Med Surg Final Review

37. A nurse cares for a client with right sided heart failure. The client ask why do i need to weigh myself everyday. How would the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all clients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

"Weight is the best indication that you are gaining or losing fluid."

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have your spouse watch you for irritability and anxiety. "b. "Notify the clinic if you notice muscle twitching. "c. "Call your primary health care provider for diarrhea. "d. "Bake or grill your meat rather than frying it."

"c. "Call your primary health care provider for diarrhea.

46. A nurse is caring for a client notes for the following assessment. WBC 3800, blood glucose level 198, and temp 96.2. What action by the nurse takes priority? a. Document the findings in chart b. Give the client warmed blankets c. Notify the provider immediately d. Prepare to administer insulin per scale

c. Notify the provider immediately

30. A nurse administers prescribed adenosine to a client. Which response would the nurse assess for as the expected response? a. Decreased IOP b. Increased HR c. Short period of asystole d. Hypertensive crisis

c. Short period of asystole

19. A client has been taking isoniazid for TB for three weeks. What lab results need to be reported to the primary HCP immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/μL (5.2 x10^12/L) d. White blood cell (WBC) count: 12,500/mm3 (12.5 x 109/L)

Alanine aminotransferase ( ALT) 180U/L

47. A client is receiving norepinephrine from shock. What assessment findings best indicate a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denies chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

Alert and oriented and answering questions

54. An older adult is on cardiac monitoring after myocardial infarction. The client shows frequent dysrhythmias. What is action by the nurse most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the primary health care provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

Asses for any hemodynamic effects of the rhythm

35. A nurse cares for a client who is on a cardiac monitor. The monitor displaces the rhythm displayed below: What action would the nurse take first? a. Assess airway, breathing, and circulation. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

Assess airway breathing and circulation (Ventricular tachycardia)

36. While assessing a client on a cardiac unit. A nurse identifies the presence of an S3 gallop, what action would the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the primary health care provider immediately. d. Transfer the client to the intensive care unit.

Assess for symptoms of left sided heart failure

71. The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include? a. "Use the drug before every meal to prevent aspiration." b. "Increase your intake of citrus foods to help with healing." c. "Use the drug only at bedtime because you won't be eating." "Be sure to check food temperatures before eating."

Check food temp before eating

34. Nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks why do you want to know if I used cocaine? What is the nurse 's best response? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

Clients who use cocaine are at risk for fatal dysrhythmias

61. A nurse cares for a client who possibly has a SIADH. The client serum sodium level is 114. What nursing action would be appropriate? a. Consult with the dietitian about increased dietary sodium. b. Restrict the client's fluid intake to 600 mL/day. c. Handle the client gently by using turn sheets for repositioning. d. Instruct assistive personnel to measure intake and output.

Restrict the fluid to 600ml/day

6. A nurse assess a client who is prescribed furosemide for hypertension. For which acid base imbalance does the nurse assess to prevent complication of this therapy. a. Respiratory acidosis B. respiratory alkalosis C. metabolic acidosis D. metabolic alkalosis

D. metabolic alkalosis

40. A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this clients teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

Do not take this med within 1 hr of taking an antacid

17. A nurse cares for a client with COPD who appears thin and disheveled. which question would the nurse ask first? a "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

Do you experience shortness of breath with basic activities

18. A client has been diagnosed with TB. what action by the nurse takes the highest priority: a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

Educating the client on adherence to the treatment regimen

31. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client? a. Make sure that the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 J. d. Ensure that everyone is clear of contact with the client and the bed.

Ensure everyone is clear of contact with the client in the bed

15. The nurse cares for a client with COPD, the client stated that going out with friends is no longer enjoyable. How will the nurse respond? a. "There are a variety of support groups for people who have COPD." b. "I will ask your primary health care provider to prescribe an antianxiety agent." c. "I'd like to hear about thoughts and feelings causing you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."

I'd like to hear about thoughts and feeling causing you to limit social activities

70. The nurse assesses a client with DKA. which assessment finding would the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

Increase rate and depth of respirations

The nurse assess a client with diabetes mellitus who is admitted with acid base balance ph 7.36 PACO2- 33 bicarb (HCO3) 18 Which sign or symptom does the nurse identify as an example of the clients compensatory mechanism? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys

Increased rate and depth of respirations

39. After administering the first dose of Captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption b. Instruct the client to ask for assistance when rising from bed c. Collab with AP to bathe client d. Monitor potassium

Instruct the client to ask for assistance when rising from bed

69. A nurse teaches a client who is diagnosed with DM. which statement would the nurse include in the clients plan of care to dietary the onset of microvascular and macro-vascular complications? "a. Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2 L a day." c. "Prevent hypoglycemia by eating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis."

Maintain tight glycemic and prevent hyperglycemia

21. 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? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

Measure and compare cuff pressure

56. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the primary health care provider immediately. c. Reposition the chest tube. d. Take the tubing apart to assess for clots.

