Med Surg Exam 4
A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority A Assess the client's neurologic status. B Notify the Rapid Response Team. C Prepare to administer vitamin K. D Turn down the infusion rate.
B
A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer A Carbamazepine (Tegretol) B Dexmedetomidine (Precedex) C Diazepam (Valium) D Mannitol (Osmitrol
B
A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client A Impending brain herniation B Poor prognosis and cognitive function C Probable complete recovery D Unable to tell from this information
B
A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care A "I know I can take care of all these needs by myself." B "I need to seek counseling because I am very angry." C "Hopefully things will improve gradually over time." D "With respite care and support, I think I can do this."
A
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best A Ask the client how long ago the clip was placed. B Have the client sign an informed consent form. C Inform the provider about the aneurysm clip. D Reschedule the client for computed tomography.
A
A client has a subarachnoid bolt. What action by the nurse is most important A Balancing and recalibrating the device B Documenting intracranial pressure readings C Handling the fiberoptic cable with care to avoid breakage D Monitoring the client's phlebostatic axis
A
A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities A "I can use a heating pad on my legs if it's set on low." B "I should not cross my legs when sitting or lying down." C "I will go out and buy some warm, heavy socks to wear." D "It's going to be really hard but I will stop smoking."
A
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding A Difficulty with proprioception B Peripheral motor disorder C Impaired cerebellar function D Positive pronator drift
A
A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client A "You may return to your previous activity level immediately." B "You are radioactive and must use a private bathroom." C "Frequent assessments of the injection site will be completed." D "We will be monitoring your renal functions closely."
A
A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment A "Tell the client where food items are on the breakfast tray." B "Place the client in a high-Fowler's position for all meals." C "Make sure the client's food is visually appetizing." D"Assist the client by placing the fork in the left hand."
A
A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best A "No, women should only have one beer a day as a general rule." B "No, you should not drink any alcohol with hypertension." C "Yes, since you are larger, you can have more alcohol." D "Yes, two beers per day is an acceptable amount of alcohol."
A
A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best A Ask if the client eats grapefruit. B Assess the client for dehydration. C Facilitate admission to the hospital. D Obtain a random urinalysis.
A
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider A Shingles on the client's back B Client is claustrophobic C Absence of intravenous access D Paroxysmal nocturnal dyspnea
A
After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care A Ambulate only with a gait belt. B Encourage double swallowing. C Monitor lung sounds after eating. D Perform post-void residuals.
A
The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider A Furosemide (Lasix)/potassium: 2.1 mEq/L B Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L C Spironolactone (Aldactone)/potassium: 5.1 mEq/L D Torsemide (Demadex)/sodium: 142 mEq/L
A
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention (Select all that apply.) A Apply compression stockings. B Assist with ambulation. C Encourage coughing and deep breathing. D Offer fluids frequently. E Teach leg exercises.
A B D
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching (Select all that apply.) A Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches B Client with an aneurysm clip who states that his family is happy there is no chance of recurrence C Client who had a coil procedure who says that there will be no problem following up for 1 year D Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation E Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
A B
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure (Select all that apply.) A Ensure that an informed consent is present. B Ask the client about any allergies. C Evaluate the client's renal function. D Auscultate bilateral breath sounds. E Assess hematocrit and hemoglobin levels.
A B C
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization (Select all that apply.) A Assess for allergies to iodine. B Administer intravenous fluids. C Assess blood urea nitrogen (BUN) and creatinine results. D Insert a Foley catheter. E Administer a prophylactic antibiotic. F Insert a central venous catheter.
A B C
A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best (Select all that apply.) A Ask the client to describe his or her current emotions. B Assess the client for support systems and family. C Offer to stay with the client if he or she desires. D Relate how smoking contributed to this situation. E Tell the client that many people have amputations
A B C
A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care (Select all that apply.) A Assess tube placement per agency policy. B Keep the head of the bed elevated at least 30 degrees. C Listen to lung sounds at least every 4 hours. D Run continuous feedings on a feeding pump. E Use blue dye to determine proper placement
A B C D
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP) (Select all that apply.) A Applying a cool washcloth to the head B Assisting the client to a position of comfort C Keeping voices soft and soothing D Maintaining low lighting in the room E Providing antipyretics for fever
A B C D
A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this client's care (Select all that apply.) A "Plan to bathe the client in the evening when the client is most alert." B "Encourage the client to use a cane when ambulating." C "Assess the client for symptoms related to pain and discomfort." D "Remind the client to look at foot placement when walking." E "Schedule additional time for teaching about prescribed therapies."
A B D
A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care (Select all that apply.) A Assess the client for bleeding. B Monitor the daily activated partial thromboplastin time (aPTT) results. C Stop the IV for aPTT above baseline. D Use an IV pump for the infusion. E Weigh the client daily on the same scale.
