patient enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the patient pulled out his IV line and is now attempting to climb over the bedrails. Which of the following phenomena most likely underlies this change in the patient's cognition? 1 Depression 2 Delirium 3 Dementia 4 Disorientation

2

A nurse is planning the client assignments for the shift. Which of the following clients would the nurse appropriately assign to the nursing assistant? 1 a client admitted with a stroke and needs assistance with feeding 2 a client requiring frequent ambulation with a walker 3 a client on a bowel management program requiring rectal suppositories 4 a client with atrial fibrillation requiring Coumadin teaching

2 Assignment of tasks needs to be implemented on the basis of the job description of the nursing assistant, the level of clinical competence, and state law.

A patient is admitted with a positive culture for methicillin resistant Staphylococcus aureus (MRSA). Which are components of contact precautions? 1 Wearing a mask when working within 3 feet of the patient. 2 Placing the client in a private room. 3 Wearing an N-95 respirator. 4 Placing the client in a negative pressure room.

2 Client should be placed in a private room or in a room with a client with the same organism.

A nurse is caring for a patient admitted with Hepatitis A. The patient is incontinent of stool. A patient care tech (PCT) is assisting the RN with patient care. The RN determines that the PCT understands correct infection prevention when the PCT is observed: 1 Wearing a mask when taking VS 2 Wearing a gown and gloves when changing the patient's incontinent briefs 3 Wearing gloves when providing perineal care 4 Wearing a gown and gloves when assisting the patient in filling out a menu for lunch

2 Hepatitis A is a virus which is present in feces for 2 weeks after symptoms appear. The virus can live for several months outside the body, there fore contact precautions are recommended when caring for clients who are incontinent of stool No need to wear a mask as the virus is not airborne. Wearing gloves for perineal care is correct but is not enough protection, gowns should be worn too. No need to wear PPE when filling out a menu.

A family member of an older adult client objects that restraints are being used to prevent the client from wandering in the evening. What should the nurse consider in order to avoid the use of restraints? 1 Providing visual and auditory stimuli 2 Using anti-anxiety medications as prescribed 3 Assigning client to a room near the nurse's station 4 Locking the door to the client's room

3

A student nurse is caring for a client with C diff infection. Which observation made by the faculty indicates that the student needs additional information about this disease? 1 Wearing gloves during a physical assessment 2 Entering the room without first putting on a mask 3 Performing frequent hand hygiene with an alcohol based hand disinfectant 4 Wearing a gown and gloves while providing perineal care

3 Alcohol based solutions are not as effective against C diff as is soap and water. Contact precautions are necessary Wearing a mask is not necessary

A nurse is caring for a patient who is unable to perform oral hygiene. The patient has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene? 1 Don sterile gloves before removing the dentures. 2 Use a foam swab to pry the upper dentures loose. 3 Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removing it. 4 Leave the dentures in the patient's mouth and use a toothbrush to brush the teeth.

3 Removing the denture plate is a clean procedure. Dentures must be removed to properly clean the patient's mouth and the dentures.

A male client is experiencing weakness and is unable to shave himself. When assisting this client with shaving, which of the following would be most important? 1 Ensuring that the face is dry 2 Keeping the skin loose 3 Shaving in the direction of hair growth 4 Angling the razor at 45 degrees

3 To avoid cuts, soften the beard with warm towels before shaving. Use soap lather or shaving cream, pull the skin taut, and shave in the direction in which the hair grows to decrease irritation.

A nurse is caring for a patient in restraints. The nurse knows that skin integrity should be assessed how often? 2 hours 3 hours 4 hours 30 minutes

4 CMS checks should be done every 30 minutes

Which of the following assessment findings of a 77 year old male patient should signal the nurse of a potentially pathologic finding rather than a normal age related change? 1 The patient's gait is slow and his posture appears stooped 2 The patient claims to her high pitched sounds less clearly than earlier in life 3 The patient states that his urine stream is less strong than in the past 4 The patient is oriented to person and place, but is unsure of the month

4 Rationale: Age-related physiological changes include a weakening of bladder emptying, presbycusis, and a slow gait that may be accompanied by a stooped posture. Disorientation to time, however, should always prompt the nurse to perform to further assessment and should never be considered a normal age-related change.

An acute medicine unit of a hospital currently has a number of patients who have tested positive for clostridium difficile (c-diff). Which of the following measure should the nursing staff prioritize in preventing the spread of c-diff to patients who are currently c-diff negative? 1 Reduce the length of stay for c-diff positive patients 2 Constant use of gloves when on the unit 3 Prophylactic antibiotic therapy for c-diff negative patients 4 Diligent hand washing practices

4 Rationale: As with all other forms of infection, thorough hand washing is the most important infection control measure. Gloves at all times would not be necessary and prophylactic antibiotics are not typically used.