Notify Health Care provider

65. A nurse assess a client who is recovering from a subtotal thyroidectomy and observes the development of stridor. What is response for the nurse to take? a. Apply oxygen via nasal cannula at 2 L/min. b. Document the finding and assess the client hourly. c. Place the client in high-Fowler position in the bed. d. Contact the Rapid Response Team and prepare for intubation.

Rapid response

32. A nurse cares for a client with atrial fibrillation who reports fatigue when completing ADL. what intervention would the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 L per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask assistive personnel (AP) to help bathe the client.

Schedule period of exercise and rest during the day

58. Nurse prepares a lenient for coronary artery bypass surgery. The client states I'm afraid I might die. What is the nurse's best response? a. "This is a routine surgery and the risk of death is very low." b. "Would you like to speak with a chaplain prior to surgery?" c. "Tell me more about your concerns about the surgery." d. "What support systems do you have to assist you?"

Tell me more about concerns of the surgery

14. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the patient correctly understands the teaching? a. The client lies on his or her side with knees bent. b. The client places his or her hands on the abdomen. c. The client lies in a prone position with straight. d. The client places his or her hands above the head.

The client places his hands on the abdomen

16. A nurse is caring for a client who has cystic fibrosis (CF). the client ask for information about gene therapy. What response by the nurse is best? a. "Unfortunately, gene therapy is only provided to children upon diagnosis." b. "Do you know that you will have to have genetic testing?" c. "There is a good treatment for the most common genetic defect in CF." d. "Gene therapy will only help improve your pulmonary symptoms."

There is good treatment for the most common genetic deficit in CF

11. A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. how will the nurse respond? a. "I will consult the speech therapist to ensure you are swallowing properly." b. "This is normal after surgery. What types of food do you like to eat?" c. "I will ask the dietitian to change the consistency of the food in your diet." d. "Replacement of protein, calories, and water is very important after surgery."

This is normal after surgery what types of food do you like to eat

67. While assess a client with graves disease. The nurse notes that the client temperature has risen to 1 F. what does the nurse do first? a. Turn the lights down and shut the patient's door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the client's apical-radial pulse deficit. d. Administer a dose of acetaminophen.

Turn the light down and shut the door

8. A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse: a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

Tying a knot at the back of the neck

45. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208mg/dl (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

a. "High glucose is common in shock and needs to be treated."

20. A nurse provides pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What client would be considered a priority when administering the pneumonia vaccination? a. A 22-year-old client with asthma b. Client who had a cholecystectomy last year c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

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

9. A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

a. Absorptive atelectasis b. Combustion c. Dried mucous membranes e. Toxicity

28. .A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. e. Stay with the client and speak in a quiet, calm voice.

27. A client has been diagnosed with a very large Pulmonary Embolism and has a dropping BP, what medication would the nurse be most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium

a. Alteplase

50. Nurse studying shock understand that common signs and symptoms of this condition are directly related to which problems? a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Inc systematic perfusion

a. Anaerobic metabolism c. Hypotension

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3- 22 mEq/L. Which intervention should the nurse implement first? a. Assess the airway b. Administer prescribed bronchodilators. c. Provide oxygen. d. Administer prescribed mucolytics.

a. Assess the airway

10. A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next? a. Assess the client for obstructive sleep apnea b. Arrange a home sleep apnea test c. Encourage the client to begin exercising d. Schedule a polysomnography

a. Assess the client for obstructive sleep apnea

38. A nurse is teaching a client with heart failure who has been prescribed Enalapril, which statement would the nurse include in this clients teaching a. Avoid using salt subs b. Take your med w. Food c. Avoid using aspirin containing products d. Check your pulse daily

a. Avoid using salt subs

52. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What is a response by the faculty member best? a. Continue to educate the client on possible healthy changes b. Emphasize complications that can occur with noncompliance c. Tell the client that denial is normal and will go away

a. Continue to educate the client on possible healthy changes

57. Client is to receive dopamine infusion. What does a nurse do to prepare for infusion? a. Gather central line supplies b. Mark the pt pedal pulses c. Monitor vital signs d. Ensure an accurate wt is charted

a. Gather central line supplies

60. The nurse is caring for a client who has acromegaly. What physical change would the nurse expect? a. Large hands and face b. Thin, dry skin c. Short height d. Truncal obesity

a. Large hands and face

33. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Midsternal chest pain b. Inc urine output c. Mild orthostatic hypertension d. P wave touching the T wave

a. Mid-sternal chest pain

64. A nurse assesses a client with Cushing disease. Which assessment findings would the nurse expect? a. Moon face b. Weight loss c. Hypotension d. Petechaie e. Muscle atrophy

a. Moon face d. Petechaie e. Muscle atrophy

22. A nurse assess a client who is 6 hours post surgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? 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. e. Administer a nasal steroid to decrease edema. Change the nasal packing.

a. Observe for clear drainage b. asses the pt 4 signs of bleeding c. Watch for frequent swallowing d. ask client to open his or her mouth

43. A nurse assesses a client with left-sided heart failure. For which clinical manifestations would the nurse assess? a. Pulmonary crackles b. Confusion c. Pulmonary hypertension d. Dep edema e. Cough that worsens at night f. JVD

a. Pulmonary crackles b. Confusion e. Cough that worsens at night

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

b. "I will weigh myself each morning before I eat or drink."

