Medsurg II final

A nurse is providing teaching to a client who has a new prescription for tamoxifen to treat breast cancer. The nurse should include that which of the following is an adverse effect of this medication?

Hot flashes

A nurse is assessing a client who has thyrotoxicosis after taking high dosage of levothyroxine. Which of the following manifestation should the nurse expect?

Hyperthermia

which statement made by a client with chronic kidney disease and who is on hemodialysis indicated the need for further teaching?

I take my prescribed antihypertensive drugs daily

The nurse performs discharge teaching for a client with a thoracic spinal cord injury (T2) from a construction accident. Which client statement indicates teaching about autonomic dysreflexia is successful?

I will perform self-catheterization at least six times per day

The client with Cirrhosis is being taught self-care. Which statement indicated the client needs more teaching?

If I notice a fast heart rate or irregular beats, this is normal for cirrhosis

When planning care for a client with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority?

Ineffective airway clearance related to cervical spinal cord injury

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Auscultate the client's lungs

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?

"This infection is treated with one dose of azithromycin."

A nurse is caring for a client with diabetes insipidus and is receiving desmopressin (DDAVP), the nurse should identify which of the following findings as an indication that the medication is effective?

A decrease urine output

A rehabilitation nurse is caring for a client with a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which action should the nurse take?

Establish a plan of care with the client that sets attainable goals

The nurse is caring for a client admitted to the hospital with a diagnosis of sickle cell crisis and reports a severe headache with pain of 9/10. Which actions should the nurse take first?

Administer Morphine 2 mg IV push for pain.

A client is admitted to the hospital with acute cholecystitis. A client has been vomiting and in pain. What will be the most appropriate for this client?

Administer Morphine IVP as ordered

A nurse is preparing to administer a dose of laculose to a client who has liver cirrhosis. The client states, " I don't need this medication. I am not constipated". The nurse should explain that lactulose is used to decrease levels of which of the following components in the blood stream?

Ammonia

A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary?

An excess amount of doxorubicin can lead to cardiomyopathy

A nurse is assessing a client with a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function?

Apply downward pressure while the client shrugs his shoulders upward

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following?

Apply hydrating lotion

A client with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is the most appropriate?

Assess bowel movements for frequency, consistency, and volume

A client is admitted to the ICU after sustaining a knife wound to the back. Assessment findings include motor weakness and altered sensation in the upper extremities and dysesthesic burning pain in upper extremities. Vital signs are stable and he is alert and oriented. No other injuries are noted. Based on the preceding information, which type of incomplete spinal cord injury syndrome is likely to be developing?

Central cord syndrome

The nurse is caring for a client with spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mmHg. What should the nurse do first?

Check the client's bladder for distention

A nurse is planning care for a client who has liver cirrhosis and ascites. Which of the following interventions should the nurse of care?

Decrease the clients fluid intake

A nurse is planning care for a client with a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the clients plan of care?

Encourage fluid intake up to 8-10 glasses unless contraindicated

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the clients plan of care?

Fresh flowered and potted plants in the room

A client diagnosed with myxedema coma has changes in intellectual function, such as impaired memory, decreased attention span, and lethargy. The client's husband, who is upset, shares his concerns with nurse. Which statements by the nurse would be helpful to the client's husband?

It's obvious that you are concerned about your wife's condition, but the symptoms may improve with continued therapy.

A nurse is planning care for a client with liver cirrhosis. Which of the following actions should the nurse include in the plan?

Measure the client's abdominal girth, implement a low-sodium diet, Administer furosemide

The nurse is admitting a client following spinal cord injury. The nurse concludes that the client has developed Brown-Sequard syndrome after detecting which assessment finding in the client?

Motor loss on either right or left side of the body and sensory loss on either right or left side of the body

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned what administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication?

Nonmaleficence

A nurse admits a client to the intensive care unit due to neurogenic shock following a C4 spinal cord injury. The nurse anticipates the following prescriptions from the health care provider.

O2 Therapy

A nurse in a clinic is caring for a female client who was exposed to gonorrhea. which of the following actions should the nurse take?