In planning to meet the nutritional needs of a critically ill patient in the intensive care unit, which factor will increase the patient's basal metabolic rate? 1 Prolonged fasting 2 Long periods of sleep 3 Advanced age 4 Infection

4 Rationale: Factors that increase a patient's basal metabolic rate include growth, infection, fevers, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones (epinephrine and thyroid hormones). Aging, sleep and prolonged fasting all decrease BMR.

The nurse is giving report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. every 2 hrs 2. every 3 hrs 3. every 4 hrs 4. every 30 min

4. every 30 min (restraints should be checked every 30 min and removed every 2 hrs) NCLEX

To promote the safe use of a cane as an assistive device for a client who is recovering from a musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? A) hold the cane on the right side B) remove the rubber tip from the end of the cane C) adjust the height of the cane so the arm is straight D) place the cane 18 in in front of the feet before advancing.

A) hold the cane on the right side

The nurse has given a client instructions about crutch safety. Which client statement indicates that the client understands the instructions? *Select all that apply* A. "I should not use someone else's crutches." B. "I need to remove any scatter rugs at home." C. "I can use crutch tips even when they are wet." D. "I need to have spare crutches and tips available." E. "When I'm using the crutches my arms need to be completely straight."

A, B, D,

A nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. Which of the following actions should the nurse take? A. Keep the padded portion of the restraints against the wrists. B. Ensure enough room to fit one finger between the restraint and the wrist C. Attach the ties of the restraint to a non-movable part of the bed frame D. Use a knot that will tighten as the client moves

A.

1. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet? A. Peanut butter and jelly sandwich B. Baked potato topped with sour cream C. Bagel with cream cheese D. Fruit salad

A. Peanut butter and jelly sandwich

A nurse is providing hygiene care for a client who has right sided weakness. Which of the following actions is appropriate for the nurse to take? A. Place a clean gown on the client by dressing the weak arm first B. Wash the client from areas that are dirtiest to cleanest C. Shave the client's face in the opposite direction of hair growth D. Wash the client's extremities from proximal to distal

A. Place a clean gown on the client by dressing the weak arm first Response Feedback: When providing hygiene care, you bath clean to dirty and distal to proximal. You would shave with the direction of hair growth. You would dress the client starting with the weakest extremity.

The nurse has prepared a sterile field using a pre-packaged kit. Which would be important for the nurse to keep in mind? A. The field is contaminated if it is out of the nurse's site. B. The items contained in the kit are considered clean. C. No other sterile items can be added to the sterile field at this point. D. Sterile gloves are not needed to obtain any items from the field.

A. The field is contaminated if it is out of the nurse's site. Feedback: The sterile field is considered contaminated if the nurse turns their back on the field.

A nurse is caring for a client who has recently undergone a stem cell transplant. Which of the following should the nurse recognize as appropriate isolation precaution guidelines? A ) the client should be placed in a negative airflow room. B) the client is not permitted to have fresh flowers or potted plants. C) the client may be placed in a semi private room with another stem cell transplant client. D) the client is protected by visitors who wear gloves prior to entering the room.

B) the client is not permitted to have fresh flowers or potted plants.

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond? A. "It is comforting to have moist oral mucosa during this time." B. "Mouth care during this time helps prevent complications such as pneumonia." C. "Without swallowing, bacteria get trapped in the mouth." D. "Dental care is still important, even when not chewing."

B. "Mouth care during this time helps prevent complications such as pneumonia." Response Feedback: Mouth care helps to prevent complications such as infection

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following should the nurse include in the discussion? A. Personality changes are common in older adults B. Decreased gastrointestinal motility C.Decreased systolic blood pressure D. Increased cough reflex

B. Decreased gastrointestinal motility

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first? A. Place a transfer belt on the client B. Determine if the client can bear weight C. Assist the client in a seated position D. Position the bed at an appropriate height

B. Determine if the client can bear weight Response Feedback: The first thing the nurse should do is determine the patient's mobility status. The other responses may be appropriate depending on the mobility status.