68. A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?" How would the nurse respond? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

b. "Your brain needs a constant supply of glucose because it cannot store it."

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position

b. Assess client further for fall risk.

44. A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 and the pulse rate increased from 86 to 98 since the client was last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain med b. Assess using the MEWS score c. Document the findings in chart d. Increase the rate of patient IV infusion

b. Assess using the MEWS score

53. A client has hemodynamic monitoring after a MI. what safety precaution does the nurse implement for this client? a. Document the PAOP readings and asses their trend b. Ensure the balloon does not remain wedged c. Keep the client NPO d. Maintain the client in a semi-fowler position

b. Ensure the balloon does not remain wedged

42. A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down. b. Friction rub at the left lower sternal border. c. Presence of a regular gallop rhythm. d. Coarse crackles in bilateral lung bases.

b. Friction rub at the left lower sternal border

26. A client with ARDS, receives a minimal amount of fluid. A new nurse notes the client is scheduled to receive diuretic at this time. The nurse consults the staff development nurse to determine the best course of action. What will the new nurse do? a. Contact the primary provider b. Give the ordered diuretic as scheduled c. Request an inc in IV rate d. Calculate the client 24 hr fluid balance

b. Give the ordered diuretic as scheduled

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretic

b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretic

49. A nurse is caring for several clients at risk for shock. Which lab value requires the nurse to communicate with the primary HCP? Lactate: 5.4mg/dL a. Creatinine 0.9 b. Lactate 5.4 c. Na: 150 d. WBC 11,000

b. Lactate 5.4

63. A nurse teaches a client with Cushing's disease. Which dietary requirements would the nurse include in the clients' health teaching? a. Low calcium b. Low carb c. Low protein d. Low calories e. Low sodium

b. Low carb d. Low calories e. Low sodium

29. A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition: a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea w/ activity

b. Speech alterations

55. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."

b. The best source is fish, but pills have benefits too

51. A client received a tissue plasminogen activatoir. after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs the this medication. What response by the nurse is best? a. The t-PA didn't dissolve the entire coronary clot b. The heparin keeps that artery from getting blocked again c. Heparin keeps the blood as thin as possible for a longer time d. The heparin prevents a stroke from occurring as the t-PA wears off

b. The heparin keeps that artery from getting blocked again

13. After teaching a client who is prescribed a long acting beta 2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching? a. I will carry this medication with me at all times in case i need i b. I will take this medication when i start to experience an asthma attack c. I will take the med every morning to prevent an acute asthma attack

c. I will take the med every morning to prevent an acute asthma attack

25. An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority: a. Determine if the tube is kinked b. Ensure that all the connections are patent c. Listen to the clients lung sounds d. Suction the endotracheal tube

c. Listen to the clients lung sounds

23. A client is admitted with Pulmonary Embolism. the client is young healthy and active and has no known risk factors for PE. what action by the nurse is most appropriate? a. Encourage the client to walk 5 min each hr b. Refer the client to smoking cessation classes c. Teach the client about factor V leiden testing d. Tell the client that sometimes no cause for disease is found

c. Teach the client about factor V leiden testing

24. A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What is a response by the nurse best? a. Breathing so rapidly interferes w. Oxygenation b. Maybe the client has respiratory distress syndrome c. The blood clot interferes with perfusion in the lungs d. The client needs intubation

c. The blood clot interferes with perfusion in the lungs

59. A nurse plans care for a client with a growth hormone deficiency. Which action would the nurse include in this clients plan of care? a. Avoid intramuscular medications. b. Place the client in protective isolation c. Use a lift sheet to reposition the patient. d. Assist the client to dangle before rising

c. Use lift sheet to reposition patient

66. A nurse assess a client on the med surg unit. Which statement made by the client alerts the nurse to assess the patient for hypothyroidism. a. "My sister has thyroid problems." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "I am always tired, even with 12 hours of sleep."

d. "I am always tired, even with 12 hours of sleep."

12. A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first? a. Assess the clients pain level b. Keep the client head elevated c. Teach the client about the causes of nasal bleeding d. Assess airway

d. Assess airway

48. A nurse on the general med Surg unit is caring for a client in shock and assess the following: RR: 10, Pulse 136, BP 92/78. LOC: responds to voice, TEMP: 101.5, urine output for the last 2 hours: 40ml/hr. What action by the nurse is best? a. Transfer the client to ICU b. Continue monitoring every 30 mins c. Notify charge nurse d. Call rapid response team

d. Call rapid response team

62. A client is being treated with DI with a synthetic vasopressin. What is the priority health teaching that the nurse provides regarding drug therapy? a. The need to check the client's urinary specific gravity. b. The need to take blood pressure at least twice a day. c. The need to monitor blood glucose every day. d. The need to weigh every day and report weight gain.

d. The need to weigh every day and report weight gain.

41. A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the clients stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

dyspnea upon exertion