Med Surg: Final

A nurse in the emergency department is caring for a client who has fruity breath odor, dry mouth, and extreme thirst. Which of the following assessments should the nurse make? Blood glucose level Pupillary reaction to light Deep tendon reflexes Liver function tests

Blood glucose level

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? Administer 0.9% sodium chloride until TPN is available from the pharmacy. Check the client's capillary blood glucose level every 4 hr. Obtain the client's weight each week. Change the IV tubing every 3 days.

Check the client's capillary blood glucose level every 4 hr. or according to facility policy, due to the client's risk for hyperglycemia while receiving TPN. The dextrose concentration in TPN places the client at risk for this complication.

A nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder? Cholesterol level 195 mg/dL Elevated HDL levels Elevated LDL levels Triglyceride level 135 mg

Elevated LDL levels The nurse should identify that total cholesterol levels less than 200 mg/dL are recommended to help reduce the incidence of developing atherosclerosis. The nurse should identify that an elevated LDL level increases a client's risk for artherosclerosis. The client's desirable LDL level is below 100 mg/dL.

A nurse is preparing to care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse assess first? A client who has benign prostatic hyperplasia (BPH) and reports dysuria A client who has ulcerative colitis and reports diarrhea A client who has emphysema and reports dyspnea A client who has esophageal cancer and reports painful swallowing

A client who has emphysema and reports dyspnea The nurse should apply the ABC priority-setting framework.

A nurse is teaching a client how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer? Lumps that are mobile and tender upon palpation prior to a menstrual period Multiple round masses that are tender and found in both breasts Bilaterally darkened areolas A nontender, hard lump that is palpated in one breast

A nontender, hard lump that is palpated in one breast

A community health nurse is teaching a group of clients about melanoma. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? One solid color Symmetrical in shape Less than 6 mm in diameter An irregular border

An irregular border

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? Have the client gently blow clots from the nose every 5 min. Instruct the client to sit with his head hyperextended. Apply ice compresses to the back of the client's neck. Apply lateral pressure to the client's nose for 10 min.

Apply lateral pressure to the client's nose for 10 min. The nurse should apply direct, lateral pressure to the nose for 10 min to control epistaxis. If after 10 min the epistaxis continues, the client might require nasal packing or other interventions.

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Instill proparacaine hydrochloride eyedrops. B. Perform ocular irrigation of the right eye. C. Place the client in a supine position with the head turned toward the affected side. D. Ask the client about first aid performed at the scene.

Ask the client about first aid performed at the scene. the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered.

A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first? Estimation of burn injury Characteristics of the cough and sputum Extent of peripheral edema Amount of urine output

Characteristics of the cough and sputum The nurse should apply the ABC priority-setting framework. The nurse's priority assessment is the client's cough characteristics. A client who has burns to the face is at risk for pulmonary injury and the development of a brassy cough can indicate impending loss of airway

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect? Kussmaul respirations Diaphoresis Decreased skin turgor Ketonuria

Diaphoresis a client who has a blood glucose level below 70 mg/dL to exhibit manifestations of hypoglycemia. Expected findings associated with hypoglycemia include weakness, hunger, diaphoresis, nausea, shakiness, and confusion

A nurse is providing postoperative care for a client who has two chest tubes in place following a lobectomy. The client asks the nurse the reason for having two chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? Removing air from the pleural space Creating access for irrigating the chest cavity Evacuating secretions from the bronchioles and alveoli Draining blood and fluid from the pleural space

Draining blood and fluid from the pleural space

A nurse is planning care for a client during a sickle cell crisis. Which of the following interventions should the nurse include in the client's plan of care? A. Maintain the client's knees and hips in a flexed position. B. Apply cold compresses to painful joints. C. Withhold opioids until the crisis is resolved. D. Encourage increased fluid intake.

Encourage increased fluid intake. because dehydration increases the viscosity of the blood, which can increase sickling and client discomfort.

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? Provide oxygen. Place the client in a side-lying position. Provide privacy. Lower the client to the floor.

Lower the client to the floor. if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect him from injury.

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (Select all that apply.) Place the client on respiratory isolation. Monitor vital signs every 2 hr. Assess neurological status every 4 hr. Maintain the client in a modified Trendelenburg position. Keep the client's room darkened.

Monitor vital signs every 2 hr. Assess neurological status every 4 hr. Keep the client's room darkened. Pt have increased intracranial pressure.

