Med Surge Final

The nurse si caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching?

" don't have ot have a bowel movement every day"

Anurse is reinforcing teaching with a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching?

" wil call my doctor if my pulse rate is less than 50"

The clinic nurse assesses a client with complaints of pain and numbness in the left hand and fingers. Which question should the nurse ask the client?

"Do you do repetitive movements with your Left fingers?"

To assess whether there is any improvement in a patient's dysuria, which question will the nurse ask?

"Do you have pain when you urinate?"

The client diagnosed with a cold is taking an antihistamine. Which statement indicates to the nurse the client needs more teaching concerning the medication?

"I need to be careful when I drive my car."

The nurse is discharge teaching for a client with a short leg cast. Which statement indicated the client understands the discharge teaching?

"I need to keep my leg elevated on two pillows for the first 24 hours"

Which statement by the client prescribed calcitonin, athyroid hormone, indicates ot hte nurse the teaching has been effective?

"I should administer the medication in a different nostril each day."

The nurse si preparing a client diagnosed with GERD for discharge following and esophagogastroduodenoscopy. Which statement indicates the client understands the discharge instructions?

"I should avoid orange juice and eating tomatoes until my esophagus heals."

The client with a new colostomy si being discharged. Which statement made by the client indicates the need for further teaching?

"I should drink only liquids until the colostomy starts ot work"

The home health care nurse is visiting an elderly client who is taking furosemide (Lasix) twice daily. Which statements made by the client indicates the need for further teaching? SATA

"I should expect to experience some ringing in my ears" "I can drink coffee and tea in an effort to get enough fluid" "I will take my medication in the morning and before bedtime"

The nurse requests the client to sign surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed?

"I will be glad when this is over so I can go home today"

The client si diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis?

"My pain goes away when Ihave bowel movement."

The client is scheduled for a computed tomography (CT) scan. Which question is most important for the nurse to ask before the procedure?

"are you allergic to seafood or iodine?"

The nurse has completed the teaching plan for the client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?

"the coal tar ointments and lotions will not stain my clothes"

The male client tells the nurse he has ben experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask?

"what have you done ot alleviate the heartburn?"

The client is being admitted to the outpatient psychiatric clinic diagnosed with bulimia. Which question should the nurse ask ot identify behaviors suggesting bulimia?

"what over the counter medications do you take?"

The client has end-stage liver failure secondary ot alcoholic cirrhosis. Which complication indicates the client si at risk for developing hepatic encephalopathy?

"when did you have your last alcoholic drink"

A client recovering from a total hip replacement has developed a deep vein thrombosis. The healthcar provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the ритр?

30 mL/hr

The nurse si preparing to hang a new bag of total parental nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?

85 mL/hr

Which Laboratory test should the nurse monitor ot identify an allergic reaction for the client diagnosed with contact dermatitis?

IgE

Anurse at aprovider's office si reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicate the client is at risk for heart disease? SATA

LDL 140 mg/dL cholesterol (total) 245 mg/dL

A 79-year-old man has been admitted with benign prostatic hyperplasia. What is most appropriat to include in the nursing plan of care?

Leave a Light on in the bathroom during the night

The client is diagnosed with acute exacerbation of Irritable Bowel Disease. Which primary intervention should the nurse implement?

Record the frequency, amount, and color of the stool

The client in end-stage liver failure has vitamin Kdeficiency. Which interventions should the nurse implement?

SATA monitor the platelet count avoid rectal temperatures use only a soft toothbrush use small-gauge needles

A nurse on an orthopedic unit is caring for a client following a total knee arthroplasty. Which of the following actions by the nurse are appropriate?

SATA check continuos passive motion device settings palpate dorsal pedal pulses elevates heels off bed

A client who had a myocardial infarction receives a prescription for a beta blocker and a nitroglycerin patch. Which reduction would the nurse determine is the purpose of the nitroglycerin patch that is prescribed?

The preload of the heart decreases thereby reducing the cardiac workload.

Which signs and symptoms should the nurse expect to find in a client diagnosed with ulcerative colítis?