Obtain information about the patient's recent sexual experiences

A client with sickle cell anemia is experiencing a vaso-occlusive crisis. Which of the following interventions are appropriate to this clinic?

Pain medication first

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Pantoprazole 80 mg IV bolus twice daily

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestation should the nurse expect?

Petechiae

When a client is on diuretic phase of acute kidney injury, the nurse must monitor which serum electrolyte imbalances?

Potassium= 3meq/L ; Sodium = 130 meq/L

A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodine (SSKI) or Lygols solution is prescribed preoperatively for the client. What is the expected outcome of this drug?

Reduce the vascularity of the thyroid gland

A client brain surgery, ABG was done and revealed that his pH 7.61, PaCO2 22mmHg and HCO3 15 mEq/L. What is the ABG interpretation based on the finding?

Respiratory alkalosis, Uncompensated

When planning care for a client a client diagnosed with myxedema coma, which complication of this disease most commonly result in death?

Respiratory failure

. A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever". Which response by the nurse conveys the best understanding of the client's behavior?

Reviewing your losses is a way to help you work through your grief and loss.

After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching?

Roasted chicken breast, baked potato with chives, and orange juice

A charge nurse is supervising a newly licensed nurse caring for a client who has sickle cell anemia. The client is receiving a blood transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new licensed nurse requires intervention by the charge nurse?

The nurse collects a urine specimen

A nurse is instructing the family of a client receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

The purpose of this device is to immobilize the cervical spine

Which teaching approach for the client with chronic kidney disease who has difficulty concentrating due to high uremia levels would be most appropriate?

Validate the clients understanding of the material frequently

A nurse is caring for a client who has liver cirrhosis and prothrombin time of 30 seconds. Which of the following Medicaiton should the nurse plan to administer?

Vitamin K

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?

WBC 2300/mm3

A nurse is assessing a client post craniotomy who developed a syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestation should the nurse anticipate?

Weight gain

The nurse is admitting a client diagnosed with acute kidney injury. Which question is most important for the nurse to ask during the admission interview?

What over the counter medication do you take regularly?

A client with breast cancer who is receiving radiation therapy. Her hemoglobin level is 12 g/dL, hematocrit level is 40% and platelet count of 120,000/uL. Based on the laboratory results, the priority nursing goal is to prevent?

injury related to decreased platelet count

. A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps)

o Ask the client about having a history of abdominal pain o Inspect the abdomen for skin integrity o Auscultate the abdomen for bowel sounds o Percuss the abdomen in each of the four quadrants o Palpate the abdomen lightly for tenderness

A nurse is planning to perform a blood transfusion for a client with sickle cell anemia. Which of the following actions should the nurse plan to take? (SATA)

o Insert an IV with a 18 gauge needle o Check the expiration date of the blood product with a second nurse o Check vital signs before a transfusion

A client with cirrhosis has increased abdominal girth from ascites. Which items identify the pathophysiology related to ascites (SATA)?

o Portal hypertension causes leaking of protein and water into the peritoneal cavity o Aldosterone is released to stabilize intravascular volume by saving salt and water o Inability of the liver to synthesize albumin reducing intravascular oncotic pressure

The nurse is interviewing a client with newly diagnosed syphilis. In order to prevent the spread of the disease, the nurse should focus the interview by:

obtaining a list of the client's sexual contacts.

A nurse is reviewing the arterial blood gas values of a client who has liver cirrhosis and who had episodes of vomiting. Which of the following sets of values should the nurse expect?

pH 7.25, HCO3 19, PaCO2 30

A client has asthma and his ABG results showed that the pH 7.35, PaCO2 72mmHg and HCO3 38 mEq/L. what is the acid-base disorder of the client?

· Respiratory Acidosis, Fully Compensated

A client develops syndrome of inappropriate anti-diuretic (SIADH) secondary to a traumatic brain injury. The client reports thirst, weight gain and fatigue. Lab testing reveals a serum sodium level of 127 mEq/L. which action should the nurse implement when caring for this client ?

· Restrict fluid intake to 800-1000 mL/day