A practitioner orders a clear liquid diet for a patient. Which food should the nurse teach the patient to avoid when following this diet? A. Strawberry gelatin B. Ice cream C. Decaffeinated tea D. Coffee

B. Ice cream

A nurse is assessing an older adult who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the clients spine. The nurse should expect the provider to document which of the following disorders? A. Scoliosis B. Kyphosis C. Lordosis D. Ankylosis

B. Kyphosis

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray? A. Gloves B. Gown C. Mask D. Goggles

C. Mask Feedback: Droplet precautions require the use of a mask for all patient care activities.

The nurse wraps the sleeves of a pneumatic compression device around the legs of a client. How would the nurse determine if the fit is correct? A. One finger should fit between the leg and the sleeve. B. Three fingers should fit between the leg and the sleeve. C. Two fingers should fit between the leg and the sleeve. D. The nurse's fist should fit between the leg and the sleeve.

C. Two fingers should fit between the leg and the sleeve. Response Feedback: Two finger widths should be used when sizing pneumatic compression devices

A nurse is assessing a client who has right sided weakness and impaired mobility. Which of the following findings would the nurse recognize as a consequence of immobility? A. Bradycardia B. Diarrhea C. Polyuria D. Crackles in the Lungs

D. Crackles in the Lungs

A nurse is applying wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse taking when using restraints? A. Secure the restraints to the side rails. B. Remove the restraint to check integrity of the skin every 4 hr. C. Tie the restraint using a double knot. D. Ensure that 2 fingerwidth of space is between the client's wrists and the restraint.

D. Ensure that 2 fingerwidth of space is between the client's wrists and the restraint. Response Feedback: Restraints should have 2 fingerwidths between the wrist and restraint

A nurse is teaching a client with diabetes how to care for his feet. The nurse determines that additional teaching is needed when the client states which of the following? 1 "I need to soak them frequently in water." 2 "I should use warm water and a mild soap to clean them." 3 "I can apply lotion to the tops, but not between the toes." 4 "I need to inspect my feet every day."

1 Patients with diabetes require special attention to foot care. They have decreased sensation in the feet, placing them at great risk for injury from burns or foreign objects. The feet should be inspected daily, cleaned thoroughly with warm water and a mild soap, and carefully dried, especially between the toes. The feet should not be soaked in water because soaking will dry skin, which may lead to cracking. Lotion or cream can be applied to the tops and bottoms of the feet, but not between the toes.

A nurse is providing care for a patient who has been newly admitted to a long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the patient? 1 The patient's ability to assist 2 The patient's body weight 3 The patient's age 4 The patient's cognitive status

1 Rationale: The nurse assesses several parameters when choosing whether to use a mechanized assistive device for a patient transfer. The most important consideration, however, is the patient's ability to assist with his or her transfer.

A nurse is admitting a patient to a geriatric medicine unit following the patient's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the patient's chance of experiencing a fall while on the unit? 1 Provide the patient with a bedpan to reduce the need to transfer to a commode or bathroom 2 Orient the patient to the room and environment thoroughly upon admission 3 Place the patient in a shared room with a patient who is stable and oriented 4 Administer pain medications sparingly in order to minimize cognitive or musculoskeletal side effects

2 Rationale: A person who is familiar with his or her surroundings is less likely to experience an accidental injury. As part of the hospital admission routine, it is important to orient the patient to safety features and equipment in the room. A bedpan should not be used for the sole reason of reducing the risk of falls, and pain medication should be provided in doses sufficient to treat the patient's pain. A patient should never be charged with supervising the safety of another patient.

A hospitalized patient has anti-embolic hose ordered. A nurse discusses the correct use of the stockings with the patient and spouse. Which direction should the nurse include in teaching? 1 If ambulating 10 times for 5 minutes at a time, wearing stockings is unnecessary. 2 The most appropriate time to apply the stockings is before standing to get out of bed in the morning. 3 If the stockings become painful to wear, increase use of pain medication. 4 You can cross your legs while sitting if you are wearing the stockings.

2 This will maximize the compression effects and thus lessening the venous distension and development of edema. Frequent ambulation is a positive intervention to prevent DVT formation but should be done in conjunction with anti-embolic stockings. Stockings should be removed twice a day to inspect the skin. Crossing legs impede blood flow and should be avoided with or without the use of stockings.

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client's skin

2. Safely securing the safety device straps to the side rails -safety device straps are secured to the bed frame and never to the side rails to avoid injury if the side rails are released NCLEX

A nurse is providing passive ROM to a patient's left lower extremity when he encounters resistance in the ankle. What should the nurse do first? 1 Assess the ankle for swelling 2 Continue slow ROM activity to gently increase mobility 3 Document findings in patient's chart 4 Stop movement to prevent injury

4

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 300 mL 0.9% sodium chloride IV, one 6 oz cup of coffee, 6 oz of water, and 3 oz of flavored gelatin. The client's output included 450 mL of urine and 30 mL of drainage from a bulb drain. How many mL should the nurse document as the client's total intake for the shift? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ENTER ONLY THE NUMBER (NOT THE ML).