Twenty bloody stools a day

The nurse is working in an outpatient clinic. Which client is most Likely to have a diagnosis of diverticulosis?

a 63 y/o female with hemorrhoids

The school nurse is completing spinal screenings. Which data require a referral to a healthcare provider?

a right arm lower than the left while bending over at the waist

The emergency department nurse is caring for a client with a compound fracture of the right ulna Which interventions should the nurse implement? Select all that apply

administer a tetanus toxoid injection assess the finger of the client's right hand send the client to radiology for an x-ray of the arm stabilize the arm at the wrist and the elbow apply a sterile, normal saline-soaked gauze to the arm

The nurse is caring for a client diagnosed with a fat embolism syndrome. Which healthcare provider order should the nurse question?

administer an intravenous loop diuretic

The client has an allergic reaction to poison oak 2 weeks ago. He has returned to the clinic with severe itching and weeping vesicles on the arms and legs. Which intervention should the nurse implement?

administer atopical ant-inflammatory lotion

The nurse is preparing to administer suboutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement?

administer in the anterolateral upper abdomen

The ED nurse is caring for a client admitted with extensive, dep partial-thickness and full- thickness burns. Which interventions should the nurse implement? SATA

administer morphine sulfate, a narcotic analgesic, VI estimate the amount of burned area using the rule of nines insert two 18 gauge catheters and begin fluid replacement apply sterile saline dressings to the burned areas determine the client's airway status

The nurse is caring for a client diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first?

administer oxygen via a nasal cannula

The client diagnosed with sickle-cell anemia comes ot the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4F and the pulse oximeter reading is 91%. Which action should the emergency room nurse implement first?

administer oxygen via nasal cannula

The nurse si preparing ot administer warfarin (coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's international normalized ratio (INR) is 2.7. Which action should the nurse implement?

administer the medication as ordered

The 50-year-old female client is being evaluated for osteoporosis. Which data should the nurse assess? SATA

alcohol intake Level and amount of exercise estrogen or androgen deficit family history of osteoporosis

The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan?

altered body image

The nurse si caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel?

ambulate the client to the bathroom

A nurse caring for a client who has contact dermatitis and has a new prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor?

anorexia

The client si admitted ot the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs and symptoms would the nurse expect ot find when assessing the client?

apical pulse rate of 110 and 4+ pitting edema of feet

The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis?

appearance of red, elevated, plaques with silvery white scales

The nurse is teaching clients at a community center about skin diseases. Which information about pruritis should the nurse include? SATA

apply mild skin lotion for hydration blot gently, but completely dry the skin use of increases itching

The nurse is caring for a client with complaints of a rash and itching on the face for 1 week. Which intervention should the nurse implement first?

ask the client to describe the rash when it first appeared

A male patient in the clinic provides a urine sample that is red orange in color. Which action should the nurse take first?

ask the patient about current medications

The nurse is caring for a client diagnosed with bacterial premonia. Which priority intervention should the nurse implement?

assess respiratory rate and depth

The client who had abdominal surgery tells the nurse, I" felt something give way in my stomach." Which intervention should the nurse implement first?

assess the abdominal wound incision

The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care?

assess the client for distention and vomiting

The nurse is assessing an African American client diagnosed with sickle-cell crisis. Which assessment finding is most pertinent when assessing for cyanosis in the client with dark skin?

assess the client's oral mucosa

Which intervention should the nurse implement for the client experiencing bronchospasms?

assess the clients capillary refill time

The post-anesthesia care nurse si caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first?

assess the nasogastric tube for patency

Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease?

auscultate the client's bowel sounds in all four quadrants

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contradiction to this procedure?

bronchitis 2 weeks ago

Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa?

cardiac function test

Which priority intervention should the day surgery nurse implement for a client who has had right knee arthroplasty?

check the client's pulses distally and assess the toes

Which intervention should the nurse implement for a client with a fractured hip in Buck's traction?

check the condition of the skin beneath the veloro boot frequently

A female patient with a suspected UTI is to provide a clean-catch urine specimen for culture g sensitivity testing. To obtain the specimen, the nurse will:

clean the urethral area, void a small amt into the toilet, then void into a sterile specimen cup

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first?

cleanse the area with soap and water

Phenazopyridine (Pyridium) is prescribed to a client with dysuria. The nurse explains that the client should expect which urine characteristic while taking phenazopyridine?