A B D
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge (Select all that apply.) A Client who exhibits extreme emotional lability B Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 C Client with mild forgetfulness and a slight limp D Client who has a past hospitalization for a suicide attempt E Client who is unable to walk or eat 3 weeks post-stroke
A B D E
A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider (Select all that apply.) A Glasgow Coma Scale score of 8 B Decerebrate posturing C Reactive pupils D Uninhibited speech E Diminished cognition
A B E
A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population (Select all that apply.) A Admission can overwhelm the coping mechanisms for older clients. B Alcohol is typically involved in most traumatic brain injuries for this age group. C These clients are more susceptible to systemic and wound infections. D Other medical conditions can complicate treatment for these clients. E Very few traumatic brain injuries occur in this age group.
A C D
A nursing student studying the neurologic system learns which information (Select all that apply.) A An aneurysm is a ballooning in a weakened part of an arterial wall. B An arteriovenous malformation is the usual cause of strokes. C Intracerebral hemorrhage is bleeding directly into the brain. D Reduced perfusion from vasospasm often makes stroke worse. E Subarachnoid hemorrhage is caused by high blood pressure.
A C D
An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess (Select all that apply.) A Memory loss B Personality changes C Difficulty with sound interpretation D Speech difficulties E Impaired taste
A C D
A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide (Select all that apply.) A Dietary restrictions B Driving restrictions C Follow-up laboratory monitoring D Possible drug-drug interactions E Reason to take medication
A C D E
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess (Select all that apply.) A Alcohol intake B Diabetes C High-fat diet D Obesity E Smoking
A C D E
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess (Select all that apply.) A Thrombophlebitis B Stroke C Pulmonary embolism D Myocardial infarction E Cardiac tamponade
A C E
A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis (Select all that apply.) A Total cholesterol: 280 mg/dL B High-density lipoprotein cholesterol: 50 mg/dL C Triglycerides: 200 mg/dL D Serum albumin: 4 g/dL E Low-density lipoprotein cholesterol: 160 mg/dL
A C E
A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include (Select all that apply.) A Discharging the client on a statin medication B Providing the client with comprehensive therapies C Meeting goals for nutrition within 1 week D Providing and charting stroke education E Preventing venous thromboembolism
A D E
A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders (Select all that apply.) A A client with a moderate trauma may need hospitalization. B A Glasgow Coma Scale score of 10 indicates a mild brain injury. C Only open head injuries can cause a severe TBI. D A client with a Glasgow Coma Scale score of 3 has severe TBI. E The terms "mild TBI" and "concussion" have similar meanings
A D E
The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation (Select all that apply.) A Atherosclerosis B Down syndrome C Frequent heartburn D History of hypertension E History of smoking
A D E
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best A Assess the client's support system. B Assist in finding one change the client can control. C Determine what stressors the client faces in daily life. D Inquire about delegating some of the client's obligations.
B
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client A Alteplase (Activase) B Clopidogrel (Plavix) C Heparin sodium D Mannitol (Osmitrol)
B
A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met A Ambulates with assistance B Oxygen saturation of 98% C Pain of 2/10 after medication D Verbalizing risk factors
B
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching A "The best way to lose weight is a high-protein, low-carbohydrate diet." B "You should balance weight loss with consuming necessary nutrients." C "A nutritionist will provide you with information about your new diet." D "If you exercise more frequently, you won't need to change your diet."
B
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal A Teach high school students heart-healthy living. B Participate in blood pressure screenings at the mall. C Provide pamphlets on heart disease at the grocery store. D Set up an "Ask the nurse" booth at the pet store.
B
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure (Select all that apply.) A Assist the provider to place a central venous access device. B Prepare for continuous blood pressure and pulse monitoring. C Administer the client's prescribed beta blocker. D Give the client nothing by mouth 3 to 6 hours before the procedure. E Explain to the client that dobutamine will simulate exercise for this examination.
B D E
A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging (Select all that apply.) NOT: Client Needs Category: Health Promotion and Maintenance A Long-term memory loss B Slower processing time C Increased sensory perception D Decreased risk for infection E Change in sleep patterns
B E
What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins (Select all that apply.) A Administering mild analgesics for pain B Applying elastic compression stockings C Elevating the legs when sitting or lying D Reminding the client to do leg exercises E Teaching the client about surgical options
B C D
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram (Select all that apply.) A Hypertension B Fatigue despite adequate rest C Indigestion D Abdominal pain E Shortness of breath
B C E
After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess (Select all that apply.) A Decreased respiratory rate B Increased heart rate C Decreased level of consciousness D Increased force of contraction E Decreased blood pressure
B D
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important (Select all that apply.) A Administer pain medication. B Assess distal pulses every 10 minutes. C Have the client sign a surgical consent. D Notify the Rapid Response Team. E Take vital signs every 10 minutes.
