Med- surgery

A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important?

Obtain pulse oximetry reading.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action would the nurse take?

Request a prescription for permethrin

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem?

· Increase in ventilator rate from 6 to 10 breaths/min

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate?

· Increase the heparin rate

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic action?

· Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system.

The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial rounding? (metabolic acidosis)

· Client with Kussmaul respirations

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next?

· Collect the nasal drainage on a piece of filter paper.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first?

· Contact the primary health care provider and prepare for intubation.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the chest tube is dislodged. Which action by the nurse is best?

· Cover the insertion site with sterile gauze.

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 nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect?

· Fatigue and shortness of breath

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

· Friction rub at the left lower sternal border

After teaching a client who was malnourished and is being discharged, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood teaching to decrease risk for the development of metabolic acidosis?

· I will eat three well-balanced meals and a snack daily."

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching?

"Avoid using salt substitutes."

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan?

Calculate pulse pressure with each blood pressure reading. Assess for pitting edema in dependent body areas. Monitor trends in the client's daily weights. Assist the client to change positions frequently. Teach client and family how to read food labels for sodium.

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching?

Call your primary health care provider for diarrhea."

The nurse is caring for a client with facial fractures following a fall. Which assessment finding requires immediate nursing intervention?

Clear glucose+ fluid draining from nares

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?

Client has reduced breath sounds—nurse calls primary health care provider immediately.

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first?

Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately?

Continuous bubbling in the water-seal chamber

A nurse is field- triaging clients after an industrial accident. Which client condition would the nurse triage a red tag?

· Multiple fractured ribs and shortness of breath

The nurse is providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal continuous positive airway pressure ventilation. Which assessment finding is most important to report to the health care provider?

· Tracheal deviation to the right

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first?

· Transfer the client to a negative-pressure room.

While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action will the nurse take next?

· Use pulse oximetry to assess the patient's oxygen saturation.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure?

· Validate that informed consent has been given by the client.

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (

· Verify that the informed consent was obtained. · Review laboratory results. · Monitor the client for at least 24 hours afterwards · Document the client's allergies

Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing health care provider before administration?

· Warfarin 1.0 mg PO

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time

· Assess the client for hypoglycemia and hypoxia.

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. What action would the nurse take first?

Administer an epinephrine autoinjector and call 911.

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis?

· A 68-year-old client with chronic emphysema

A nurse is triaging clients in the emergency department. Which client would be considered urgent?

· A 75-year-old female with a cough and a temperature of 102° F (38.9° C)

The nurse is caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes priority?

· A deviated trachea

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?

· Assess the client's gag reflex before giving any food or water.

A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement?

· Administer oxygen via a nonrebreather mask.

A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will:

Administer the IV antibiotic as scheduled in a second IV access site.

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

· Airway patency

A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately?

Alanine aminotransference (ALT) 180 U/L

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure?

· Allergies to iodine-based agents

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 client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial?

· Alteplase

An older client takes ibuprofen 1600 mg daily for osteoarthritis. Which health teaching will the nurse provide for the client related to this medication? Select all that apply.

"Be sure and take your medication with food to prevent stomach ulcers." "Avoid any over-the-counter medications that may contain ibuprofen." "Take your blood pressure often because ibuprofen can cause it to go up." "Ask your physician about acetaminophen because it has fewer side effects than ibuprofen."

The nurse is caring for a male dying client in hospice who becomes very agitated, trying to get out of bed. What of the following is the nurse's best response?

. Assess the client for urinary retention.

A patient is ordered to receive 2 units of packed red blood cells. The first unit was started at 1400 and ended at 1800. You send for the other bag of red blood cells. As the nurse you know it is priority to:

. obtain a new y-tubing set for this unit of blood

Your patient needs 1 unit of packed red blood cells. You've completed all the prep and the blood bank notifies you the patient's unit of blood is ready. You send for the blood and the transporter arrives with the unit at 1200. You know that you must start transfusing the blood within _________.

30 minutes

A patient who needs a unit of packed red blood cells is ordered by the physician to be premeditated with oral diphenhydramine and acetaminophen. You will administer these medications?

30 minutes before starting the transfusion

Which client will the emergency nurse triage as the priority?

59-year-old with sweating, jaw pain, and pain in the left arm

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? (Hypervolemic shock clinical manifestation)

A 34 year old who is NPO and receiving rapid intravenous D5W infusions.

As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which patient below it is at most RISK for a febrile (non-hemolytic) transfusion reaction?

A 38 year old male who has received multiple blood transfusions in the past year.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next?

· Assess the color and temperature of the left leg.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the nurse correlate with these results? (metabolic acidosis)

· Anxiety-induced hyperventilation

Which assessment finding calls for the most immediate action by the nurse?

· Bluish color around the lips and earlobes

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

· Assess for other signs of hypoxia.

The RN is supervising a student nurse caring for a patient with hypertension. The health care provider prescribed enalapril 2.5 mg orally twice a day. The student tells the nurse that the patient has swelling around the eyes and lips. What does the nurse tell the student is the first best action?

Assess the patient's ability to speak and breathe.

Your patient is having a transfusion reaction. You immediately stop the transfusion. Next you will:

Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%.

A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will the nurse advocate for first?

Gabapentin

A patient with O+ blood received A+ blood. The patient is at risk for?