color that is orange or red

The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing?

compartment syndrome

The client is in the preicteric phase of hepatitis. Which signs and symptoms should the nurse expect the client to exhibit during this phase?

complaints of fatigue and diarrhea

Which clinical manifestation would the nurse include when teaching a client with heart failure about the signs and symptoms of cardiac decompensation? SATA

coughing at night difficulty breathing extreme fatigue

The nurse is preparing a plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?

cover the area with an occlusive dressing after applying a steroid cream

For which problem would the nurse encourage bed rest and reduction of fatigue?

decreased cardiac output caused by cardiac insufficiency

Which intervention should the nurse implement first when administering the first dose of intravenous antibiotic to the client diagnosed with a respiratory infection?

determine if a culture has been collected

The nurse is teaching the client diagnosed with atopic dermatitis. Which information should the nurse include in the teaching?

discuss skin care using hydrating lotions and minimal soap

The occupational health nurse si preparing a presentation ot a group of factory workers about preventing colon cancer. Which information should be included in the presentation?

eat several servings of cruciferous vegetables daily

Which nursing interventions should the nurse implement for the client who has a respiratory disorder?

encourage the client to cough and deep breathe monitor the client's pulse oximeter reading administer oxygen via a nasal cannula assess the client's lung sounds increase the client's fluid intake

Which client signs and symptoms indicate contact dermatitis ot the nurse?

erythema and oozing vesicles

The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client?

explain the client shout be following the BRAT diet

The client si 1day post operative major abdominal surgery. Which client problem is priority?

fluid and electrolyte imbalance

The nurse is admitting a client with a hypertensive emergency and a history of renal insufficiency. The nurse should ensure that which diuretic is readily available for use if ordered?

furosemide (Lasix)

Which condition would the nurse include when teaching potential complications to a client recovering from a myocardial infarction? SATA

heart failure cardiogenic shock cardiac dysrhythmias ventricular aneurysm and rupture thromboembolism sudden cardiac death

Which medication taken at home by a 47-year-old patient with decreased renal function will be o most concern to the nurse?

ibuprofen (motrin)

The nurse assessing the urinary system of a 45-year-old female would use auscultation to:

identify renal artery bruits

Which reason would the nurse give for beginning an exercise program when instructing a client with hypertension on Lifestyle modification ot manage the disease? SATA

improves cardiac efficiency

The client is diagnosed with pericarditis. Which are the most common signs and symptoms the nurse would expect to find when assessing the client?

increased chest pain with inspiration

The client with ahistory of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement?

insert nasogastric tube and begin saline Lavage

The female client comes ot the clinic complaining of abdominal cramping and at Least 10 episodes of diarrhea every day for the last 2 days. The client just returned from a trip to Mexico. Which intervention should the nurse implement?

instruct the client ot take a cathartic laxative only

The nurse and the unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the LAP to improve gas exchange? SATA

keep the head of the bed elevated encourage deep breathing exercises record pulse oximeter reading

Which information should the nurse teach the client regarding sports injuries?

keep the injury immobilized and elevated for 24 to 48 hours

Which outcome should the nurse identify for the client scheduled ot have a cholecystectomy?

knowledge of postoperative care

The nurse is caring for a client 1-day postoperative sigmoid resection notes a moderate amount of dark reddish-brown drainage on the midline abdominal incision. Which intervention should the nurse implement first?

mark the drainage on the dressing with the time and date

The nurse si preparing the plan of care for a client diagnosed with stevens-Johnson syndrome. Which intervention should the nurse include? Select all that apply.

monitor intake and output every 8hours assess breath sounds and rate every 4 hours assess vesicles, erosions, and crusts frequently

Which intervention should the nurse include for a client diagnosed with carpal tunnel syndrome?

monitor safety during occupational hazards

A 46-year-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim § sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take?

obtain a midstream urine specimen for culture and sensitivity testing

The nurse is caring for a client with a left fractured humerus. Which data warrant intervention yb the nurse?

pain is not relieved by the patient-controlled analgesia

When working in the urology/ nephrology clinic, which patient could the nurse delegate to an experienced LVN?