A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the client a bedpan every 2 hr. B. Limit the client's daily fluid intake until he is no longer incontinent. C. Request a prescription for an indwelling urinary catheter from the client's provider. D. Ambulate the client to the bathroom every 30 min.

Offer the client a bedpan every 2 hr. Following a stroke, the client might have bladder incontinence due to confusion, impaired sensation in response to bladder fullness, and decreased sphincter control. The nurse should encourage and assist the client to void every 2 hr while awake to promote bladder control. By offering a bedpan, the nurse promotes client safety.

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mm HG, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

Respiratory alkalosis

A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply.) A. Take allopurinol as prescribed. B. Exercise several times a week. C. Limit intake of foods high in purine. D. Decrease daily fluid intake. E. Avoid citrus juices.

Take allopurinol as prescribed. Exercise several times a week. Limit intake of foods high in purine.

A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard electroencephalogram (EEG). Which of the following instructions should the nurse include in the teaching? Remain NPO 6 to 8 hr prior to the EEG. Take a sedative the night prior to the EEG. Thoroughly shampoo hair prior to the EEG. Sleep for at least 8 hr the night prior to the test.

Thoroughly shampoo hair prior to the EEG. because hairsprays, oils, and other hair preparations interfere with recording results of the EEG.

A nurse is providing discharge teaching about improving gas exchange to a client who has emphysema. Which of the following instructions should the nurse include in the teaching? Use pursed-lip breathing during periods of dyspnea. Limit fluid intake to 1,500 mL per day. Practice chest breathing each day. Wear home oxygen to maintain an SaO2 of at least 94%.

Use pursed-lip breathing during periods of dyspnea.

A nurse is providing teaching to a client who has a new diagnosis of multiple sclerosis (MS). The clients asks the nurse about the usual course of MS. Which of the following responses should the nurse make? "Each client is different; we cannot predict what will happen." "I can see that you are worried, but it's too soon to predict what will happen." "Acute episodes are usually followed by remissions, which can vary in duration." "It's too early to think about the future; let's focus on the present and take one day at a time."

"Acute episodes are usually followed by remissions, which can vary in duration." The nurse should identify that the client is asking an information-seeking question. The nurse should provide the client with factual information.

A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? A. "I will use a soft toothbrush or foam swab for oral care." B. "I will use lemon and glycerine swabs after meals." C. "I will remove my dentures except while eating." D. "I will rinse my mouth frequently with hydrogen peroxide solution."

"I will use lemon and glycerine swabs after meals." they cause drying and irritation of the mucous membrane

A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Obtain sample menus from the dietitian to give to the client. Ask the client to identify the types of foods she prefers. Identify the recommended range for the client's blood glucose level. Discuss long-term complications that can result from nonadherence to the dietary plan.

Ask the client to identify the types of foods she prefers. the nurse should first ask the client about individual food preferences to provide an opportunity for the nurse to include these foods in her diet. Involving the client in the planning will help promote her adherence to the dietary plan.

A nurse is caring for a client who has an upper gastrointestinal bleed and a hematocrit of 24%. Prior to initiating a transfusion of packed red blood cells (RBCs), which of the following actions should the nurse take? (Select all that apply.) Assess and document the client's vital signs. Restart the IV with a 22-guage needle. Verify with another nurse the blood type and Rh of the packed RBCs. Hang a bag of lactated Ringer's IV solution. Change IV tubing to a set that has a filter.

Assess and document the client's vital signs. Verify with another nurse the blood type and Rh of the packed RBCs. Change IV tubing to a set that has a filter.

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation. Which of the following actions should the nurse take? Elevate the residual limb on a soft pillow. Assist the client to a prone position every 4 hr. Reapply a bandage to the residual limb every 12 hr. Apply dressings to the site in a proximal-to-distal direction.

Assist the client to a prone position every 4 hr. because it reduces the risk of flexion contractures.

A nurse is monitoring a client following a thyroidectomy for the presence of hypoparathyroidism. Which of the following findings should the nurse expect? A. Elevated blood pressure B. Involuntary muscle spasms C. Cold intolerance D. Weight loss

B Involuntary muscle spasms The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are damaged or removed during a thyroidectomy. Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and calcium deficiency.

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? Obtain the prescribed irrigation solution. Don personal protective equipment. Check the client's pain level. Place a waterproof pad under the client's extremity.

