Med/Surg - Funds Proctor

A nurse if teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll wear nonsterile gloves." B. "I'll use adhesive remover each time." C. "I'll take my pain pill after I change the dressing." D. "I'll fold the dressing with the soiled surface facing outward."

A. "I'll wear nonsterile gloves." Rationale: Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes.

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain med. Which of the following actions should the nurse take first? A. Ask why the client is refusing the pain med B. Administer a PRN antianxiety med C. Help the client change positions D. Offer the client a heat or cold pack to place on painful areas

A. Ask why the client is refusing the pain med Rationale: Using the nursing process, the nurse should first assess the reason for the client's refusal of the opioid pain med.

A nurse is using the I-SBAR comm tool to give a client's provider info about the client. The nurse should convey this client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation

A. Assessment The nurse provides info about assessment findings in this portion of the report, including VS, pain assessment, and changes in assessment findings.

A nurse enters the room of an older adult client and finds him attempting to crawl over the side rail of his bed. Which of the following actions should the nurse take? A. Tell the client that he will be put in restraints if he attempts to get out of bed again. B. Ask an AP to sit with the client. C. Remind the client to stay in bed. D. Restrain the client immediately to prevent self harm.

B. Ask an AP to sit with the client. Rationale: This client is at risk of falling. Having an AP sit with the client protects him from harm. Then, the nurse can contact the provider to discuss care options for this client (e.g. restraints or placing an audible alarm).

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Cap refill of <2 sec

B. Faint pedal pulses Rationale: Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity. A 3+ Achilles reflex does not indicate a risk of impaired skin integrity. Reflex testing provides info about the sensory & motor fxns of the neuro system; this indicates a more active reflex than expected. Feet that are warm to the touch bilaterally do not indicate a risk of impaired skin integrity; this indicates the adequacy of the client's peripheral circulation. A cap refill of <2 sec does not indicate a risk of impaired skin integrity; this provides info about the adequacy of tissue perfusion.

A CN is observing a newly licensed nurse perform trach care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for trach care B. Obtaining cotton balls for trach care C. Obtaining sterile gloves for trach care D. Obtaining a sterile brush for trach care

B. Obtaining cotton balls for trach care Rationale: Cotton ball particles can be aspirated into the trach opening, possibly causing a tracheal abscess. The CN should intervene for this action.

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium? A. Gradual memory loss B. Reduced level of consciousness C. Difficulty with abstract thought D. Verbalized feelings of hopelessness

B. Reduced level of consciousness Rationale: When a client has delirium, the nurse should expect a reduced LOC, sudden memory impairment, illogical thinking, and sleep disturbances.

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a med error report. B. Notify the prescribing provider. C. Assess the client. D. Notify the CN.

C. Assess the client. Rationale: The greatest risk to the client's safety is adverse effects from either receiving the wrong med or not receiving the prescribed med. The nurse should assess the client first for any possible adverse effects. This assessment also serves as a baseline for further monitoring for adverse effects.

A nurse in a provider's office is assessing a client who has heart failure. The client has gained wt since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulse

D. Bounding pulse Rationale: This is an expected finding of fluid volume excess. Sunken eyeballs, hypotension, and poor skin turgor are clinical manifestations of fluid volume deficit.

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should ID that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document

D. Durable power of attorney document Rationale: A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.

A nurse is planning care for a client who had a stroke. Which of the following goals should the nurse ID as the priority for this client? A. The client's skin will remain intact during hospitalization. B. The client will verbalize one new word each week. C. The client will begin to help turn himself in bed, indicating improved mobility. D. The client's airway will remain clear, as evidenced by clear breath sounds.

D. The client's airway will remain clear, as evidenced by clear breath sounds. Rationale: The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human fxning: having an open airway, being able to breathe inadequate amts of O2, & circulating O2 to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is the nurse's priority concern.

