Med Surg I Exam 1 Practice Questions

B. Aspirate stomach contents and check pH

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first? A. Flush the NG tube with the ordered amount of water B. Aspirate stomach contents and check pH C. Check gastric residual D. Pour a premeasured amount of tube feeding formula into the nasogastric tube

C. Radiographic confirmation of position

A nurse has just inserted an NG tube in a client. Which method is most reliable for verifying the correct placement of the tub? A. Off-white fluid aspirated B. Green fluid with particles aspirated C. Radiographic confirmation of position D. Confirmation that pH of the aspirate is less than 5.5

B. Every 4-8 hours

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube? A. Nasogastric tubes should not be irrigated B. Every 4-8 hours C. Every 8-10 hours D. Every 1-2 hours

A. Cranberry juice

A nurse is caring for a client who has been prescribed a clear liquid diet. Which liquid can be included in the client's diet? A. Cranberry juice B. Tomato soup C. Low fat milk D. Orange juice

B. Press and rotate the swab several times over the wound surfaces C. Place the swab in the culture tube when done D. Insert a swab into the wound

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. A. Use the same swab for both wound sites B. Press and rotate the swab several times over the wound surfaces C. Place the swab in the culture tube when done D. Insert a swab into the wound E. Touch the swab to the intact skin at the wound edge F. Tap the outside of the culture tube with the swab before placing it in the tube

A. The client should use an electric razor

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy ot the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? A. The client should use an electric razor B. The client would like the spouse to assist with shaving C. The client prefers shaving gel over shaving cream D. The client likes to shave while in the shower

A. Help the client turn towards the opposite side of the bed and fan fold soiled linens as close to the client as possible B. Put on gloves before removing soiled linens F. Place a bath blanket over the client

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply. A. Help the client turn towards the opposite side of the bed and fan fold soiled linens as close to the client as possible B. Put on gloves before removing soiled linens C. Grasp the mattress and shift it down to the foot of the bed D. Place soiled linens on the floor E. Secure clean top linens under the head of the mattress F. Place a bath blanket over the client

C. Every 48-72 hours

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy? A. Every 12-24 hours B. Every 8-12 hours C. Every 48-72 hours D. Every 24-36 hours

C. Client who has a fractured rib

In which client would a back massage be contraindicated? A. Client who has diabetes mellitus B. Client who is ambulatory C. Client who has a fractured rib D. Client who is experiencing anxiety

A. Body fluid secretions C. Nonintact skin D. Mucous membranes E. Blood

Standard precautions apply to which items? Select all that apply. A. Body fluid secretions B. Sweat C. Nonintact skin D. Mucous membranes E. Blood F. Intact skin

D. The new nurse places the client in the left lateral recumbent position

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse? A. The new nurse interrupts the feeding every 4 hours and aspirates gastric contents B. The new nurse changes gloves before preparing the feeding bag C. The new nurse asks the client whether nausea or abdominal pain are present D. The new nurse places the client in the left lateral recumbent position

A. Notify the health care provider of the situation immediately B. Adjust the position of the arm so that it is higher than heart level D. Prepare for bivalving of the cast

The client with a full arm plaster cast reports pain unrelieved by the analgesic and a feeling of tightness in the arm. In addition, the fingers are cool, with sluggish capillary refill. What intervention(s) should the nurse implement? Select all that apply. A. Notify the health care provider of the situation immediately B. Adjust the position of the arm so that it is higher than heart level C. Administer PRN dose of pain medication and reassess after 30 minutes D. Prepare for bivalving of the cast E. Place ice pack on arm for 20 minutes

D. "Use the call bell for any needs and wear nonslip footwear."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching the client? A. "You will most likely stay in bed while you are hospitalized." B. "It is important to us that you remain free from injury." C. "Do not get up without assistance for any reason." D. "Use the call bell for any needs and wear nonslip footwear."

B. Dim the lights and speak softly about something the client enjoys

The nurse considers applying restraints to an agitated client. Which actions does the nurse take? A. Ensure the client cannot reach any objects in the room B. Dim the lights and speak softly about something the client enjoys C. Assess the client for existing injuries to the wrists and hands D. Call a family member to come and sit with the client

D. Assess the circulation to the client's fingers and hands

The nurse in a critical care unit is caring for a child who is restrained with elbow restraints during a procedure. Which intervention should take priority? A. Encourage the client to wear low heeled, rubber soled shoes B. Keep a call bell within easy reach of the client C. Assess respirations to help prevent asphyxiation D. Assess the circulation to the client's fingers and hands