Check the client's pain level.

A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? Ecchymosis of the thigh Serous drainage at the pin site Chest petechiae Muscle spasms in the left leg

Chest petechiae The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones, such as the femur, are at increased risk for fat emboli. Fat emboli typically occur 12 to 48 hr after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress into acute respiratory failure.

A nurse is teaching about a low-cholesterol diet to a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching? Chicken breast and corn on the cob Shrimp and rice Cheese omelet and turkey bacon Liver and onions

Chicken breast and corn on the cob

A nurse in an emergency department is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A depressed fracture of the forehead Clear fluid coming from the nares Motor loss on one side of the body Bleeding from the top of the scalp

Clear fluid coming from the nares The nurse should identify cerebrospinal fluid, which appears as a clear fluid, coming from the nares or ears as an indication of a basilar skull fracture.

A nurse is providing teaching to a client who has tuberculosis and prescriptions for rifampin and ethambutol. The nurse should identify which of the following findings as an adverse effect of these medications that the client should report to the provider? A. Red-orange discoloration of urine B. Unexpected weight gain C. Ringing in the ears D. Decreased visual acuity

Decreased visual acuity The nurse should identify optic neuritis as an adverse effect of ethambutol. The nurse should instruct the client to monitor for changes in visual acuity or color identification as indications of optic neuritis to report to the provider. This adverse effect necessitates termination of ethambutol therapy because irreversible blindness can result.

A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? Turn the client from side to side. Elevate the height of the dialysate bag. Lower the head of the client's bed. Advance the catheter approximately 2.5 cm (1 in) further.

Turn the client from side to side. to side to facilitate removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter.

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider? Output equal to the instilled irrigant Report of bladder spasms Viscous urinary output with clots Report of a strong urge to urinate

Viscous urinary output with clots The nurse should report urine output that is bright red with clots or urine that resembles ketchup to the provider because this is an indication of arterial bleeding.

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if the herpes zoster is contagious. Which of the following responses should the nurse make? "Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox." "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant." "A client who has herpes zoster is not contagious if blisters are present on the skin." "Herpes zoster is not contagious to people who have had chickenpox."

"Herpes zoster is not contagious to people who have had chickenpox." The nurse should inform the AP that varicella zoster is the causative agent of both chickenpox and herpes zoster. This virus is contagious to people who have not had chickenpox or have not received vaccination for varicella.

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? "I need to lie still in bed during my brachytherapy treatment." "I will have an implant placed once a month during my brachytherapy treatment." "I must stay at least 3 feet away from others between brachytherapy treatments." "I should expect some blood in my urine after each brachytherapy treatment."

"I need to lie still in bed during my brachytherapy treatment." remain on bed rest with limited movement while the radioactive implant is in place to prevent dislodgment.

A nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? "I should check my heart rate at the same time each day." "I don't have to take my antihypertensive medications now that I have a pacemaker." "I should keep a pressure dressing over the generator until the incision is healed." "I cannot stand in front of our new microwave oven when it is on."

"I should check my heart rate at the same time each day." The nurse should instruct the client to check his heart rate at the same time each day and to document the rate in a log for communication with the provider.

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? "I will need to take methotrexate even if I'm in remission." "I'm thankful that this type of lupus only affects the skin." "Each day I should apply a sunblock with a sun protection factor of 15." "A mild fever is common with SLE and usually does not require medical intervention."

"I will need to take methotrexate even if I'm in remission." The nurse should inform the client that SLE is an autoimmune disorder characterized by exacerbations and remissions. It affects the skin as well as joints, organs, and any structure in the body that contains connective tissue. Methotrexate is an immunosuppressive medication given during remission to help prevent exacerbation. The medication is also given when exacerbations occur to reduce the severity of manifestations.

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates understanding of the teaching? "I will ask my provider to change my contraception to an intrauterine device." "I will notify my doctor before I have dental procedures." "I will avoid using antiseptic mouthwash during my oral care." "I will wear a mask when I go out in public."

"I will notify my doctor before I have dental procedures." The nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to invasive or dental procedures due to the need for prophylactic antibiotic therapy to reduce the risk of a streptococcal infection.

A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? "Because most of my colon is still intact and functioning, my stool will be formed." "My stoma will appear large at first, but it will shrink over the next several weeks." "My colostomy will begin to function 2 to 6 days after surgery." "My diet will have to change to a soft diet after surgery."