patient who will have catheterization to check for residual urine after voiding

The client has ben experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client?

place the client on a high-fiber diet

The client has had a liver biopsy. Which postprocedural intervention should the nurse implement?

place the client on the right side

The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select al that apply

position the client semirecumbent provide meticulous skin care to stoma maintain the indwelling catheter

Which Laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?

potassium 2.4 mEa/L

Which problem should the nurse identify as a priority for client who is one day postoperative?

potential for hemorrhaging

The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (LAP)?

prepare the client by removing all metal objects

The client diagnosed with end-stage liver failure si admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse ot address the complication?

reduce protein intake ot 60 to 80 g/day

The client si 4 hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse?

refusal to turn, deep breathe, and cough

Which indicator would the nurse use to determine effectiveness after administration of sublingual nitroglycerin?

relief of anginal pain

A client is being prescribed oxybutynin (Ditropan) for a neurogenic bladder. The nurse determines that the client is possibly experiencing toxic effects of this medication after noting which manifestation?

restlessness

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication?

risk for depressed respiratory pattern

Anurse is assisting with a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first?

smoking cessation

The client diagnosed with end stage liver failure is admitted with esophageal bleeding. The healthcare provider inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?

stay with the client at all times

The nurse si discussing angina with a client who is diagnosed with coronary artery disease. Which intervention should the nurse implement?

stop the activity immediately and rest

How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected pyelonephritis?

strike a flat hand covering the costovertebral angle (CVA)

A nurse in a provider's office is collecting data from a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn?

superficial thickness

The client is complaining of severe itching following a course of antibiotics. Which independent nursing action should the nurse implement?

take baths with an OTC colloidal

Two WAD's are using the transfer board to move the client from the bed to the wheelchair. Which action should the nurse take?

take no action this is the correct procedure for transferring a client

The client is prescribed Fosamax, a bisphosphonate. Which information should the nurse teach?

take this medication with a full glass of water

Which action would the nurse take after being notified that the latest potassium Level for a client in acute renal failure is 6.2 mEq?

take vital signs and call the healthcare provider

Which action would the nurse implement first for a client with a serum potassium Level that has increased to 5.8 mEq/L (5.8 mmol/L)?

take vital signs and notify the healthcare provider

The nurse is in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement?

tape the medal to the client and allow the client to wear the medal

101. The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? SATA

teach ways to manage postoperative pain discuss how to cough and deep breathe effectively discuss events which occur in the post-anesthesia care unit

The home health nurse is visiting an elderly client who shows the nurse an area of rough skin with a greasy feel and multiple papules. Which information should the nurse provide the client?

tell the client to discuss this with the healthcare provide at the next appointment

70. The nurse and unlicensed assistive personnel (UAP) are caring for a client with a stage Iv pressure ulcer. Which action by the UAP warrants intervention by the nurse?

the WAP places multiple diapers on the client

The client who had an abdominal surgery has a jackson Pratt (P) drainage tube. Which assessment data warrant immediate intervention by the nurse?

the bulb is round and has 40 mL of fluid

A client sustained a fractured femur in a motor-vehicle accident. Which data requires immediate intervention by the nurse?

the client has petechiae over the neck and chest the client has yellow globules floating in the urine

Which assessment data indicate ot the nurse the client recovering from an open cholecystectomy may require paín medication?

the client has shallow respirations

The client si postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?

the client will be able to ambulate down the nurse's station

Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?

the client will follow medical protocols

The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long- term care facility. Which client should the nurse question receiving the vaccine?

the client with a documented allergy to eggs

The elderly client is admitted to the hospital for severe back pain. Which data should the nurse assess first during the admission assessment?

the client's current pain Level

The charge nurse has just received the shift report. Which client should the nurse see first?

the elderly client admitted from another facility who is complaining of constipation

A nurse is assisting in the care of a client who began having chest pain 2 hours ago. Which of the following laboratory findings should the nurse identify as an indication the client has sustained injury ot the heart?

troponin T 0.8 ng/mL

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?

use of nonstreroidal anti-inflammatory drugs

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways ot prevent acute exacerbation of diverticulosis? SATA

walk 30 minutes a day increase fluid intake eat a high-fiber diet