B D E
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse (Select all that apply.) A Blood pressure of 140/88 mm Hg B Serum potassium of 2.9 mEq/L C Warmth and redness at the site D Expanding groin hematoma E Rhythm changes on the cardiac monitor
B D E
A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find (Select all that apply.) A Loss of smell B Impaired swallowing C Visual changes D Inability to shrug shoulders E Loss of gag reflex
B D E
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management (Select all that apply.) A Does not want to purchase a thermometer B Is allergic to acetaminophen (Tylenol) C Laughing, says "Strenuous What's that" D Lives alone and is new in town with no friends E Plans to have a beer and go to bed once home
B D E
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP) (Select all that apply.) A Assess neurologic status with the Glasgow Coma Scale. B Check and document oxygen saturation every 1 to 2 hours. C Cluster client care to allow periods of uninterrupted rest. D Elevate the head of the bed to 45 degrees to prevent aspiration. E Position the client supine with the head in a neutral midline position
B E
The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client A Can ambulate independently B May have trouble swallowing C Needs frequent re-orientation D Will need near-total care
C
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement A Educate the client about strict bedrest after the procedure. B Place an indwelling urinary catheter to closely monitor output. C Obtain a prescription for intravenous fluids. D Contact the provider to cancel the procedure
C
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met A Chooses preferred items from the menu B Eats 75% to 100% of all meals and snacks C Has clear lung sounds on auscultation D Gains 2 pounds after 1 week
C
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met A Pain rated as 2/10 after medication B Distal pulse on affected extremity 2+/4+ C Remains on bedrest as directed D Verbalizes understanding of procedure
C
A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority A Administer pain medication. B Assess the client's vital signs. C Notify the Rapid Response Team. D Raise the head of the bed.
C
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time A Inability to communicate B Nutritional deficit C Risk for acquiring an infection D Risk for skin breakdown
C
A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this" How should the nurse respond A "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." B "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." C "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." D "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures
C
A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider A Weak pedal pulses B Nausea and vomiting C Increased thirst D Hives on the chest
C
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect A Excruciating pain on inspiration B Left lateral chest wall pain C Disorientation and confusion D Numbness and tingling of the arm
C
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease A An 86-year-old man with a history of asthma B A 32-year-old Asian-American man with colorectal cancer C A 45-year-old American Indian woman with diabetes mellitus D A 53-year-old postmenopausal woman who is on hormone therapy
C
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery A Administration of IV furosemide (Lasix) B Initiation of an external pacemaker C Assistance with endotracheal intubation D Placement of central venous access
C
A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." How should the nurse respond A "Chili is high in fat and calories; it would be a good idea to stop eating it." B "The provider has prescribed an antacid for you to take every morning." C "What do you understand about what happened to you" D "When did you start experiencing this indigestion"
C
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best A Ask if the weight loss was intended. B Encourage a high-protein, high-fiber diet. C Measure for new compression stockings. D Review a 3-day food recall diary.
C
A nurse is caring for four clients. Which one should the nurse see first A Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg B Client who had a first dose of captopril (Capoten) and needs to use the bathroom C Hypertensive client with a blood pressure of 188/92 mm Hg D Client who needs pain medication prior to a dressing change of a surgical wound
C
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client A Help the client identify each medication by its color. B Provide written materials with large print size. C Sit on the client's right side and speak into the right ear. D Allow the client to use a white board to ask questions.
C
A student nurse asks what "essential hypertension" is. What response by the registered nurse is best A "It means it is caused by another disease." B "It means it is 'essential' that it be treated." C "It is hypertension with no specific cause." D "It refers to severe and life-threatening hypertension."
C
Which statements by the client indicate good understanding of foot care in peripheral vascular disease (Select all that apply.) A "A good abrasive pumice stone will keep my feet soft." B "I'll always wear shoes if I can buy cheap flip-flops." C "I will keep my feet dry, especially between the toes." D "Lotion is important to keep my feet smooth and soft." E "Washing my feet in room-temperature water is best."
C D E
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain A Loss of bladder control B Other medical conditions C Progression of symptoms D Time of symptom onset
D
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure A Client's level of anxiety B Ability to turn self in bed C Cardiac rhythm and heart rate D Allergies to iodine-based agents
D
A nurse assesses a client's recent memory. Which client statement confirms that the client's remote memory is intact A "A young girl wrapped in a shroud fell asleep on a bed of clouds." B "I was born on April 3, 1967, in Johnstown Community Hospital." C "Apple, chair, and pencil are the words you just stated." D "I ate oatmeal with wheat toast and orange juice for breakfast."
D
A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble sleeping at night." How should the nurse respond A "I will consult the provider to prescribe a sleep study to determine the problem." B "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." C "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." D "Use pillows to elevate your head and chest while you are sleeping."
D
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure A Creatine phosphokinase (CPK) of 100 IU/L B Atrioventricular graft C Blood urea nitrogen (BUN) of 50 mg/dL D Internal insulin pump
D
A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client A Assess for bladder retention and/or incontinence. B Listen to the client's lungs after eating or drinking. C Prop the client's right side up when sitting in a chair. D Rotate the client's meal tray when the client stops eating
D
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first A A 42-year-old female who describes her pain as a dull ache with numbness in her fingers B A 49-year-old male who reports moderate pain that is worse on inspiration C A 53-year-old female who reports substernal pain that radiates to her abdomen D A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
D
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning A Cholesterol: 126 mg/dL B High-density lipoprotein cholesterol (HDL-C): 48 mg/dL C Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL D Triglycerides: 198 mg/dL
D
A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP) (Select all that apply.) A Administering preoperative medication B Ensuring the consent is signed C Marking pulses with a pen D Raising the siderails on the bed E Recording baseline vital signs
D E