"My diet will have to change to a soft diet after surgery." After surgery the client's diet quickly returns to a regular diet and there are not any food restrictions, unless the client chooses to decrease intake of foods that increase gas or odor.

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make? "You should try a little harder to stick to your diet." "Why do you think you've gained 3 pounds this week?" "Were there any issues last week that kept you from focusing on your diet?" "You should put this week behind you and adhere to your diet from this point forward."

"Were there any issues last week that kept you from focusing on your diet?" The nurse should use an open-ended question that allows the client to reassess the past week in a non-threatening manner

A nurse is providing teaching about antiretroviral medication therapy to a client who has a new diagnosis of AIDS. Which of the following statements should the nurse include in the teaching? A. "Your provider will prescribe one single antiretroviral medication at a time." B. "You should take antiretroviral medications on a routine schedule." C. "You should increase your intake of raw fruits and vegetables while taking antiretroviral medications." D. "Your provider will prescribe antiretroviral therapy to kill the HIV virus."

"You should take antiretroviral medications on a routine schedule."

A nurse is providing teaching to a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include? "It is necessary to take this medication for the rest of your life to prevent recurrence." "Your provider will monitor your thyroid function while you are taking this medication." "You should take this medication on an empty stomach." "It is recommended to take this medication with an antacid."

"You should take this medication on an empty stomach." The nurse should instruct the client to take isoniazid on an empty stomach to improve absorption of the medication. To ensure the stomach is empty, the client should take the medication either 1 hr before or 2 hr after a meal.

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? Instruct the client to blink several times after instilling the medication. Ask the client to look straight ahead during instillation of the medication. Apply pressure to the puncta after instilling the medication. Place each drop of the medication directly on to the client's cornea.

Apply pressure to the puncta after instilling the medication. The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 min afterwards to prevent systemic absorption of the medication.

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? Document the client's food allergies on the medical record. Ask the client to identify the specific food allergies. Monitor the client for indications of anaphylaxis. Have epinephrine available for administration.

Ask the client to identify the specific food allergies. the first action the nurse should take is to assess the client's allergies and identify the specific allergens so that the nurse can ensure that the specific foods are not offered to the client during meals.

A nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include? Avoid IM injections. Assess the client for ecchymosis once per shift. Do not allow the client to have visitors. Encourage daily flossing between teeth.

Avoid IM injections. The nurse should identify that the client's platelet count of 48,000/mm3 indicates thrombocytopenia; therefore, the nurse should avoid invasive procedures, such as an IM injection, which can increase the client's risk for bleeding.

A nurse is teaching a client about transmission prevention of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? Maternal-fetal Fecal-oral contamination Genital sexual contact Blood to blood

Fecal-oral contamination

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? (Select all that apply.) Gown Gloves Mask Hair cover Goggles

Gown Gloves

A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following actions should the nurse include in the plan of care? Infuse the heparin using an electronic IV pump. Administer vitamin K if the client has indications of hemorrhage. Adjust the dosage of heparin based on the client's PT levels. Inform the client that the heparin will dissolve the thrombus.

Infuse the heparin using an electronic IV pump. rather than by gravity, to prevent an accidental increase or change in the rate of infusion.

A nurse is caring for a client who is to have his chest tube removed. Which of the following actions should the nurse take? Cover the insertion site with a hydrocolloid dressing after removal. Provide pain medication immediately after removal. Instruct the client to perform the Valsalva maneuver during removal. Delegate removal of the chest tube to a licensed practical nurse (LPN).

Instruct the client to perform the Valsalva maneuver during removal. to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space.

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take? Recap the needle on the syringe. Schedule a nurse to administer future injections for this client. Explain to the client that the syringe should be disposed of in the bathroom trash can. Place the syringe in a puncture-proof disposal container.

Place the syringe in a puncture-proof disposal container.

A nurse is caring for a client following a hip arthroplasty. The nurse places an abduction pillow on the client for which of the following purposes? Raising the bed linens off the client's feet to prevent plantar flexion Keeping the client's heels off the bed to prevent pressure ulcers Positioning the client off of the operative site while in bed Preventing dislocation of the hip during position changes or movement

Preventing dislocation of the hip during position changes or movement Following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. The nurse should place the wedge-shaped pillow between the client's legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to subluxation or total dislocation of the hip joint.