Med Surg Final

The nurse assesses an older client. What age-related physiologic changes would the nurse expect?

dehydration

A pt with multiple sclerosis is discharged from rehabilitation. What would the nurse include in the discharge teaching?

"Avoid overexertion, stress, and extreme temperature if possible."

A nurse is teaching a pt who has cystic fibrosis (CF). Which statement would the nurse include in this pts teaching?

"Eat a well-balanced, nutritious diet."

An ER nurse obtains the health history of a pt. What statement would alert the nurse to the occurrence of heart failure?

"I get short of breath when I climb stairs."

A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information?

"I will shower daily using a super-fatted soap."

A client asks what "essential hypertension" is. What response by the registered nurse is best?

"It is hypertension with no specific cause."

a pt admitted to the cardiac unit. What statement by the pt alerts the nurse to of it being right-sided heart failure?

"My shoes fit really tight lately."

a pt is in skeletal traction. The pt asks, "What is the purpose of this type of traction?" How would the nurse respond?

"Skeletal traction will assist in realigning your fractured bone."

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.)

-First-degree relative with prostate cancer -Advanced age -Eating too much red meat -Race

How curable is prostate cancer?

100%

What is the normal urine output?

30 mL/hr

Which client does the nurse recognize has the highest risk for development of prostate cancer?

75-year-old African American whose father and brother developed prostate cancer

A nurse assesses pts on the med-surg unit. Which client is at greatest risk for development of obstructive sleep apnea?

A 55-year-old woman who is 50 lb (23 kg) overweight.

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?

A 58-year-old American Indian

How does acromegaly present?

Acromegaly is the excess production of growth hormone from a growth hormone secreting adenoma in the pituitary. 1) It presents with enlargement of the head (hat size), fingers (ring size), feet (shoe size), nose, and jaw. 2) In addition, there is intense sweating from enlargement of the sweat glands.

nurse is assessing pts for their risk of kidney disease. What racial/ethnic group is at the greatest risk as they age?

African Americans

A pt has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

Airway

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

Airway patency

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

Ask about medications the client is currently taking.

A nurse is caring for an older pt who exhibits dehydration-induced confusion. Which intervention by the nurse is best?

Assess client further for fall risk

The family of a neutropenic pt reports that the client "is not acting right." What action by the nurse is the priority?

Assess the client for infection

pt has been informed of a positive HIV test. The pt is upset and does not know what to do. What is best for nurse to do?

Assess the client for support systems.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?

Assess the client's lung sounds every 2 hours.

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?

Assess the client's respiratory status.

A nurse is caring for a pt who has a nonhealing pressure injury on the rt ankle. What action would the nurse take first?

Assess the right leg for pulses, skin color, and temperature.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?

Assessing the IV site and blood return every hour

A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Assessing vaccination records for booster shot needs

When a patient has obstructive jaundice what causes itching?

Bile salts

A nurse is caring for four clients. Which one would the nurse see first?

Client who had a first dose of captopril and needs to use the bathroom.

A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first?

Client who has had cataract surgery and has worsening vision

A nurse is caring for four clients. Which client would the nurse assess first?

Client who is 1 hour post angioplasty, has tongue swelling and anxiety

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first?

Client with a red, hot, swollen right wrist

The (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

Client with a respiratory rate of 6 breaths/min

nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?

Consult with the wound care nurse.

client who has facial trauma, the nurse auscultates stridor. pt is anxious and restless. What would the nurse do Ist?

Contact the primary health care provider and prepare for intubation.

A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for HIV on an annual basis? (Select all that apply.)

Couples planning on getting married Those who are sexually active with multiple partners Injection drugs users Sex workers and their customers

a pt who is diagnosed with diabetes insipidus (DI). what common complication will the nurse monitor?

Dehydration

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?

Determine if the client can switch to a nasal cannula during the meal.

A nurse assesses a client who presents with renal calculi. Which question would the nurse ask?

Do any of your family members have this problem?

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

A pt is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is priority concern for pt?

Electrolyte and fluid imbalance

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

Ensure informed consent is on the chart

A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description?

Suspected deep tissue injury: nonblanchable deep purple or maroon

pt has polycystic kidney disease (PKD). Which assessment finding would alert the nurse to immediately contact the Dr?

Periorbital edema

A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find?

Friction rub at the left lower sternal border

The nurse is caring for an older pt who has kyphosis and a widened gait. For which health problems is the pt at risk?

Falls

pt and has pale conjunctivae the nurse finds on assessment. Which focused assessment will the nurse complete next?

Hemoglobin and hematocrit

The nurse plans care for pt with Parkinson disease. What would the nurse include in this client's plan of care?

Keep the head of the bed at 30 degrees or greater.

During an interview pt tells the nurse that they has a duodenal ulcer. Which assessment finding would the nurse expect?

Melena

pt is given lasix for hypertension. For which acid-base imbalance does the nurse assess to prevent complications?

Metabolic alkalosis

A nurse cares for a pt with a recently fractured tibia. Which assessment would alert the nurse to take immediate action?

Numbness in the extremity

The nurse is caring for a client who just had a laparoscopic total abdominal hysterectomy. Which assessment finding requires immediate nursing intervention?

One saturated perineal pad per hour

A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority?

Participating in hand-off report

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important?

Perform hand hygiene

A client has a bone density score of -2.8. What intervention would the nurse anticipate based on this assessment?

Planning to teach about bisphosphonates

A pt has an open traditional hiatal hernia repair this morning. What is the nurse's priority for pt care at this time?

Preventing respiratory complications

The nurse caring for pts with gastrointestinal disorders would recall that omeprazole is a drug in which classification?

Proton pump inhibitor

The nurse learns that the most important function of inflammation and immunity is which purpose?

Providing maximum protection against infection

A nurse assesses a pt after administering a prescribed beta blocker. Which assessment would the nurse expect to find?

Pulse decreased from 100 to 80 beats/min.

What is the marker for appendicitis?

Right lower quadrant pain

When assessing a dark skinned pt for pallor, where do you assess?

Root of mouth

After a hysterectomy, what should be monitored?

Saturation of pad and incision site

Which teaching point is most important for the client with a peritonsillar abscess?

Take all antibiotics as directed.

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action would the nurse take?

Teach the client fall prevention measures.

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

Tying a square knot at the back of the neck

A client has external otitis. About what comfort measure would the nurse instruct the client?

Use of a heating pad to the ear

a nurse notes a bluish tinge to the pts palms, soles, and mucous membranes. Which action will the nurse take next?

Use pulse oximetry to assess the patient's oxygen saturation

A nurse learns that which of the following is the single biggest risk factor for developing cancer?

advancing age

The nurse caring for oncology clients knows that which form of metastasis is the most common?

bloodborne

The nurse is caring for a client who has chronic pyelonephritis. What assessment finding would the nurse expect?

hypertension

What is pursed lip breathing?

involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client?

left lateral

The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect?

pain

What is an aura?

precedes a migraine and is usually a visual disturbance

nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use?

standard precautions

The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura?

visual disturbances