750

The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint? A. The patient refuses to call for help to go to the bathroom B. The patient continues to remove the nasogastric tube C. The patient gets confused regarding the time at night D. The patient does not sleep and continues to ask for items

B. The patient continues to remove the nasogastric tube. Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria.Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching? A. "Dementia is characterized by a sudden onset of confusion." B. "Dementia can be triggered by a high fever or dehydration." C."The signs of dementia are progressive and irreversible." D. "An altered level of consciousness is associated with dementia."

C. "The signs of dementia are progressive and irreversible." Feedback: Dementia is progressive and irreversible. The other responses are characteristic of delirium.

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait? A. A client who is able to bear full weight on both lower extremities B. A client who has bilateral leg braces due to paralysis of the lower extremities C. A client who has a right femur fracture with no weight bearing on the affected leg D. A client who has bilateral knee replacements with partial weight-bearing on both legs

C. A client who has a right femur fracture with no weight bearing on the affected leg Response Feedback: Three point gait is used for patients with a non-weight bearing status.

When the client who has been diagnosed with influenza has been hospitalized, the type of isolation the nursing staff should observe is: A. Contact precautions B. Standard precautions C. Droplet precautions D. Protective precautions

C. Droplet precautions Feedback: Influenza requires the use of droplet precautions.

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) a. Check the patient's peripheral pulse in the restrained extremity b. Evaluate the patient's need for toileting c. Offer the patient fluids if appropriate d. Release both limbs at the same time to perform range of motion (ROM) e. Inspect the skin under each restraint

a. Check the patient's peripheral pulse in the restrained extremity b. Evaluate the patient's need for toileting c. Offer the patient fluids if appropriate e. Inspect the skin under each restraint Fundamentals ch 27

A nurse is caring for a client following a total hip arthroplasty. The client is confused, moving his leg into positions that could dislocate the new hip joint, and he repeatedly attempts to get out of bed. After determining that restraint application is indicated, which of the following actions should the nurse take? (Select all that apply) a. secure the restraint to the frame of the bed b. get a prescription for restraints from the provider c. have a family member sign the consent for restraints d. use a square knot to secure the restraints to the bed e. ensure that only 1 finger can be inserted between the restraint and the client

a. secure the restraint to the frame of the bed b. get a prescription for restraints from the provider c. have a family member sign the consent for restraints -secure restraints to an immovable part of the bed -quick-release knot must be used to secure the restraint -the distance between the restraint and pt should be 2 finger widths ATI Leadership and Management

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? a. Fasten the ties on the restraint to the side rails of the bed b. Tie the restraint with a quick-release knot c. Allow one finger's breadth between the restraint and the client's chest d. Place the restraint under the client's clothing

b. Tie the restraint with a quick-release knot ATI

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. What is the correct order for applying a wrist restraint? a. Be sure that patient is comfortable with arm in anatomic alignment. b. Wrap wrist with soft part of restraint toward skin and secure snugly. c. Identify patient using two identifiers. d. Introduce self and ask patient about his feelings of being restrained. e. Assess condition of skin where restraint will be placed.

c, d, a, e, b 1. c. Identify patient using two identifiers. 2. d. Introduce self and ask patient about his feelings of being restrained. 3. a. Be sure that patient is comfortable with arm in anatomic alignment. 4. e. Assess condition of skin where restraint will be placed. 5. b. Wrap wrist with soft part of restraint toward skin and secure snugly. Fundamentals ch 27

A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching? a. "Look down at your feet before moving the crutches." b. "Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot." c. "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches." d. "Support your body weight on the underarm crutch pads."

c. "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches." The nurse should instruct the client to use this method of crutch walking for a three-point gait. The nurse should instruct the client who is using four-point gait to bear weight on opposing feet and crutches. The nurse should instruct the client to maintain his head and neck erect. The client should look forward when walking with crutches to help prevent falls and an uneven gait. The nurse should instruct the client to avoid placing weight from the axilla on the crutch pads to decrease the risk of neurovascular damage.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? a. Creatine kinase b. Troponin c. Total bilirubin d. Albumin

d. Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition. Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition. Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.

a nurse is caring for a client who cannot bear weight on his fracture ankle. which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking? 1. when i get out of a chair, ill hold both crutches on the side next to my weak leg 2. when i sit down ill transfer my weight to my crutches and my strong leg 3. when i go up stairs, ill alternate putting weight on my crutches and my strong leg 4. when i go down stirs ill start by moving both my crutches to the step below

when i get out of a chair ill hold both crutches on the side next to my weak leg