Hemolytic transfusion reaction

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find?

Increased pulse rate Distended neck veins Skeletal muscle weakness Visual disturbances

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?

Instruct the client to ask for assistance when rising from bed

Pt whit Acetaminophen (Tylenol) overdose, Antidote

N-acetylcysteine (NAC):

Before initiating the blood transfusion, you obtain the patient's baseline vital signs, which are: heart rate 100, blood pressure 115/72, respiratory rate 18, and temperature 100.8'F. Your next action is to:

Notify the physician before starting the transfusion.

A client at the urgent care reports being stung, but not seeing the stinging insect. The electronic health record indicates a history of allergies to bee stings. What is the appropriate nursing action?

Priority: Prepare to administer epinephrine IM, oral diphenhydramine, and oxygen. Them: Remove the stinger

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

Standard Precautions

Before a blood transfusion you educate the patient to immediately report which of the following signs and symptoms during the blood transfusion that could represent a transfusion reaction:

Sweating, Chills, Hives, Headache, Back pain, Pruritus, Shortness of Breath, Nausea

A patient rates their pain at a 2 or 3 on a pain rating scale on a calibrated 0-to-10. How does the nurse interpret this finding?

The patient has mild pain

What blood type is known as the "universal recipient"?

Type AB

What blood type is known as the "universal donor"?

Type O

During a home visit to an 88-year-old client who is taking digoxin0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most important to communicate to the health care provider? (sings of digoxin toxicity)

Vision that is becoming "fuzzy"

The nurse recognizes that a client with sleep apnea may benefit from which intervention(s)? (Select all that apply.)

Weight loss Nasal mask to deliver BiPAP A change in sleeping position Position-fixing device that prevents tongue subluxation

You're gathering supplies to start a blood transfusion. You will gather?

Y-tubing with in-line and 0.9% Normal Saline

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury development?

· A 65 year old with hemiparesis and incontinence

Before starting a blood transfusion the nurse will perform a verification process with __________. This will include?

licensed personnel only (another RN); physician's order, patient's identification, blood bank's information, patient's blood type and donor's type along with Rh factor, expiration date, assess the bag of blood for damage or abnormal substances

Which documentation indicates that the nurse properly evaluated a pain medication's effectiveness after administration? The client...

reports decrease in pain.

What key instruction must the nurse give to the unlicensed assistive personnel (UAP) who is assisting with morning care for an older patient prescribed apixaban, 2.5 mg orally twice a day, for chronic atrial fibrillation?

· "Be sure to tell me if you notice any bleeding from the gums when the patient brushes his or her teeth."

A nurse has educated a client on isoniazid. What statement by the client indicates that the teaching has been effective?

· "I will take this medication on an empty stomach

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?

· A 45 year old reporting chest pain and diaphoresis

The nurse has just received a change-of-shift report about these clients on the coronary step down unit. Which one will the nurse assess first?

· A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change

A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation?

· A 50-year-old who is post coronary artery bypass graft surgery.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client would the nurse assess first?

· A 52 year old in a tripod position using accessory muscles to breathe

A nurse assesses clients on the medical-surgical 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 on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease?

· A 65 y/o woman whit diabetes mellitus

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema Which physiologic process would the nurse correlate with this client's history and clinical signs and symptoms?

· Increased pulmonary pressure creating a higher workload on the right side of the heart

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms? (metabolic acidosis)

· Increased rate and depth of respirations

A client in the emergency department is taking rifampin for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)

· International normalized ratio (INR): 6.3 · Prothrombin time: 35 seconds

A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment?

· Keep padded clamps at the bedside for use if the drainage system is interrupted.

The nurse is caring for a client who experiences frequent generalized tonic- clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance?

· Metabolic acidosis

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?

· Neurologic status

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.)

· New-onset cough · Tachypnea · Rapid, shallow respirations

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage stops suddenly. What action by the nurse is most important?

· Notify the primary health care provider immediately.

A nurse plans care for a client who is bedridden. Which assessment would the nurse complete to ensure to prevent pressure injury formation?

· Nutritional intake and serum albumin levels

A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.)

· Observe for clear drainage. · Assess for signs of bleeding. · Watch the client for frequent swallowing. · Ask the client to open his or her mouth

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags

· Partial-thickness burns covering both legs · Neck injury and numbness of both legs · Small pieces of shrapnel embedded in both eyes · Bruising and pain in the right lower abdomen

The nurse is making a room assignment for a newly arrived patient whose laboratory test results indicate pancytopenia. Which patient will be the best roommate for the new patient?

· Patient with digoxin toxicity

A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce this risk, what activity would the nurse delegate to the assistive personnel (AP)?

· Provide oral care every 4 hours.

A nurse is assessing a female client who is taking hormone therapy for breast cancer. What assessment finding requires the nurse to notify the primary health care provider immediately?

· Red, warm, swollen calf

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately?

· Respiratory rate of 8 breaths/min

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?

· Sit the client up with a pillow to lean forward on.

A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition?

· Speech alterations

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)?

· The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min.

The health care provider (HCP) prescribes permethrin application for all family members of a client who has scabies. Which client information will be most important for the nurse to discuss with the HCP before client teaching about the medication?

· The client has a newborn infant.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

· The trachea is shifted toward the opposite side of the neck.