C. The alternative measures attempted before applying the restraints

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? A. The type of PPE used by the nurse during restraint application B. A detailed description of the restraint application process C. The alternative measures attempted before applying the restraints D. A verbal prescription for the restraints, renewed every 48 hours

C. Pull the shoulder blade forward and out from under the client

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity? A. Assess for pain B. Place the call bell within reach C. Pull the shoulder blade forward and out from under the client D. Cover the client with bed linens

A. Increase the parent's social interaction D. Ensure the parent engages in regular exercise E. Provide frequent reorientation

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instructions(s) by the nurse? Select all that apply. A. Increase the parent's social interaction B. Ensure the parent to take naps frequently C. Ensure that the parent's routine changes frequently D. Ensure the parent engages in regular exercise E. Provide frequent reorientation

C. Remove restraints more frequently and perform range of motion (ROM)

The nurse is caring for a middle aged adult who has been prescribed elbow restraints. The nurse observes that when the restraints are removed, the client cries and reports pain in the elbow. What is the best action by the nurse> A. Eliminate the use of restraints B. Apply a padded dressing under the restraints C. Remove restraints more frequently and perform range of motion (ROM) D. Reassess the client and consider a different type of restraints

A. There is spilled water on the floor B. The IV is not infusing at the correct rate D. The skin is a bluish-color E. The client is wearing the oxygen around the neck

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. A. There is spilled water on the floor B. The IV is not infusing at the correct rate C. The client's television is turned off D. The skin is a bluish-color E. The client is wearing the oxygen around the neck

C. Support the client's body against the nurse and gently slide the client onto the floor E. Firmly grasp the client's gait belt

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial actions are appropriate? Select all that apply? A. Ask the client to lean against the wall while the nurse obtains a wheelchair B. Apply oxygen and wait several minutes for the weakness to pass C. Support the client's body against the nurse and gently slide the client onto the floor D. Ask the client, "When was the last time you ate?" E. Firmly grasp the client's gait belt

B. Sterile drape positioned with the moisture-proof side facing up

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? A. Sterile 4 x 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field B. Sterile drape positioned with the moisture-proof side facing up C. Sterile drape hanging off the work surface D. Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field

A. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning B. Use a toothbrush and paste to gentry brush all surfaces E. Provide privacy while the client removes dentures from the mouth

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply. A. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning B. Use a toothbrush and paste to gentry brush all surfaces C. Rinse the dentures with normal saline if the client is dehydrated D. Use a sterile 4 x 4 gauze to remove debris from the gums and mucous membranes E. Provide privacy while the client removes dentures from the mouth F. After cleaning, insert the lower denture followed by the upper denture

B. Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct? A. retract the foreskin while washing the penis; allow 10 to 15 minutes for the glans penis to dry, and then replace the foreskin in its original position B. Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place C. Avoid retraction of the foreskin because injury and scarring could occur D. Soak the end of the penis in warm water before cleaning the shaft of the penis

B. The NG tube is in the client's airway

The nurse is slowly advancing an NG tube when the client begins to gasp and is unable to vocalize. Which has likely occurred? A. The NG tube is curled in the back of the client's throat B. The NG tube is in the client's airway C. The client is forcefully resisting the procedure D. The client is experiencing a vasovagal reaction

A. Perform hand hygiene with alcohol-based hand rub

The nurse prepares for a sterile procedure. What action does the nurse perform first? A. Perform hand hygiene with alcohol-based hand rub B. Put on personal protective equipment, if required C. Place all necessary supplies in the room D. Identify the client the procedure is prescribed for

B. Touch the inside of the gown and pull it away from the torso

The nurse removes personal protective equipment after caring for a client on transmission based precautions. Which action by the nurse is correct? A. Remove the respirator at the doorway of the client's room B. Touch the inside of the gown and pull it away from the torso C. Slide one gloved hand under the other glove for removal D. Remove the goggles before removing other equipment

C. The client went to the emergency department to be evaluated after a fall

The nurse typically delegates a situational assessment to the UAP for the home care client with heart failure. Which finding causes the nurse to perform the assessment rather than delegate it? A. The manager wants the UAP to go through additional training on documentation B. The regulations of the Nurse Practitioner Act state this cannot be done C. The client went to the emergency department to be evaluated after a fall D. The UAP has a large work load and does not feel able to do the task

B. Apply moist saline compresses to loosen crusts before attempting to remove the staples

What action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them? A. Apply a warm compress to the surgical staples to allow the dried blood to melt B. Apply moist saline compresses to loosen crusts before attempting to remove the staples C. Notify the health care provider of the dried blood and wait for a prescription to proceed D. Go ahead and remove the staples as they will pop up and out of the skin