A nurse is reviewing the lab data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

B. Sodium 150 mEq/L Rationale: A sodium level of 150 mEq/L is > the expected reference range of 135 to 145 mEq/L. The client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider. Calcium expected reference range = 9 to 10.5 mg/dL Potassium expected reference range = 3.5 to 5 mEq/L Magnesium expected reference range = 1.3 to 2.1 mEq/L

A nurse in the emergency dept. is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? A. Inform the guard that the warden must request this information B. Ask the guard to sign a release of information form C. Instruct the guard to ask the inmate D. Complete an incident report

C. Instruct the guard to ask the inmate Rationale: The nurse is not able to supply this information to the guard. In order for the guard to obtain this info, the client must offer the info freely. Therefore, the nurse should instruct the guard to ask the client for this information.

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? A. The deceased was a close friend. B. The client lived far from the deceased. C. The death was sudden. D. The client has not visited the deceased in a long time.

C. The death was sudden. Rationale: Complicated grief can occur when the death of a loved one is sudden and unexpected. The other answers would only be a risk factor for complicated grief if the grieving individual has had multiple recent losses, had unresolved issues with the deceased, or is influenced by another compounding factor.

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, ranitidine 50 mg in 50 mL at 1000 & 1600, 250 mL of blood over 2 hr, and a NG flush of 30 mL q2h. What is the total intake in mL that the nurse should document for this client for this 12-hr period?

2130 mL 125 mL x 12 hr = 1500 mL + 100 mL + (50 mL x 2 = 100 mL) + 250 mL + (30 mL x 6 = 180 mL) = 2130 mL

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? A. Assessment B. Plan of care C. Nursing interventions performed D. Eval of progress

A. Assessment Rationale: When caring for a client, the nurse should apply the nursing process priority-setting framework. The nursing process is used to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision.

A newly licensed nurse is preparing to administer meds to a client. The nurse notes that the provider has prescribed a med that is unfamiliar to him. Which of the following actions should the nurse take? A. Consult the med reference book available on the unit B. Ask a more experienced nurse for info about the med C. Call the client's provider and verify the prescription D. Ask the client if she takes this med at home

A. Consult the med reference book available on the unit Rationale: A nurse must have knowledge about meds to administer them safely. The nurse should become familiar with the med by looking it up in the med reference on the unit.

A nurse is caring for a client who is postop following abd surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

A. Cover the incision with a moist sterile dressing Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to ID which risk poses the greatest threat to the client. An open wound increases the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate d/c planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. On the day prior to d/c

A. During the admission process Rationale: The nurse should intiate d/c planning as soon as the client is admitted to the facility. This is intended to ensure the continuity of care and meet the client's care needs. The process should include each member of the client's health care team.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in Trendelenburg position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain

A. Place the client in Trendelenburg position Rationale: The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe. The nurse should perform percussions over single layer of clothing. The nurse should use a cupped hand to provide percussions. Chest percussions should not cause pain when the procedure us performed correctly.

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia

A. Sanguineous Rationale: This type of drainage contains large amts of RBCs, indicating that damaged capillaries are allowing the escape of RBCs from the plasma. Purulent drainage is exudate that is thicker than other drainages, indicating the presence of pus (consists of leukocytes, liquefied dead tissue debris, and dead & living bacteria). Serous drainage is mostly serum (the clear portion of blood appears watery & contains few cells). Hyperemia is a red coloration of the skin in clients who have light skin or as a blue coloration of the skin in clients who have dark skin (not a type of drainage).

A nurse is planning to administer pain med to a client following abd surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain med with the client C. Obtain the client's vital signs D. Check the client's allergies

A. Use the pain scale to determine the client's pain level Rationale: The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority. The levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations.

A nurse is caring for a client who has a C. diff infection and is in contact iso. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown. B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest.

A. Wear gloves when changing the client's gown. Rationale: The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client in contact iso. The nurse should use soap and water to cleanse the hands. Alcohol-based hand sani is ineffective against the spores of C. diff. The nurse should wear a mask when working within 3 ft of a client who has an infection, and droplet precautions are req. The nurse should not place the client on complete bed rest because this places him at risk for the hazards of immobility, such as impaired skin integrity and retained respiratory secretions. The nurse should instruct the client to remain in his room but to move, cough, and deep breathe at least q2h.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amt of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."

