med surg study set
The nurse is caring for a client with a burn injury who is experiencing hypersecretion of gastric acid. The nurse should monitor for development of what complication?
gastrointestinal ulceration
A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, the nurse should suggest that the client ask the physician about which topic?
genetic counseling
An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching?
"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently."
A nurse working in a community clinic is discussing lifestyle modifications with a client. The client has been advised to lose weight because of a BMI greater than 25. Which statement by the nurse would be most therapeutic in helping the client?
"I can offer you some information outlining a variety of ways to lose weight."
A client newly diagnosed with hypothyroidism asks the nurse how long it will be necessary to take the prescribed levothyroxine sodium. What should the nurse tell the client?
"It will be necessary to take the medication for the rest of your life."
A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?
"My finger joints are oddly shaped."
A client with stage IV pancreatic cancer is admitted to hospice. The spouse breaks down crying, stating "I just don't know what I will do if my partner dies!" What is the best response by the nurse?
"What has helped you cope with the illness so far?"
A client is admitted to the facility with an exacerbation of chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't answered immediately. What is the nurse's most appropriate response?
"You seem angry. Would you like to talk about it?"
The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns?
"Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so the physician will be able to provide it if you can't tell him yourself."
A client is receiving radiation therapy. What should the nurse teach the client about skin care?
Avoid shaving with straight-edge razors.
A client with acute pyelonephritis receives a prescription for co-trimoxazole P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the ordered regimen?
Bacteria are absent on urine culture.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). Their blood pressure is 104/68 mm Hg. Their pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?
Contact the physician and report the findings.
A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention?
Control the pain and support breathing and oxygenation.
The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions?
Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.
A client is to have a below-the-knee amputation. Before the surgery, what should the circulating nurse in the operating room do?
Initiate a time-out.
The nurse is caring for a client who has been placed on phenobarbital 30 mg daily for newly diagnosed seizure activity. Which instruction would be included in client teaching specifically related to anticonvulsant drug efficacy?
Maintain a seizure frequency chart.
A client who had a splenectomy is being discharged. What should the nurse teach the client to do?
Report early signs of infection.
A client is recovering from transsphenoidal hypophysectomy. What should the nurse instruct the client to do to ensure oral hygiene?
Rinse the mouth with saline.
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Risk for injury related to neurologic deficit
A 29-year-old client is concerned about their personal risk factors for malignant melanoma. They are upset because their 49-year-old sibling was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse should tell the client which information?
Some melanomas have a familial component, and the client should seek medical advice.
A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. What should the nurse determine is the most likely cause of the client's constipation?
The client is experiencing an adverse effect of aluminum hydroxide.
The nurse is developing a discharge plan for a client who has lymphoma. What should the nurse emphasize to the client?
Use analgesics as needed.
The nurse is developing a plan of care for a client who has joint stiffness due to rheumatoid arthritis. Which measure will be the most effective in relieving stiffness?
a warm shower before performing activities of daily living
When starting the client's intravenous infusion line, the nurse applies a tourniquet and selects the site for inserting the needle. When should the nurse remove the tourniquet?
as soon as the needle is in the vein
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which is an indication that hepatic encephalopathy is developing?
decreased mental status
Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment?
free, easy movement of the joints
The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor?
gangrene
A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?
history of aortic valve replacement
A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for
pathologic bone fractures.
The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. What is the nurse's appropriate intervention when caring for the visitor?
protecting the visitor's head with a pad to prevent injury
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
scale
A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see?
serum potassium level of 6.8 mEq/L (6.8 mmol/L)
The nurse is discharging a client who had a fish hook embedded in their eye. The fish hook was removed surgically in the emergency department, but the client currently has no vision in that eye. The surgeon has informed the client that a corneal transplant may restore some vision but the surgery cannot be performed for 6 to 8 weeks and only if no infection occurs. What information should the nurse include in the discharge teaching plan?
washing hands carefully to keep the area clean and decrease risk for infection
A client is diagnosed with hypothyroidism. What additional information should the nurse obtain when conducting a focused assessment?
weight gain