C. "Keep a diary of the foods your child eats each day." Rationale: The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack.

An adolescent client in an outpt mental health facility tells the nurse that he struggles to follow his tx plans because his friends discourage him. Which of the following statements should the nurse make? A. "Don't worry; teens often have friends who give bad advice." B. "I think you should stop seeing those friends since they discourage you from following your tx plan." C. "Tell me more about how your friends discourage you." D. "Where did you meet these friends?"

C. "Tell me more about how your friends discourage you." Rationale: The nurse should ask an open-ended question that encourages the client to elaborate on these problems.

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? A. "Wake up every 2 hr to urinate during the night." B. "Drink citrus juices throughout the day." C. "Try to block the urge to urinate until the next scheduled time." D. "Limit fluids to no more than 1L (34 oz) during waking hours."

C. "Try to block the urge to urinate until the next scheduled time." Rationale: When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, she should try slow, deep breathing to help reduce the urge. She can also try 5 or 6 strong and quick pelvic muscle exercises. The client should wake up q4h to urinate during the night; for most clients, this occurs just once during sleeping hrs. Citrus juices can irritate the bladder, increasing the likelihood of incontinence episodes. The client should reduce her fluid intake during the 4 hours before bedtime; however, she should drink plenty of fluids during the rest of her waking hours and avoid drinking large amts all at once.

A charge nurse is teaching adult CPR to a group of newly licensed nurses. Which of the following actions should the CN teach as the first response in CPR? A. Call for assistance. B. Begin chest compressions. C. Confirm responsiveness. D. Give rescue breaths.

C. Confirm unresponsiveness. Rationale: The nurse should apply the nursing process priority-setting framework to plan client care & prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

A nurse is planning care for a YA client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? A. Death is unacceptable under any circumstances. B. Magical thinking helps avoid thoughts of death. C. Death is viewed as an interruption of what might have been. D. Death is a natural consequence of a deteriorating body.

C. Death is viewed as an interruption of what might have been. Rationale: YAs tend to see a whole life ahead if them, so death is often seen as interrupting that life. YAs do not typically welcome death at this time. Adolescents tend to reject the end of life, especially their own. Preschoolers tend to avoid thoughts of death by employing magical thinking. Accepting the deterioration of the body is more likely among older adults, some of whom might consider death a relief from chronic or terminal illness.

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client? A. Make eye contact with the interpreter. B. Break sentences into shorter segments to allow time for interpretation. C. Ensure the interpreter and the client speak the same dialect. D. Speak in a loud tone of voice.

C. Ensure the interpreter and the client speak the same dialect. Rationale: To encourage effective communication and promote client understanding, the nurse should first ensure this. To enhance the nurse-client relationship, the nurse should direct info, instructions, and questions to the client, not to the interpreter. The nurse should make every effort to speak in short sentences but should not break sentences into fragments. The nurse should speak slowly and distinctly and avoid the use of metaphors that might be challenging to translate; the nurse should speak clearly, not loudly.

The nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

C. Remove the IV catheter Rationale: The client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site. These manifestations do not suggest that the infusion tubing is punctured, contaminated, occluded, or expired. Flushing the IV could worsen the complication. Warm, moist heat is part of the tx protocol for the complication (not cool).

A nurse is preparing to instill a vaginal med in suppository form to a client. Which of the following actions should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall

C. Use the index finger to insert the suppository Rationale: To ensure adequate distribution of the vaginal med, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible. The nurse should wear clean gloves for this procedure, not sterile gloves. The nurse should use the nondom hand to retract the labia and the dom hand to insert the suppository. The nurse should ease the suppository along the posterior vaginal wall.

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device to remove air after emptying

D. Collapse the device to remove air after emptying Rationale: The nurse should collapse the device to remove air after emptying the contents periodically. This will create enough suction to pull fluid exudate into the collection area of the device. The nurse should keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage; this is not made for irrigating. The nurse should cleanse the drain opening with an alcohol wipe after opening it to decrease the entry of m-o's. The nurse should maintain the drainage tubing below the level of the incision to enhance drainage.